Supporting Immunization Decision-Making in Low- and Lower-Middle-Income Countries

"[S]kills such as leadership, change management, and stakeholder engagement are crucial to sustainable decisions in a world with many competing priorities."

The International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) defines immunisation decision-making as the synthesis of clinical, epidemiological, policy, and behavioural research, data, and expert opinion to ensure effective delivery of vaccines and immunisation services to priority populations. This process typically includes considerations of disease burden, health need, and potential impact; cost-effectiveness and financing; different vaccine formulations, products, and/or dosages; how to ensure equitable access to vaccines; social, political, and ethical factors affecting vaccine promotion and uptake; the logistics of introducing new vaccines and/or scaling up vaccine delivery efforts; monitoring and evaluation (M&E) of immunisation delivery and uptake efforts; and the long-term sustainability of immunisation programmes and systems for vaccine delivery. In this context, to identify potential areas for donor and partner engagement, JHSPH/IVAC conducted an assessment of the types of initiatives funded to support immunisation decision-making efforts in low- and middle-income countries (LMICs), particularly countries ever eligible for Gavi support.

In the summer of 2019, the researchers assessed both the global landscape and specific country approaches through a literature review, conversations with key informants, where possible, and review of institutional knowledge. The results are presented as follows:

• In Table 1 of the report, each partner, donor, or initiative identified through this assessment as funding or funded to support country immunisation decision-making is classified by entity type/category (e.g., donor, multi-partner initiative, advisory group) and role in supporting decision-making (e.g., provide scientific advice, complete project work, develop policy recommendations, advocate). Examples of each category are included.
• Figure 1 presents various decision-making factors (e.g., public perceptions of the disease, public trust in health authorities).
• Table 2 maps priorities and areas of need identified through literature against known funding, partner prioritisation, and potential impact. For example, in the area of technical support, the action of implementing community-based approaches to social mobilisation, handling vaccine noncompliance, and addressing vaccine safety issues is described as a "moderate opportunity" (e.g., some existing funding, moderate impact) for funding, funder/partner priority, and potential impact (e.g., lives saved).
• Table 3 outlines characteristics of countries reporting the existence of a National Immunization Technical Advisory Group (NITAG), which is a decision-making or -supporting entity. NITAGs, by definition, are not the final decision-making body but, rather, operate as a recommending authority.

Interpreting the results, the authors assert that key components of efforts to support sustainable, cross-cutting immunisation decision-making include, but are not limited to: prioritising cross-domain engagement (e.g., scientific, economic, and implementation input); approaching decision-making as a holistic issue across immunisation (rather than focusing exclusively on one antigen); incorporating country or community partners and input; including a significant and explicit capacity strengthening component; including some type of advocacy or agenda-setting activity to help cultivate political will and a longer-term enabling environment; and assessing geographic reach.

Looking at country and regional approaches, the authors suggest that "Supporting multiple partners and in-country entities - including ministries, NITAGs and their subcommittees, and in-country scientific, economic, and programmatic actors, as well as advocates - to understand and apply evidence, evaluate options, and make informed recommendations is a critical area needing support in order to be institutionalized in many countries." There is a need to understand the drivers of country decisions in a broader context.

A few of the communication-related takeaways and recommendations:

• Immunisation decision-making initiatives benefit from a comprehensive perspective across the continuum: advocacy and agenda-setting, introduction decision-making (including scientific, economic, policy, and implementation questions), programme planning, implementation, and evaluation.
• There is a need to prioritise capacity building and identifying and addressing skills gaps. For instance: "Decision makers need to lead, influence, communicate, advocate, and understand the broader picture to consider trade-offs. They need to understand the value of quality data and how to use it; current data initiatives may not be sufficient to help strengthen this area. Future initiatives should also look for ways to engage social scientists in decision-making processes."
• Immunisation needs to be integrated with other health programmes; this requires an understanding of and engagement with multiple diverse stakeholders.
• Immunisation across the life-course needs to be prioritised, which requires, for example a shift in how we communicate the value of vaccination and implement immunisation programmes in non-traditional populations.

In conclusion: "Decision-making is context-specific and the immunization space is quite dynamic....Future initiatives should recognize this and focus on building skills and defining approaches for effective evidence-based decision-making that can be adapted and applied in multiple situations based on the varying context and priorities of the country."