Lower-middle Income Countries: Study Results On Adoption .

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Lower-middle income countries:study results on adoption andfinancing of new vaccinesSAGENovember r

Organization of presentationBackgroundWhy LMIC new vaccine adoption?Study TORsMethods: country case studies, key informantinterviews, quantitative analyses Limitations Findings from country cases, industry interviews, andquantitative work Summary of what is new

BackgroundWHO/GatesLMICNewVaccineAdop9onStudy Overseen by Bill and Melinda Gates Foundation and WHO Advisory Group provided guidance and support Study implemented by Results for Development Institute (R4D),Washington, DC Began in November 2009, nearing completion

StudyAdvisoryGroup AGinaTambini,PAHO

LMICs World Bank definition: 2008 GNI/capita 976 - 3,855Population 3.8 billion (1.4 billion excluding China and India)Birth cohort 76 million (33 million excluding China and India)Unlike LICs, most do not receive GAVI funding2008 LMIC, GAVI ineligible2008 LMIC, graduating from GAVI in 20112008 LMIC, will remain GAVI eligible

LMIC Hib %)12(22%)Birthcohort(millions)22(29%)54(71%)2008 LMIC, Adopted Hib2008 LMIC, Yet to adopt HibSource: WHO Immunization surveillance, assessment and monitoring. Reported immunization schedules by vaccine [Internet]. Geneva: WHO; [updated 2010 Oct 11; cited 2010 Nov 8].Available from http://apps.who.int/immunization monitoring/en/globalsummary/scheduleselect.cfm

LIC Hib %)4(11%)Birthcohort(millions)29(81%)7(19%)2008 LIC, Adopted Hib2008 LIC, Yet to adopt HibSource: WHO Immunization surveillance, assessment and monitoring. Reported immunization schedules by vaccine [Internet]. Geneva: WHO; [updated 2010 Oct 11; cited 2010 Nov 8].Available from http://apps.who.int/immunization monitoring/en/globalsummary/scheduleselect.cfm

Hib adoption: comparing LICs and 22%)54(71%)

NIP performance in LMICsNumberofcountries302520271512105970 90%80- ‐89%70- ‐79% 70%

TermsofReferencePurpose: ndopDonsforaddressingconstraintsObjecDves: MICdemandFocuses: upport Vaccines:Hib,Pneumo,Rota,andHPV

nsfromselectedUMICsMixofadopters/non- Dallist,replacedbyIndonesia

Data collectionIn-Depth LMIC Country StudyIn-Depth UMIC Country StudyRemote LMIC Country StudyCountryStudiesRemote UMIC Country ape VerdeThailandPanamaSyriaEcuadorIndonesiaSouth AfricaPhilippines

Countrycasestudies Interviewswith5- inesuppliersLessons,suggesDons

Data collectionExpertConsulta9ons Immunization program experts (20)Vaccine manufacturers (10 total: 5 IFPMA, 5 DCVMN)Regional Working Group membersProcurement agencies (UNICEF, PAHO)

Dataanalysis Kaplan- romDmeofavailability– Samples:UMICs,LMICs,andLICs Coxsurvivalmodelregressions– Dependentvariables:Dmefromavailabilityofpre- ‐qualifiedHibandHepBvaccinetoadopDon– toaffectdecisions– Samples:LICs MICs;MICsonly

LimitaDons MuchofinformaDoncollectedandanalyzedisobservaDonal SelecDonofcountriesnon- ‐random,ratheritwasdeliberate tmeasurable AccesslimitedtosomesensiDvedata

Status of studyCompletecomponents All country case studies, manufacturer interviews,and global vaccine expert interviews Third draft report on country and global expertinterviews following AG input Draft section on findings from manufacturers Draft quantitative analysis Session on preliminary results at NUVI in June

Status of studyComponentstobecompleted Report to SAGE (November 11, 2010) Integration of manufacturer interview results andquantitative analysis with country and global expertinformation Analysis of impact of projected faster adoption onvaccine markets

udgetforvaccinesEpidemiologyCost- ‐effec9venessCost- XXXX14XXXXXX5XXXXX423X6X7333X3

Summary of findingsLMICvaccinedecision- ‐makingisdeliberateandra9onalGrouping of factors in country decision making: Factors important in the majority of countriesFactors important in multiple countriesOther factors mentioned by countriesHypothesized factors of small importance

Summary cinesCost- ‐effec9venessPrice02468101214

Summary commenda9onBudgetforvaccinesCost- ‐effec9venessPrice02468101214

Summary of ntbyReg/GlobOrgs02468101214

Summary of PStrengthPrivatemarkets02468101214

Summary of tries Vaccine characteristics Media

Summary of findingsIndustryperspec9ve LMICs important—but LMICs not seen as a single market No capacity constraint to meeting demand from LMICsoutside India and China (latter are special cases) IFPMA members appreciate UNICEF SD for forecasting,multi-year contracts, standard requirements DCVMN members want more tech transfers Wish to preserve ability to pursue company pricingstrategies (for IFPMA members “tiered pricing”)

Summary of findingsIndustryperspec9ve Pools provide advantages to industry – simplifymarketing, standardize products, allow large volumes DCVMN members feel disadvantaged by some LMICregulatory practices and lack of presence DCVMN members mainly focused on domestic markets,but working to enter MIC and HIC markets Believe budget availability, political commitment, andprogram performance more important than price incountry adoption decisions – worry about GAVI grads

Summary of findingsQuan9ta9veanalysisresultsKaplan-Meier survival functions Hep B UMICs and LMICs adopted at statistically similar rates,significantly faster than LICs LICs began to catch up following start of GAVI Hib UMICs adopted faster than LMICs and LICs that adopted atstatistically similar rates

Summary of findingsQuan9ta9veanalysisCox survival model regression analysis of years toadoption of Hep B and Hib vaccines Measurable independent variables: Income, NIP strength, region, govt health spending, govtimmunization spending, line-item, BOD evidence, Hep Band meningitis BOD, neighbors’ adoption Analyses conducted for: (1) MICs and (2) LICs and MICstogether

Summary of findingsQuan9ta9veanalysisresultsSignificant positive associations with vaccine adoptionin multiple analyses: Adoption by neighbors (HepB across income groups) Strength of NIP (LMICs/LICs across vaccines) AMR countries (Hib across income groups)Significant positive associations in only one analysis: Income levelLine-item for immunizationsWPR countriesEMR countries

Sowhatisnew?1. Costandprice- lueformoneyandsustainability2. tinvestmuchingatheringhigh- ‐qualitydata.ThereisliMletonointer- ‐countrycooperaDonorcollaboraDon3. ementofcompeDDon4. mentopDons,andmarketdynamics

Sowhatisnew?4. inedecisiontakenatNIPDirectorlevel5. oinfluencedecisions6. nancing,eventhoughotherpeerLMICsaredoingso7. Noone- ‐size- ‐fits- ‐allapproachpossibleforthisdiversesetofcountries


LMIC GAVI eligibility in 20112008 LMIC, GAVI ineligible2008 LMIC, GAVI eligible

LIC LMIC Hib 22%)54LIC34(89%)4(11%)382008 LMIC, Adopted Hib2008 LIC, Adopted Hib2008 LMIC, Yet to adopt Hib2008 LIC, Yet to adopt HibSource: WHO Immunization surveillance, assessment and monitoring. Reported immunization schedules by vaccine [Internet]. Geneva: WHO; [updated 2010 Oct 11; cited 2010 Nov 8].Available from http://apps.who.int/immunization monitoring/en/globalsummary/scheduleselect.cfm

Advisory Group involvement Advice on methodsInput into selection of countriesIdentification of key informantsProviding documents, data, and introductionsTracking progress (monthly phone calls, NUVI faceto-face)Assisting with decision making along the wayReview and comment on draft reportsAssistance with prioritizing recommendations

BackgroundRelevancetoSAGENovember 2008 SAGE:“WHO conduct further situation analysis of financialchallenges for low and middle-income countries andconsultation with countries concerned & partners to distilissues to more actionable activities”.2008 WHA requested the DG:“To collaborate with international partners, donors as wellas vaccine producers to mobilize necessary resources tosupport low income and middle income countries with theaim of increasing supply of affordable vaccines of assuredquality”.

Tunisia Syria Armenia Albania Remote LMIC Country Study In-Depth LMIC Country Study In-Depth UMIC Country Study Remote UMIC Country Study . Country&case&studies& Interviews&with&5V10&key&informants& Vaccine&adopDon&decision&making& Regulatory&system& Financial&allocaDons& External&support

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