What influences government adoption of vaccines in developing countries? A policy process analysis

doi:10.1016/j.socscimed.2007.05.054

Social Science & Medicine

Volume 65, Issue 8, October 2007, Pages 1751-1764

https://doi.org/10.1016/j.socscimed.2007.05.054 Get rights and content

Abstract

This paper proposes a framework for examining the process by which government consideration and adoption of new vaccines takes place, with specific reference to developing country settings. The cases of early Hepatitis B vaccine adoption in Taiwan and Thailand are used to explore the relevance of explanatory factors identified in the literature as well as the need to go beyond a variable-centric focus by highlighting the role of policy context and process in determining the pace and extent of adoption. The cases suggest the feasibility and importance of modeling ‘causal diversity’—the complex set of necessary and sufficient conditions leading to particular decisional outcomes—in a broad range of country contexts. A better understanding of the lenses through which government decision-makers filter information, and of the arenas in which critical decisions are shaped and taken, may assist both analysts (in predicting institutionalization of new vaccines) and advocates (in crafting targeted strategies to accelerate their diffusion).

Introduction

The 20th century saw tremendous advances in vaccine technology and, in the last two decades primarily, its broadened application to health problems afflicting the poor throughout the world (World Bank, 1993). The expanded program for immunization (EPI) package of vaccines alone is estimated to have saved approximately 20 million lives in the past two decades (UNICEF website, 2006). Yet the process of diffusion of these vaccines has been far from even, as countries with different priorities and access to resources adopt and sustain vaccines to different extents. Differences in mortality and morbidity rates across even similarly situated poor countries were quite pronounced by the late 1980s, due largely to the different extent to which these countries had adopted and successfully implemented the ‘basic’ EPI package of vaccines (Wang, 2002; Wilkinson, 1992).

What determines the pace at which countries move to incorporate emerging vaccines with potentially great positive health impacts into their vaccination programs? Given the dynamism characterizing vaccine development, this question is highly relevant and important. A better understanding of the lenses through which government decision-makers filter information, and of the arenas in which critical decisions are shaped and taken, may help us anticipate the diffusion of new vaccines, and help advocates craft targeted strategies to influence their adoption (Batson, 1998; Vaccine Alliance, 2006; Walt & Gilson, 1994).

This paper examines the process by which adoption of one important vaccine—that for Hepatitis B–took place in two middle-income countries, Taiwan and Thailand. These countries were in the first wave of countries to adopt the vaccine into their mass immunization schedules, several years after the vaccine became available in 1984, but before the WHO's endorsement in 1992. It asks, what were the factors that led to early adoption in these cases? Were these countries highly idiosyncratic, or were there important common factors at work? Beyond shedding light on the two cases, the purpose of this paper is to present a framework that can be used as a starting point for the more systematic modeling of the decision-making dynamics underlying vaccine adoption in developing countries. We have labeled this a ‘policy process’ approaches because of the salience of the sequencing and policy context in which critical decisions are made.

Section snippets

Government decision-points in vaccine development

The introduction and expanding use of vaccines follow a typical pattern (Vandersmissen, 2001). During a period of early demand, the vaccine is launched in the private market of industrialized countries, with low quantities and high prices. It is subsequently integrated into the public health policies of industrialized markets. As quantities grow, a multi-tiered price structure appears, with supplies to the public market at a lower price than sales to the private market. The loss of the

Hypothesized factors predicting uptake

Despite its importance, this question of how to predict vaccine uptake remains only lightly researched in the literature on the role of vaccines in the public health systems of developing countries. The focus in the literature has instead been on issues such as system capacity and sustainability (Salisbury, Beverley, & Miller, 2002), socioeconomic determinants of individual access to vaccines, vaccine cost-effectiveness (Glennerster, Kremer, & Williams, 2006; Stanton, 1994) and financing

Taiwan

Taiwan in the early 1980s was considered a high endemic country for liver cancer; nearly half of all male and one in every seven female in Taiwan were likely to develop cirrhosis or hepatoma (Republic of China (ROC) Department of Health (2004)). Studies conducted on the population in the 1960s and 1970s revealed the association between these diseases and the hepatitis B virus (HBV) infection (Huang & Lin, 2000). Evidence showed that over 9000 people annually died of hepatocellular carcinoma,

Conclusions

The case of the introduction of Hepatitis B in these two middle-income countries can be used to reflect both on the broad set of determinants of government vaccine adoption and on the methods necessary to gain a deeper understanding of the process underlying adoption. On the most basic level, we can examine the similarities and differences in the policy process by which the two countries reached the same ultimate outcome (early adoption). In each country, fixed characteristics (such as the

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