Immunisation
Readiness:
analysis of policies promoting availability,
access and administration across 30 countries

FOUNDING SPONSOR

FOUNDING SPONSORSILVER SPONSOR

Immunisation Readiness Index

3

Contents
5

About this report

7

Foreword

9

Prologue

11 Executive summary
11

The Economist Group’s Vaccine Ecosystem Initiative

11

The Immunisation Readiness Index

13

Recommendations arising from the Index

15 The Vaccine Ecosystem
16

Fostering a sustainable vaccine ecosystem

17 Understanding immunisation readiness to improve public health
19

Framework

20 Gauging performance in the Index
27

Overarching findings from the Index

29 Equity is central to a healthy vaccine ecosystem
30 Even though policies exist, their operationalisation requires improvement
31

Immunisation readiness is associated with better health outcomes

32 Using the Index to improve country readiness levels

33 Domain 1: Planning
35 Key findings
36 Examples of best practices
36 Actions to improve performance in Planning

37 Domain 2: Regulation
39 Key findings
39 Examples of best practices
40 Actions to improve performance in Regulation©Economist Impact 2023

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41 Domain 3: Procurement
43 Key findings
44 Examples of best practices
44 Actions to improve performance in Procurement

45 Domain 4: Delivery
47 Key findings
47 Examples of best practices
48 Actions to improve performance in Delivery

49 Domain 5: Outreach51

Key findings

52 Examples of best practices
52 Actions to improve performance in Outreach

53 Improving immunisation readiness: building a resilient future
53 Immunisation Readiness Index demonstrates need for improvement acrossall countries and all domains
55 A strengthened vaccine ecosystem

56 Appendices57

Appendix A: The pillars of The Vaccine Ecosystem Initiative

60 Appendix B: Methodology
68 Appendix C: The Index framework
76 Appendix D: Case studies of selected countries over-performing relative to expectations
81

Appendix E: Case studies of selected countries under-performing relative to expectations

86 References©Economist Impact 2023

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About this report

The objective of this report is to present the findings and analysis from the Immunisation ReadinessIndex. The Index examines thirty countries to evaluate their current readiness to harness the fullpotential of vaccines for all diseases that are amenable to prevention or treatment by vaccination.
By developing comparable country-level assessments, the research team identified trends andbest practices, as well as gaps in capacity, to provide insights into the prioritisation of pathways for
improvements at both national and global levels. In-depth discussions were held with experts on theAdvisory Council to supplement and validate the findings and to incorporate the latest thinking andexpertise of those working directly within this arena.
The team is truly grateful for the time, dedication and commitment of the Advisory Council throughout
this exploration of The Vaccine Ecosystem. Members of the Council are, in alphabetical order:• Thomas Cueni, Director-General, International Federation of Pharmaceutical Manufacturers andAssociations (IFPMA)• J Peter Figueroa, OJ, BSc, MBBS, DPH, PhD, FFPH, Professor of Public Health, Epidemiology and
HIV/AIDS, University of the West Indies• Margaret A Hamburg, MD, Former Commissioner, US Food and Drug Administration• Laura H Kahn, MD, MPH, MPP, Co-founder, One Health Initiative• Nigel Lightfoot, CBE, MBBS, FRCPath, MSc, FFPH, Former Director, Emergency Response andFormer Head, Influenza Planning UK Health Protection Agency• Patrick Osewe, MD, MPH, Chief, Health Sector Group, Asian Development Bank.
Thanks are also due to various stakeholders working within the vaccine ecosystem for many informal
conversations and opportunities to share ideas. Specifically, gratitude is expressed to the experts who
attended virtual roundtable discussions on the formulation of the Index, and discussions to review theoverall approach. They are, in alphabetical order:• Laetitia Bigger, PhD, Director, Vaccines Policy, International Federation of Pharmaceutical
Manufacturers and Associations (IFPMA)• J Gabrielle Breugelmans, PhD, MPH, MSc, Director of Epidemiology and Data Science,
Coalition for Epidemic Preparedness Innovations (CEPI)• Elize Massard da Fonseca, MPH, PhD, Associate Professor, Fundação Getulio Vargas; Visiting
Fellow, Latin America and Caribbean Centre, LSE• Nigel Lightfoot, CBE, MBBS, FRCPath, MSc, FFPH, Former Director, Emergency Response andFormer Head, Influenza Planning UK Health Protection Agency• Tikki Pangestu, PhD, FRCPath, Visiting Professor, Yong Loo Lin School of Medicine, National
University of Singapore; Co-chair, Asia-Pacific Immunization Coalition (APIC)©Economist Impact 2023

Immunisation Readiness Index

6• Kristine Sørensen, PhD, President, International Health Literacy Association• Charles Shey Wiysonge, MD, MPhil, PhD, Regional Advisor for Immunisation
and Team Lead for Vaccine Preventable Diseases, WHO Regional Office for Africa;
Extraordinary Professor of Global Health, Stellenbosch University;
Honorary Professor of Epidemiology and Biostatistics, University of Cape Town
We are grateful for the support from our founding sponsors who provided funding for the initiationof this project in 2020: MSD, a research-intensive biopharmaceutical company and leader invaccines, and BD (Becton, Dickinson and Company), a global medical technology company andthe world’s leading manufacturer of syringes and needles. We would also like to thank our silver
sponsor, Siemens Healthineers.
Work on the first iteration of the Immunisation Readiness Index was completed in July 2023.
The findings and views expressed in this report do not necessarily reflect the views of these sponsors,and Economist Impact retains full editorial control over it and is solely responsible for the content.
The Economist Group’s Vaccine Ecosystem Initiative was led by Dr Mary Bussell. The Immunisation
Readiness Index is an important component of the work, and was undertaken to understand, analyse
and address the development, deployment and uptake of vaccines throughout the world. Researchon the Index was coordinated and compiled by Miranda Baxa. The report was written by Michael
Guterbock, Miranda Baxa and Mary Bussell (with contributions and assistance from Dr Vivek Muthu)
and was edited by Maria Carter. Barinder Chauhan managed the project. Appreciation is given also
to Michael Paterra, Marcela Casaca, Mateus Getlinger, Alan Lovell, David Humphreys and William
Shallcross who contributed to the development of the Index.

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Foreword

After many years spent gaining experience in global health security and developing plans, policies
and strategies to protect public health, it has been an honour to be a member of The Economist
Group’s Vaccine Ecosystem Advisory Council, and a privilege to work with like-minded experts atsuch a pivotal time.
Vaccines are the cornerstone of public health measures to prevent and control infectious diseases.
They are unique in delivering health benefits to individuals, communities, populations, and society
in general, and help provide a stable platform for economic development and prosperity. Our duty,
whether we work in human or animal health, or in economic development or government, is to ensurethat the progress of an effective vaccine ecosystem continues to be stimulated.
We have witnessed the successful eradication of smallpox through ring vaccination and painstaking
detection of the final cases, and are in the final (difficult) stages of achieving the eradication of polio.
Childhood vaccination programmes continue to prevent diphtheria, whooping cough, tetanus,
measles, mumps, rubella and tuberculosis, and there have been enormous strides in the protectionof children. However, vaccination coverage against these diseases has fallen in recent years, alongwith public confidence in vaccines. There is an urgent need for routine vaccine catch-up programmes
to address an eight-fold increase in the number of children paralysed by polio in 2019–2021, and adoubling of measles cases in 2022 from the preceding year. No one will be safe until everyone is safe
because these diseases travel alongside population movements, resulting in outbreaks of disease inparts of the world that were previously disease free, such as the surge of polio in New York State anddiphtheria in the UK.
Vaccines are harboured within an extensive ecosystem that comprises many factors. The term
‘ecosystem’, borrowed from the field of ecology, implies an interconnected situation whereby many
complex factors, from the vaccine development process to vaccine delivery, are influenced by anddependent on each other. This ecosystem must be nurtured to maintain current successes and fulfil
future needs.
In addition to the scientific research required for developing vaccines, there are five domains thatprovide essential support for a successful vaccine ecosystem. These domains were closely examined in
the process of creating the Immunisation Readiness Index:(1) Planning, (2) Regulation, (3) Procurement, (4) Delivery and (5) Outreach.
Without successful implementation of the actions contained within these domains, vaccines will
not be available to populations at a local level. The Economist Impact team carefully examinedpublished reports and policies from thirty countries across a geographical and economic spectrum,
and applied a quantitative banding system to explore individual country performance in eachof the domains. The goal was to identify key areas in which improvements might be made bypolicymakers. Although the performance of individual countries was not formally ranked, theirrelative performances and trends were revealed.
New vaccine technologies, such as mRNA and adenovirus vector vaccines, were under development
as potential cancer treatments for several years before the start of the covid-19 pandemic, andtranslational research then facilitated the rapid development of specific vaccines against the infection.

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Although work on their safety and efficacy progressed swiftly, the initial global response to thepandemic is viewed as a failure because of the slow progress of programmes that promoted equity
and access to mitigation efforts – including the distribution of vaccines when they became available
for public use.
These new vaccines transformed the response to the pandemic and contributed to the saving of many
lives, but there were still concerns about equitable access to them. By December 2022, for instance,
only a quarter of populations in low-income countries had received a single dose, yet high-income
countries had nearly completed their vaccination programmes, with vaccination rates of 67%. The
pandemic highlighted the fact that high-income countries can no longer put their needs above
those of low-income countries and wait for much-needed resources to ‘trickle down’. For example,
it was encouraging to see how Africa took significant steps to develop its own vaccine ecosystemfor ensuring future preparedness. Under the Africa CDC, the Partnerships for African Vaccine
Manufacturing has been established and the World Health Organization (WHO) has created a hub formRNA vaccine technology in South Africa, called Afrigen Biologics. The future for Africa looks hopeful.
It is clearer than ever that a fully functioning vaccine ecosystem is essential for combating the effectsof communicable diseases and protecting populations all over the world. The Immunisation ReadinessIndex, and its accompanying Report, is available for use by all countries. It is not intended as anindicator of individual achievements, but as a stimulus to review country policies and plans and tolearn from other countries, because sharing information and building partnerships is always beneficial.
Furthermore, Economist Impact and its Advisory Council is available to help individual countries
commence their reviews and draw up roadmaps—because immunisations save lives.
Professor Nigel Lightfoot, CBE
Advisory Council Member©Economist Impact 2023

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Prologue

Vaccinations play a vital role in combating infectious diseases, which have plagued humanity
throughout history, as well as contending with threats posed by novel pathogens that possess
epidemic potential.
Innovations in the field of vaccinology have progressed at an exceptional pace since the genetic
sequence of the SARS-CoV-2 virus was identified in January 2020. The pandemic caused by this virus*
starkly demonstrates how close the links are between science, One Health, health protection, humancapital, economic growth and global security. Indeed, a wide range of stakeholders came together
in ways not seen previously, powerfully underlining the need to invest in and apply the best possible
science and evidence to such challenges.
Public discourse on the development of covid-19 vaccines often centres around the exceptional
pace with which they were developed. Of course, research and development (R&D) is criticalfor such progress, but it is only the first step towards ensuring that public health benefits fromvaccines globally. Lessons were learned from the pandemic response, yet much remains to beachieved to ensure that effective vaccines are not only safely and rapidly developed but also
accepted by, available and administered to populations all around the world, in a timely manner.
It is this continuum, from the science of vaccinology to achieving public health protection throughimmunisation, that we term the vaccine ecosystem.
In our intimately interconnected modern world, diseases continue to threaten global security andglobal development. The protection provided by immunisations extends beyond the health ofindividual people to the health of entire communities and humanity as a whole. Therefore, investmentin the immunisation arena is an investment in national health, national economic wellbeing andglobal health security. Far more must be done to generate political will, to ensure adequate, equitable
investment and access to vaccines, as well as build public confidence in their use. The covid-19
pandemic revealed significant inequalities in access to immunisations across high-, middle- and lowincome countries, and this situation must be addressed urgently, with greater efforts made to inspire
impactful global and national leadership capable of eliminating longstanding inequities that prevent
universal access to health and universal health protection.
As became all too clear during the covid-19 pandemic, the economic wellbeing of countries isseverely impacted by national lockdowns. The effects extend beyond national borders, influencing
international trade, travel and transport. More action must be taken to make sure health-security
experts are aligned with their counterparts in the business and finance sectors, which is necessary forsound decision-making and thus for maximising the full benefits of immunisations for populations
globally. The prioritisation of and investment in the vaccine ecosystem must be endorsed by strong
leadership across countries and in all sectors.
The overarching aims of The Vaccine Ecosystem Initiative are to engage multiple stakeholders acrossthe ecosystem to encourage meaningful dialogue, spark ideas and motivate stakeholders to form
effective collaborations. Among these stakeholders are virologists, vaccinologists and other scientists,
engineers and manufacturers, regulators, public health officials, policy experts and government* One Health is an integrated, unifying approach that works to sustainably balance and optimise the health of people, animals and theenvironment. For more information, see https://www.who.int/health-topics/one-health#tab=tab_1.

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ministers, and distribution and logistical experts. The covid-19 pandemic provided a unique
opportunity to stimulate enduring changes that can profoundly improve public health.
Since its inception, The Vaccine Ecosystem Initiative endeavoured to explore the possibilities for bothradical and incremental changes that foster improved preparedness in health systems and acrossbroader society to harness the full potential of current and future vaccines. Since 2020, there havebeen efforts to impose a meaningful structure on what is a somewhat amorphous construct, resulting
in five interdependent core ‘pillars’ of The Vaccine Ecosystem, namely:• research and development (R&D)• manufacturing• procurement, pricing and finance• distribution, logistics and supply chain management• user acceptance and uptake
The Immunisation Readiness Index then built on this work, quantitatively and qualitatively
mapping policies developed by individual countries in order to suggest opportunities for enhancing
preparedness. There is no room for complacency when it comes to vaccine-preventable disease. By
working together, we can build a more resilient vaccine ecosystem in which countries can make use ofscientific knowledge to maximise the health and wellbeing of their population, while increasing global
health security through the equitable use of vaccinations. Taken together, The Vaccine Ecosystem
Initiative and the Immunisation Readiness Index provide evidence-based, specific and actionableinsights that stakeholders can implement.

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Executive summary

The Economist Group’s Vaccine Ecosystem Initiative
This initiative was established in November 2020 to support the sustainability of this truly vital
component of public health and global health security. It has identified the components of the vaccine
ecosystem and produced evidence-based research on how to maximise the utility of vaccines andpromote equitable access to them, for people worldwide. Part of the process involved breaking down
the critical aspects of the ecosystem into more easily understood elements, using global experiencesfrom the covid-19 pandemic as entry points to wider discussions. Then, by considering all aspectsof the vaccine ecosystem, it was possible to explore the potential for both incremental and radical
changes that might improve global preparedness and responses within health systems and acrosssocieties. The Initiative’s first report, Towards a stronger Vaccine Ecosystem: Building resilience beyond
1covid-19, provided the framework for the Initiative and describes four overarching themes in which
there is room for improvement. The Vaccine Ecosystem Initiative encourages us to:• focus on political will
• enhance global leadership and collaborations across sectors, represented by the different
components of the vaccine ecosystem• foster and facilitate vibrant innovation efforts to increase system-wide preparedness• nurture trust in vaccines
The relevance of these themes is reinforced by the Immunisation Readiness Index. Creation of thisinnovative tool was driven by the urgency of the pandemic caused by SARS-CoV-2. However, theIndex is not intended to be an assessment of a country’s covid-19 response. Instead, it focuses on
system-wide readiness in more general terms, analysing the systems and policies a country has inplace for addressing public health threats that are amenable to prevention or treatment throughimmunisations, including newly emerging infectious diseases. The findings of the Index research areimportant for understanding a country’s state of readiness for dealing with such threats, and serves tohighlight disparities that must be addressed, as a matter of urgency.

The Immunisation Readiness Index
The Immunisation Readiness Index considers the enabling environment for both routine andemergency vaccination programmes across thirty countries. Not only does the Index analyse countrylevel readiness to respond to public health emergencies, but it also considers the ways in whichroutine immunisation programmes can be maintained or improved to meet global vaccination goals tocounter common infectious diseases.
The Index uses the principles and ecosystem framework established by The Vaccine Ecosystem
Initiative and translates them into a tool that is both qualitative and quantitative. Fifty indicators
across all six domains were used to explore each country’s national policies, processes and approaches
to getting vaccinations to its population. This is a stepwise process, from developing a national
immunisation plan and approving new vaccines, to ensuring vaccines can be procured, delivered and©Economist Impact 2023

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12administered to the public by qualified health professionals. The research involved close examinationof concepts relating to building public trust in vaccinations and reaching all eligible members of
the population through outreach measures, as well as the governance and societal context ofeach country. Contextualising the findings helps us understand how a country’s unique conditions
contribute to its overall readiness level. The analysis was limited to the existence of publishedpolicies –­ not their operationalisation – mapping out a broad range of countries with highly variable
governance and societal contexts.
The primary goal of the Index is to highlight where substantive and specific actions are needed
to bring about policy improvements in a particular country. The decision was made not to rank
countries formally, recognising that like-for-like comparisons between countries are not the best way
to encourage meaningful improvements. It is our hope that identifying gaps and opportunities for
improvement will help governments around the world create a future that is more resilient to threats
from existing and novel pathogens that are amenable to prevention or treatment through vaccination.
This report presents the findings relating to country-specific readiness, building on the original1
2–6
Framework Report and series of policy briefing papers to further analyse opportunities forstrengthening global health security.

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Recommendations arising from the Index
The Index is a statistically significant predictor of a country’s healthy life expectancy (HALE), which
reinforces its value for understanding how improvements in immunisation readiness can improvehealth outcomes. The degree of readiness across countries varies widely: no country performed tothe highest level for overall performance, and only three countries were in the second-highest tier. In
general, the opportunities for improvement are greater in low-income countries.
In general, countries performed well in the first two domains (Planning and Regulation), which relate
to the legal and regulatory structures underlying national immunisation plans and the policy andplanning mechanisms governing immunisation efforts. All thirty countries have national immunisation
strategies or plans for guiding vaccine programming, but they often fall short in the domains that
relate to policies guiding operationalisation of such plans. Not all countries with national plans havedeveloped steps to guide implementation, and countries tended to demonstrate lower performancein Domains 3, 4 and 5 (Procurement, Delivery and Outreach, respectively). The lowest levels of
performance were seen in Procurement and Outreach, clearly highlighting where the greatest
attention is needed.
The following themes and recommendations emerged from the analysis.
Domain 1: Planning
The Planning domain examines national immunisation plans, including mechanisms for coordination,
monitoring and evaluation to ensure sufficient vaccine doses are available to immunise the population.
While the thirty countries performed well overall, more can be done to ensure that their plans areequitable and inclusive, so that any marginalised groups are not overlooked. All the countries havenational plans or strategies for guiding vaccine programming, but some have not operationalised themsuccessfully. Such plans should extend to the support and use of robust epidemiological surveillancesystems, alongside contingencies with sufficient flexibility to allow adaptation to changing events inreal time. Some countries struggle to implement and maintain the immunisation programmes set
out in their national plans, suggesting that greater efforts are needed to ensure they are adequately
financed, monitored, tested and evaluated.
Domain 2: Regulation
The Regulation domain covers the laws that govern the licensure and manufacture of vaccines withina particular country, and the way it evaluates vaccine data and R&D and manufacturing informationfrom external agencies and sources.
Index countries demonstrated efficient and rigorous regulatory agencies with national processes forapproving vaccines for use against routine infectious diseases (as well as public health emergencies),
but making sure they remain effective requires active review and investment. Streamlining datasharing among countries can speed up the dissemination of accurate knowledge on vaccine
effectiveness and safety during the approval process. Addressing opportunities for improvement
within this domain will ensure that countries keep pace with the rollout of innovative vaccines.
Domain 3: Procurement
The Procurement domain includes indicators relating to the procurement and financing of vaccinesand vaccination programmes, including budgeting and procurement strategies.
National immunisation plans often overlook the importance of forecasting and dedicatedbudgets, even though good forecasting is a critical part of all downstream planning, budgeting andoperationalisation. Our experts believe that the use of a five-year forecast is the minimum timeframe©Economist Impact 2023

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that allows adequate planning for the protection of the public from endemic diseases and publichealth emergencies.
Domain 4: Delivery
The Delivery domain addresses the infrastructure for delivering vaccines, ranging from mechanisms
to track vaccine stockpiles through to staffing and frontline facilities for maintaining accurate
vaccination records.
Further actions are required to help countries improve their performance in this domain. Reliableinfrastructure is vitally important for improving preparedness, and includes both physical and healthrelated infrastructure that is needed to create and support a healthcare workforce of sufficient size
and ability, while also maintaining vaccine storage and transportation capabilities.
Domain 5: Outreach
The Outreach domain addresses public education and outreach, with reference to riskcommunication strategies, health literacy programmes, and surveys of public perceptions of vaccines.
Countries must prioritise investment in programmes and systems that optimise the acceptanceand uptake of vaccinations in their population, by hesitancy, mistrust and other concerns. Outreachmeasures and activities should be culturally appropriate in order to engage effectively with groupsof the population who are marginalised or have a history of poor immunisation uptake. Trusted
leadership is also essential and may rely on drawing leaders from international, national, local andcommunity settings to improve understanding and dispel myths and misinformation.
Common to all of these recommendations is the need to build stronger partnerships between a broad
range of stakeholders. Forging alliances between ministries of health and public health, finance, social
services and education, health professionals and cross-sector leaders at community, national andinternational levels, is strongly encouraged.
The Vaccine Ecosystem Initiative acknowledges that more work must be done and therefore invites
wider discussions aimed at promoting a sustainable, global vaccine ecosystem, by examining andreimagining elements critical for vaccine development, deployment and adoption. This continued work
will underpin the fundamental tenet: no one is safely protected until everyone is safely protected.

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The Vaccine Ecosystem

Every major historical event reorganises society in some way. After the Second World War, United
Nations (UN) and the World Health Organization (WHO) were established, with the goals ofmaintaining international peace and promoting health and wellbeing worldwide. Likewise, the start of
the HIV/AIDS pandemic saw the formation of UN AIDS and the Global Fund. In future years, historians
will write about the impact of the covid-19 pandemic of the 2020s and how societies around the world
weathered its effects. Our hope is that the legacy of this pandemic will be a more robust, resilient,accessible and equitable global vaccine ecosystem.
WHO declared the outbreak of covid-19 a Public Health Emergency of International Concern on
730 January 2020, and as a pandemic on 11 March 2020. Approximately three years later, on 5 May
2023, its Emergency Committee for Covid-19 advised the director general, Dr Tedros Adhanom
Ghebreyesus, that while the virus is an ongoing health issue, it no longer constitutes “a public health7
emergency of international concern”. The emergency phase is over, but the virus is here to stay.
This pandemic reinforced the vital role of public health, returning it to the centre of political andeconomic discussions, debates and deliberations, and underscoring its impact on national andglobal economic wellbeing. Public health is not solely the concern of health departments. Ministersof health across the world had to work closely with their counterparts in the ministries of finance,
trade and international affairs. They participated in nuanced discussions on the most effective ways
to protect the health of the population and to collaborate on ways to protect economic health. This
renewed focus on public health provided the foundation for assuring a more prominent role for healthpromotion in the future, with improved cross-governmental partnerships and recognition of theirimpact across the entire vaccine ecosystem.
In the early days of the covid-19 pandemic, the spread of the virus began to shatter routine life andeconomies around the world. No one knew whether it could be controlled by vaccines, but throughthe extraordinary collaborative efforts of countless specialists across diverse sectors – virology,
vaccinology, engineering, manufacturing, regulatory, logistics, transport and supply chains – wewitnessed the discovery, production, distribution and administration of safe and effective vaccines
against it. Just 320 days following publication of its genetic sequence, the first vaccine was granted
permission for emergency use in the UK. This was on 2 December 2020. The same occurred in the US
on 11 December that year, then in the European Union (EU, through the European Commission) on 21
8–10
December. The largest immunisation programme in human history was underway – less than a year
after the WHO China Country Office announced the emergence of “a pneumonia of unknown origin”
11
in the city of Wuhan. The rollout of these vaccines took place at remarkable speed. However, accessto them was – and still is – uneven around the world.
The Decade of Vaccines (2011–2020)
WHO’s Decade of Vaccines was bounded by two pandemics: the 2009 Influenza A(H1N1) pandemic was declared to be over just as the decade began, and the decade finished justas the SARS-CoV-2 pandemic was announced. WHO member states unanimously endorsed the
Global Vaccine Action Plan in May 2012, acknowledging the importance of vaccines for protecting
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public health, and calling for a world free of vaccine-preventable diseases.

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The partnerships that nurtured the production of the covid-19 vaccines require a high degree ofcooperation and considerable financial investment by governments, industry, international agencies
and foundations. But success does not come without challenges. The pandemic highlighted alack of preparedness and a need to make improvements to build a stronger, more resilient andadaptive vaccine ecosystem, one capable of being more responsive to urgent needs. Addressing
any challenges that arise can only be achieved through a combination of evidence-based insights,
cross-sector dialogue and actionable recommendations enhanced by stakeholder collaboration andcommitted leadership.
The Vaccine Ecosystem, through the Immunisation Readiness Index, took the first step in identifying
whether countries have adopted national policies and processes for getting vaccinations to their
populations. The research examines the steps of the immunisation pathway, starting with the developmentof a national immunisation plan and the approval of new vaccines, through ensuring those vaccines
can be procured, delivered and, finally, administered to the public by qualified health professionals.
Immunisations are a cost-effective way to promote national wellbeing
The protection provided by vaccines relates to more than just the health of individuals;
it encompasses entire communities. Healthy populations are economically productive
populations. The movement and interaction of people underpin the functioning of societies.
Yet both are threatened by communicable diseases. This is why immunisations are one of
the greatest public health achievements and why they must be recognised as investments inhealth and as drivers of economic growth and development. Thus investments in vaccinology
are investments in national health ­– as well as national economic wellbeing and global healthsecurity. Economic analyses demonstrate that the return on investment (ROI) for each dollar
13
invested in vaccine development over a decade yields a 16-fold return; there is a 44-fold
13
return on the costs of vaccination in terms of broader economic and societal benefits.

Fostering a sustainable vaccine ecosystem
In the wake of the covid-19 pandemic, there is a once-in-a-generation opportunity to forge long-lasting
improvements in public health. Our Initiative breaks down the critical elements of the entire vaccine
field, using covid-19 as an entry point, with the aim of promoting a sustainable and equitable vaccine
ecosystem by examining and reimagining elements that are essential for vaccine development,
deployment and adoption on a global scale.
Since its inception in 2020, the Initiative has published several evidence-based outputs. The
1
Framework Report, Towards a Stronger Vaccine Ecosystem: Building resilience beyond covid-19,
defines the components of the vaccine ecosystem. In addition, a series of policy briefing papers
2–6
examines opportunities for making improvements in each of the ecosystem’s five pillars. Now, theInitiative has developed a country-specific benchmarking tool, the Immunisation Readiness Index,
that a­ llows us to look far beyond the laboratory to understand how well particular countries aroundthe world are able to maximise the availability (and therefore utility) of vaccines for people within theirborders. This Index is the result of extensive efforts to identify the level of immunisation preparednessof individual countries, and it accompanies the foundational work of the Initiative in defining thecomponents of the vaccine ecosystem.

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Understanding immunisation
readiness to improve public health
Readiness, as conceptualised within The Vaccine Ecosystem Initiative, is a broad and complex
construct, and the Immunisation Readiness Index considers readiness for both routine and emergency
vaccination programmes. It is important to consider not only the readiness of countries to respond to
public health emergencies, such as novel disease outbreaks, but also ways to improve and maintainroutine immunisation programmes to meet global vaccination goals against a range of diseases.
Many countries have taken steps to establish policies that ensure the availability of, access to andadministration of immunisations to protect health and save lives, but these policies need to be built on
rigorous public health evidence and expertise. Further, they should be routinely evaluated to ensure
they deliver effective approaches to the challenges of both existing and novel disease threats.
The Index considers the enabling environment for equitable and sustainable immunisation across thirty
countries, selected to represent different levels of economic development and demographics (Figure 1).

Figure 1. The thirty countries analysed in the first iteration of the Immunisation Readiness Index

RUS
UK

GER POL

FRA
ESP

USA

TUR
IRN
EGY

MEX

BNG
THA VNM

NGA

JPN

PAK
IND

SEN

GTM

KOR

CHN

PHL

ETH

COL

KEN
TZA

BRA

IDN

Tier 190 points or above
Tier 2
80–89.9 points
Tier 370–79.9 points

ZAF

Tier 460–69.9 points
Tier 550–59.9 points
Tier 649.9 points or less©Economist Impact 2023

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When exploring the performance of the vaccine ecosystem in a particular country, the incidence ofdiseases that can be prevented by vaccination is a significant indicator of how well its health system
is performing (as long as its surveillance systems are comprehensive). Obtaining point-in-time dataon disease rates provides a snapshot of how their vaccine ecosystem is performing at that point, andcan be useful if the infrastructure of the vaccine ecosystem is robust. It should be noted that a country
may have a low incidence of vaccine-preventable disease, but may not be capable of successfully
addressing unforeseen pressures within its overall vaccine ecosystem.
There has been remarkable progress in the use of childhood vaccinations around the world in recent
decades, due to increased development, distribution and administration of immunisations, resulting
in fewer children not receiving a single routine vaccination (so-called ‘zero-dose’ children). However,the covid-19 pandemic set us back significantly. According to UNICEF, 67 million children did notreceive their routine immunisations between 2019 and 2021; of these, 48 million did not receive a14
14
single routine vaccination. Overall immunisation coverage rates decreased in 112 countries. In thethree-year period from 2019 through 2021, there was an eight-fold increase in the number of children
paralysed by polio compared to the previous three years. In fact, this number increased by 16%
14
between 2021 and 2022, and the number of measles cases more than doubled. Zero-dose children
tend to be found in the most marginalised communities in the remotest and poorest areas of low- andmiddle-income countries.
UNICEF data have also identified countries in which the vaccine ecosystem was unable to withstandunanticipated challenges during the pandemic, despite generally low rates of vaccine-preventable14
diseases. Only a strong vaccine ecosystem is capable of withstanding threats posed by all vaccinepreventable diseases, and more work is needed to reach this goal.
The Immunisation Readiness Index assesses the extent to which national immunisation policies areable to leverage the potential of vaccines (both now and in the future), allowing the developmentof a roadmap that promotes more effective immunisation systems. The Index does not directly
evaluate the operationalisation or implementation of national immunisation policies, but examines
them and reviews how well they respond to changes in epidemiology, disruptions in distribution andsupply chains, vaccine hesitancy in the population, and the emergence of new endemic diseases ornovel pathogens with the potential to cause epidemics. Understanding a country’s strengths andweaknesses provides valuable information on what can be done to build a stronger vaccine ecosystem,
capable of meeting today’s needs and tomorrow’s challenges.

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Framework
The Immunisation Readiness Index measures fifty indicators across six domains. Each domain
provides a broad thematic view of the policies and plans that govern a country’s preparedness toimmunise their populations against diseases that are amenable to prevention or treatment throughvaccination. Each domain is comprised of a series of sub-domains covering topics of relevance.
The major themes of each domain are described in Table 1. Figure 2 shows how these domains are
inherently interconnected.

Table 1. The six domains of the Immunisation Readiness Index
DomainKey themes

1. Planning

National immunisation plans; mechanisms for coordination, monitoring and evaluationthat support and enable adequate availability of vaccines to immunise the population

2. Regulation

The laws governing licensure and manufacture of vaccines within a country;
how the country evaluates vaccine data, R&D and manufacturing informationfrom outside agencies and foreign sources

3. Procurement

The procurement and financing of vaccines, including budgetingand procurement strategies

4. Delivery

The physical and public health infrastructures for delivering vaccinations,from mechanisms for tracking vaccine stockpiles through staffing and frontline
facilities to the maintenance of accurate vaccination records

5. Outreach

Public education and outreach, including risk-communication strategies,
health literacy programmes and surveys of public perceptions of vaccines

6. Society

Quality governance and favourable socioeconomic conditions as the basisof a strong health system for supporting immunisation over the life course

For a complete list of the indicators within each domain, see Appendix C.

Figure 2. The interconnectedness of the domains established
for analysis in the Immunisation Readiness Index

Domain 1

Domain 2

Domain 3

Domain 4

Planning

Regulation

Procurement

Delivery

Domain 5

Outreach
Domain 6

Society©Economist Impact 2023

Immunisation Readiness Index

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The indicators in Domains 1–4 relate to the policies and processes involved in the development ofa national approach to getting vaccinations to a country’s population. These four domains reflecta sequence, from developing an immunisation plan (or strategy) and approving new vaccines, toensuring they can be delivered within the correct temperature-controlled environment and thenadministered to the population by qualified health professionals. Domain 5 relates to building publictrust in vaccines and reaching all members of the population through outreach.
Domain 6 represents the governance and societal context, providing context to a country’s overallfindings, but the indicators do not necessarily reflect a country’s level of readiness. Rather, theinformation included in Domain 6 provides context, revealing the unique conditions within a country
and how they contribute to the overall situation, thus providing a more nuanced understanding of theindicators in Domains 1–5. The findings from this domain provide insights into the other five domains,
but were not analysed separately.
The first five domains are examined individually later in this report to highlight specific recommended
actions that individual countries can take to strengthen their national vaccination programmes andimprove their level of readiness.

Gauging performance in the Index
Performance bands
The thirty Index countries are at varying stages of development and immunisation readiness. A
key goal of this research was to identify where improvements might be made by policymakers. To
focus attention on the substance of the Index and on constructive actions, the Immunisation
Readiness Index team chose not to formally rank countries. Instead, countries are collated into
categories, or performance bands, based on their relative performance. A quantitative banding
system was used to assess country performance based on a 100-point scale for each domain,
where higher numerical scores indicate better performance and, therefore, better immunisation
readiness. Then, countries were collated into six bands, ranging from ‘least ready’ (Tier 6) to ‘mostready’ (Tier 1) as shown in Figure 3.

Figure 3. Performance bands for the countries in the Immunisation Readiness Index
Tier 190 points or above
Tier 2

80–89.9 points
Tier 370–79.9 points
Tier 460–69.9 points
Tier 550–59.9 points
Tier 649.9 points or below©Economist Impact 2023

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Assessing system-wide readiness for all immunisations—not just covid-19 vaccines
The covid-19 pandemic had an enormous impact on the global immunisation landscape, and the
response to it demonstrated the important challenges faced by the global vaccine ecosystem,
which aims to ensure universal protection against current and future diseases that are amenable toprevention or treatment through vaccination. During work on the Index, the research team sought todifferentiate between actual performance (i.e. effectiveness or ineffectiveness) of the covid-19 vaccine
rollout and the scoring for some indicators in the Index.
This report also discusses insights into individual countries’ immunisation readiness and covid-19
vaccination coverage during 2022 because of the unique impact of the pandemic on global healthsecurity and how it underscores the need to improve all aspects of the vaccine ecosystem.
It is important to note that the Index is not a measure of the effectiveness of individual covid-19
vaccination programmes, but rather, relates to the policies that support systems addressing all
vaccine-preventable public health threats. For instance, a country that performed well when rollingout covid-19 vaccines, and achieved excellent results, might not have systems for addressing otherongoing or future threats. Conversely, a country with lower rates of covid-19 vaccination coverage(perhaps because of vaccine hesitancy or vaccine unavailability) may have more robust systems forlicensing, purchasing and delivering vaccinations. The key message is that the Index should not be
regarded as a measure of performance of covid-19 vaccination programmes, but of the state of acountry’s system-level capacity to deal with novel and existing vaccine-preventable diseases.
It is our intention that the Index will be used as a tool to understand the extent to which national
immunisation policies, systems and practices are able to leverage the potential of vaccines to prevent
and/or treat diseases now and in the future. As such, any measure of immunisation readiness must
consider the particular challenges that countries faced in responding to the covid-19 pandemic. Thus,
great care has been taken to account for covid-specific actions in the following contexts:• We studied how each country implemented long-lasting policies or practices because of, or during,the covid-19 pandemic. Points were allotted to countries for indicators where there was evidence
that the policy or practice would continue beyond the pandemic.
• We considered policies or practices that were implemented only in direct response to the covid-19
pandemic but without evidence of consideration of future vaccination needs. For indicators where
there was insufficient evidence that the policy or practice would continue, or could be harnessedin the future, countries were not given points. We recognise that some countries demonstrated
an ability to mobilise resources to respond to covid-19 without having pre-existing mechanisms inplace. For this reason, information about covid-specific policies and practices has been included in
our Data Dashboard.

Example: scoring policies related to covid-19
Emergency financing mechanism in IranWe determined whether countries have a dedicated emergency financing mechanism
or fund that can be accessed when faced with a public health emergency to procure vaccines(Indicator 3.2.2). Iran, for example, was able to allocate funds to purchase covid-19 vaccines,
but there was insufficient evidence of a dedicated funding mechanism that could be used topurchase vaccines in future emergencies. Thus, Iran was given 0 out of 100 for this indicator.
More information about the funding used for Iran’s covid-19 vaccine procurement is available
in the Notes for Iran for Indicator 3.2.2 in the Data Dashboard.

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Highlighting the need to address routine vaccine-preventable diseases
The Index considers the enabling environment for both routine and emergency vaccination
programmes. It is important to consider not only readiness to respond to a new public health threat
but also ways to improve and maintain routine immunisation programmes to combat routine and/or
endemic diseases. This is why the Index includes indicators related to policy levers and similar inputs
associated with the success of both routine and emergency immunisation efforts; it does not measure
outputs or outcomes like vaccination rates.
Although immunisation programmes have successfully reduced the spread and severity of vaccine15
preventable diseases, saving millions of lives every year, there have been variations in routine
vaccination coverage rates over the past 40 years for childhood diseases such as diphtheria, tetanus
16
and pertussis (DTP; Figure 4) and measles (MCV; Figure 5). Progress towards immunisation targets
16
has not been consistent or linear either at country or global levels. Furthermore, UNICEF estimatesthat more than 67 million children worldwide missed one or more of their routine vaccinations due to14
disruption caused by the covid-19 pandemic.
In combination, these trends (i.e., inconsistent progress in vaccination rates between 1980 and 2019and decreased vaccination coverage in 2020–2021 due to covid-19) make comparative analysis
between the Immunisation Readiness Index and immunisation rates for the countries we have studiedcomplicated and potentially unfair, as detailed below. However, vaccination rates are a criticaloutcome measure for understanding progress towards immunisation goals. To demonstrate theefforts countries have made in this regard, we include coverage rates by country for many of theroutine vaccines in our interactive Data Dashboard, subject to the availability of data frominternational vaccination databases (e.g., WHO, UNICEF).

Figure 4. Global coverage for vaccines against diphtheria, tetanus and16
pertussis (third dose) (DTP3) among 1-year-olds, 1980-2021

80%

Vaccination rate

60%

40%

20%

0%
1980

1985

1990

1995

2000

2005

2010

2015

2021

Source: WHO; UNICEF (2022)©Economist Impact 2023

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Figure 5. Global coverage for vaccines against measles (second dose)
6(MCV2) among children, 2000-2021
70%
60%

Vaccination rate

50%
40%
30%
20%
10%
0%
2000

2005

2010

2015

2021

Source: WHO; UNICEF (2022)

Comparing routine vaccination rates with the Immunisation Readiness Index
A critical step in the creation of any new index tool like the Immunisation Readiness Index is an analysis
of its ‘convergent’ and ‘divergent’ validity. Such analysis validates any of the tool’s findings (inputs) bycomparing with the associated outcomes (outputs). Because this Index measures inputs related toimmunisation, the logical outcome measures are immunisation rates. However, as mentioned previously,
trends in vaccination coverage mean it is challenging to make such comparisons. More information about
the trends and the potential pitfalls of comparative analysis are given below.
Decline in vaccinations for childhood illnesses due to disruptions caused by the covid-19 pandemic
The pandemic led to an alarming decline in the number of children receiving routine immunisations,14
whereby over 67 million children did not receive them between 2019 and 2021. As a result, global
16
vaccination rates for DTP3 and MCV2 vaccines decreased by 5% between 2019 and 2021. The
most recent data on routine vaccination rates for 2021 do not precisely describe the uptake of
immunisations for these diseases in the Index countries; rather, they relate generally to the impact ofcovid-19 disruptions on routine vaccinations. The lack of specificity in these data means we cannot use
the information for comparative analysis.
While these data were insufficient to confirm convergent validity of the Index, our research found thatdata from the year before the covid-19 pandemic began (i.e., 2018–2019) could be used to establish
the relationship between the Index and related immunisation outcomes. Therefore, to demonstrateefforts countries have made in this area, reported vaccination rates for 2018-2019, subject toavailability, are included in our interactive Data Dashboard for many of the routine immunisations
mentioned in our Index.

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Figure 6. Coverage for vaccines against diphtheria, tetanus and pertussis (DTP3) (third dose)16
among 1-year-olds in 1980-2019 in the 30 countries of the Immunisation Readiness Index
The data included in this figure are intended to illustrate the high level of variation in vaccination
rates across all 30 Index countries for the time period shown. For more information about changes invaccination coverage for individual Index countries, see ourworldindata.org
100%

80%

Vaccination rate

60%

40%

20%

0%
1980

1985

1990

1995

2000

2005

2010

2015

2019

Source: WHO; UNICEF (2022)

Inconsistent progress in vaccination coverage within individual countries between 1980 and 2019
While there has been a general upward trend in vaccination coverage over the past 40 years, there has
been notable variation in routine immunisation coverage rates for childhood vaccines, such as DTP
16
and MCV (see Figures 6 and 7). Most of the countries in the Index struggle to make steady, consistent
progress towards immunisation goals and experienced fluctuations in coverage during that time (i.e.,the 40-year period). The non-linear nature of routine vaccination coverage is not specific to a particularregion or income group, but is part of the global trend in vaccination coverage (although there aresome exceptions). Table 2 shows inconsistencies in vaccination coverage for the DTP3 vaccine between
1980 and 2019 (before the covid-19 pandemic) for the highest-performing country in each of thegeographical regions represented in the Index. The information in Table 2 describes a subset of datafrom Figures 6 and 7 to highlight the non-linear nature of vaccination coverage over this time.

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Immunisation Readiness Index

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Table 2. Variations in vaccination coverage rates for diphtheria, tetanus and pertussis (DTP3), 1980–2019(before the start of the covid-19 pandemic) for the highest-performing country in each region studied in the
16
Immunisation Readiness Index
GeographicalregionCountry

Changes in DTP3 vaccination coverage

Americas

USA

In 1980, the reported vaccination rate was 96%, with little change in coverage until
1988. Rates then began declining, reaching 83% in 1992, before increasing to 88%
and 94% in 1993 and 1994, respectively, then plateauing. Between 1994 and 2019,
there was little variation; rates fluctuated between 94% and 96%. In 2019, the USA
reported 94% coverage.

East Asia andPacific

Indonesia

In the period 1980–1982, the reported vaccination rate was 1%, which increased to
47% by 1986. It continued increasing, slowly, until 2001, when it reached 76%. It fell
to 70% in 2002, before rising to an all-time high of 92% in 2013. Rates decreased in2014 (88%) and 2015 (84%), and coverage from 2015 to 2019 fluctuated between
84% and 85%.

Europe andCentral Asia

FranceIn the period 1980–1982, the reported vaccination rate was 79%, which increased
to 96% by 1986. In 1987, the rate decreased to 88%. In 1988, it was 79%. The raterecovered in 1989, increasing to 95% before plateauing. Between 1989 and 2019, itvaried between 94% and 99%, and in 2019 was reported to be 96%.

Middle East andNorth Africa

Iran

In 1980, the reported vaccination rate was 32%, which dropped to 29% in 1981. It
rose to 41% in 1982, but went down to 33% in 1983, which was sustained during
1984. The rate increased sharply between 1984 and 1986, resulting in 57% coverage,
which was sustained in 1987. It rose again to 88% in 1988, but between 1988 and1993 the rate was irregular: 82% in 1989, 91% in 1990 and 88% in 1991, before rising
to 97% in 1992. Coverage was at an all-time high in 1993 (99%), and has remained
relatively consistent ever since, between 98% and 99%, although decreases
occurred in 1994 (95%), 2001 (96%) and 2005 (95%). In 2019, coverage was reported
to be 99%.

South Asia

Bangladesh

The reported vaccination rate was 1% until 1984, when it began to rise exponentially,reaching 74% in 1991. It decreased to 66% in 1992 before increasing in 1993 to 74%
and reaching 84% in 1994. In 1995, it dropped to 69% and partially recovered in 1996(77%). It remained relatively steady until 1998, then increased to 85% in 2001. A
small drop followed in 2002, to 83%, and it reached an all-time high of 99% in 2004.
The rate went down again in 2005 (93%) but rose to 97% in 2009. Between 2009
and 2019, it fluctuated between 94% and 98%, and in 2019 was reported to be 98%.

Sub-SaharanAfricaEthiopia

The reported vaccination rate in 1980 was 3%. This increased to 49% by 1990, butsuddenly dropped to 21% in 1991, and yet further in 1992 to 13%. Between 1992 and1995, it rose to 57%, with another decrease to 28% in 1999. A steady increase from1999 saw a rate of 68% in 2011. It varied between 2011 and 2019 and was reported to
be 68% in 2019.

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Figure 7. Coverage for vaccines against measles (MCV2) (second dose) among children,16
2000-2021 in the 30 countries of the Immunisation Readiness Index
The data included in this figure are intended to illustrate the high level of variation in vaccination
rates across all 30 Index countries for the time period shown. For more information about changes invaccination coverage for individual Index countries, see ourworldindata.org
100%

80%

Vaccination rate

60%

40%

20%

0%
2000

2005

2010

2015

2021

Source: WHO; UNICEF (2022)

There has been great variation in vaccination coverage rates within individual countries over the last 40 years,
which means that no single year between 1980 and 2019 accurately reflects the progress made towards
immunisation goals for all countries simultaneously. Point-in-time comparisons tend to favour countries withlongstanding vaccination programmes (typically, higher-income countries) and fail to acknowledge theconsiderable progress made by lower-income countries over a shorter time frame. Thus, vaccination rates
for specific years up to 2019 were not appropriate for making direct comparisons.
Inconsistent progress in vaccination coverage between countries between 1980 and 2019
Figures 6 and 7 illustrate that higher-income countries tended to have higher vaccination rates at thestart of this period, in the 1980s, with smaller improvements over time compared to low- and lowermiddle-income countries, primarily due to the inequities in access to vaccines and other necessary
supplies in the 1980s and 1990s. For example, in France and the USA, the coverage rates for DTP3
vaccinations began to plateau in 1989 and 1994, respectively, which is in contrast to Bangladesh andEthiopia, where vaccination rates began to plateau about 20 years later, in 2009 and 2011, respectively.
As such, the rate of change in vaccination coverage, which generally demonstrates progress over time,
is much lower in higher-income countries than those with lower incomes. A direct comparison of
immunisation readiness and change in vaccination rates over time (i.e. any period of years between 1980
and 2019) would not fairly characterise progress towards immunisation goals for all Index countries.
More specifically, this method would not properly credit higher-income countries with long-establishedvaccination programmes for introducing new immunisation strategies or novel policies that contributeto the equitability or sustainability of immunisation programmes after vaccination rates plateau.
Consequently, the rate of change in vaccination coverage does not sufficiently describe progress towards
immunisation goals for the Index countries, and was not used for making comparative analyses.
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Overarching findings from the Index
Readiness varies widely among countries
Overall, the countries in the Index still need to improve their capacity to harness the power of vaccines
to prevent the spread of diseases and achieve immunisation goals. As can be seen in Figure 8, mostcountries fall into Tier 4, with Tier 5 close behind. No country achieved Tier 1 status. Clearly, every
country would benefit from making improvements.

Figure 8. Country performance in the Immunisation Readiness Index
Improving readiness

Tier 6Tier 5Tier 4Tier 3Tier 2

GuatemalaNigeria
Pakistan
Senegal

Egypt
Guatemala
India
Kenya
Philippines
South Africa
Tanzania
ThailandBangladesh
BrazilChina
Ethiopia
Iran
Japan
RussiaSpain
Vietnam

Colombia
Indonesia
MexicoPolandSouth Korea
TurkeyUSA

FranceGermany
UK

Tier 1

Disparities exist between Index performance and real-world performance
While our work examines the vaccine ecosystem and state of immunisation readiness beyond theimpact of covid-19, the pandemic has provided an extremely valuable gauge for assessing countries’
responses to acute health threats. Progress continues towards delivering global vaccinations against
covid-19, yet there continue to be disparities in vaccine availability, access and uptake. In our report,
1
Towards a Stronger Vaccine Ecosystem: Building resilience beyond covid-19, we present the frameworkfor our work, noting that while the global community has made progress since the emergence of
SARS-CoV-2, a significant amount of work needed to be done to adequately and equitably confront
the pandemic, and that work continues.
Disparities exist between the Index and real-world performance against covid-19
Since the battle against covid-19 began, there has been no room for complacency. The inequality inglobal access to immunisations became glaringly obvious throughout the pandemic, and this had
to be urgently addressed, involving even greater efforts to inspire impactful global and national
leadership that was capable of eliminating the longstanding inequities that prevent universal accessand health protection.
Useful insights can be gleaned by comparing the situation within individual Index countries with theirreal-world response to covid-19. For example, covid-19 vaccination coverage in the African nations
was disproportionately low (in terms of the number of doses delivered and the number of people
who were fully vaccinated) compared with their performance in the Index. Discrepancies like thisare troubling but consistent with reports on the limitations of the Covid-19 Vaccines Global Access(COVAX) facility.

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COVAX was initiated by several parties: Gavi, the Vaccine Alliance, the Coalition for Epidemic
17
Preparedness Innovations (CEPI) and WHO with UNICEF as a delivery partner. COVAX is aworldwide initiative that aims to ensure equitable access to covid-19 vaccines to all populations.
Initially it allocated around US$7 billion for market preparation and manufacturing. The potential
benefits of COVAX investment, in minimising risks for vaccine manufacturers and to help improve thevaccine access rate, was discussed in Towards a Stronger Vaccine Ecosystem: Building resilience beyond
1covid-19 . Overall, covid vaccination coverage was poor – not because of a lack of good purchasingsystems or a lack of funds, but because of a lack of vaccine Stock. In many cases, vaccines werepurchased in bulk in the early stages of the pandemic by higher-income countries.
So-called vaccine hoarding and vaccine nationalism contributed to serious inequities in the
distribution of covid-19 vaccines and led to low levels of participation in COVAX by high- and uppermiddle-income countries. In some cases, higher-income countries chose not to join COVAX, andinstead chose to purchase stocks directly from the manufacturers.
The data in Figure 9 illustrate how access to covid-19 vaccines in lower-income countries consistently
18
lagged behind the rest of the world. By December 2021, a year after the UK and US initiated theirvaccination programmes, 5.3% of people in lower-income countries had received just one dose of acovid-19 vaccine, compared with 53.9% of people globally. In higher-income countries, this figure was
72.9%. A year later, in December 2022, around a quarter of people in lower-income countries had received
18
a single dose – but this level was reached by the rest of the world in the middle of 2021 (Figure 9).
7

On 5 May 2023, WHO declared an end to the covid-19 emergency. Vaccination rates in lower-income
countries continued to lag behind those with higher incomes, a situation that highlights the continuingunequal distribution of vaccines. This situation is a risk for worldwide immunisation readiness in the faceof a pathogen that constantly mutates as it spreads. No country can be adequately protected against
viruses such as SARS-CoV-2 until every country is adequately protected.
The data in Figure 9 show the progress in covid-19 vaccination rates from 1 March 2021 to the last dayof the global covid-19 public health emergency (4 May 2023). However, covid-19 vaccination rates fromMay 2023 are given in the Data Dashboard.
18

Figure 9. Global coverage of covid-19 vaccines 2021–2023
Proportion of global population receiving
covid-19 vaccines (dosed once)

Proportion of population receiving one dose ofcovid-19 vaccine (high-income countries )Proportion of global population receiving
covid-19 vaccines (completely vaccinated )Proportion of population receiving one dose ofcovid-19 vaccine (low-income countries )

80%
70%

Vaccination rate

60%
50%
40%
30%
20%
10%
0
1 Mar
2021

1 Jun
2021

1 Sep
2021

1 Dec
2021

1 Mar
2022

1 Jun
2022

1 Sep
2022

1 Dec
2022

1 Mar
2023

4 May
2023

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Equity is central to a healthy vaccine ecosystem
The overriding principles of public health are sometimes referred to as the ‘3 Ps’, which are healthpromotion, health protection and prevention of ill health. Ensuring equitable access to vaccinesand related supplies is paramount to achieving each of these principles. WHO’s 2030 Immunization
Agenda aims to “to extend the benefits of vaccines to everyone, everywhere” and includes vaccine
19
equity as one of its strategic priorities. Four equity indicators were therefore highlighted to help
countries benchmark their progress towards achieving equitable immunisation for all (Table 3).

Table 3. Indicators of ‘equity’ included in the Immunisation Readiness Index
Indicator

Description

1.1.1eNational immunisation strategy/plan: vaccine equity

4.1.1b

Non-traditional delivery strategies

4.3.2

Culturally appropriate distribution practices

5.2.2

Communication strategies to overcome barriers to vaccination

The Index underscores the centrality of equity and its importance within the vaccine ecosystem,
whereby the top ten performing countries demonstrate a greater dedication to equity in theirvaccination programmes than the bottom ten (Figure 10). Of the thirty countries included in thisanalysis, only South Korea does not prioritise equity in policy and activities, as described by one ormore of our equity indicators.

Figure 10. Cluster analysis of four indicators relating to vaccine equity among the top andbottom ten performing countries in the Immunisation Readiness Index
Equity indicators: top 10 performing countries
1.1.1e National immunisation strategy: vaccine equity

4.1.1b Non-traditional vaccine delivery strategies

4.3.2 Culturally appropriate distribution practices

5.2.2 Communication strategies to overcome barriers to vaccination

For more detailed information about these and other indicators, please see Appendix C.

Indicator performance

100

80

60

40

20

0

FranceGermany

UK

USA

Indonesia

PolandColombia

TurkeyMexicoSouth Korea

Country©Economist Impact 2023

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Equity indicators: bottom 10 performing countries
1.1.1e4.1.1b

4.3.2

5.2.2

Indicator performance

100

80

60

40

20

0

Thailand

Kenya

Egypt

South Africa

India

Tanzania Guatemala Pakistan

Nigeria

SengalCountry

Even though policies exist, their operationalisation requires improvement
Overall, countries performed well in the first two domains, which cover the legal and regulatory
structures underlying national immunisation plans (Figure 11). Together, Domains 1 and 2 outline thepolicy and planning mechanisms that govern immunisation efforts. All Index countries have a national
immunisation strategy/plan for guiding vaccine programming. Domain 1 (Planning) has the highest
average performance (75.9 on a 100-point scale), and Domain 2 (Regulation) is close behind (75.4). The
Index shows that, in general, the countries fall short in domains relating to the policies guiding
operationalisation of immunisation plans. While the countries may have national immunisation plans inplace, some have not developed steps for guiding the implementation of such plans, thus performance
was generally lower for Domain 3 (49.4), Domain 4 (64.0) and Domain 5 (47.5). Domains related to
Procurement (Domain 3) and Outreach (Domain 5) show the lowest levels of country performance,
indicating that these aspects of immunisation readiness are in need of the greatest attention overall.

Figure 11. Overall readiness of countries in the Immunisation Readiness Index, showing average
performance within analysed domains
100
90

Average performance

80
70

75.9

75.4

60

64.0

50

49.4

40

47.5

30
20
10
0

Planning(Domain 1)

Regulation(Domain 2)

Procurement(Domain 3)

Delivery(Domain 4)

Outreach(Domain 5)©Economist Impact 2023

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Immunisation readiness is associated with better health outcomes
Vaccinations can improve health outcomes by protecting against serious and life-threatening diseases
and reducing disease severity for infected people. Overall immunisation readiness performance, as20
calculated in this research, was positively associated (r = 0.75) with healthy life expectancy (HALE).
Countries with greater immunisation readiness tend to have a greater HALE (Figure 12), as evaluatedby simple regression analysis.
To better understand the relationship between HALE and immunisation readiness performance,
multiple linear regression analysis was used to determine whether readiness, along with income (GDPper capita) and hygiene levels (access to drinking water and sanitation), were significant predictors of2
HALE. The fitted regression model was statistically significant (R = 0.85, F[4,25] = 16.6; p = <0.000).
Furthermore, the analysis indicated that immunisation readiness is a statistically significant, independent
predictor of HALE (β = 0.16; p = 0.026). GDP per capita, access to drinking water and access to sanitation
do not confound the relationship between HALE and immunisation readiness performance (Table 4).
Taken in combination, these findings demonstrate the value of the Immunisation Readiness Index topredict differences in HALE for specific Index countries.

Table 4. Results of multivariate analysis estimating the relationship between Immunisation
Readiness performance and potential confounders
value

p

Access to drinking water-0.0259

0.8326

Access to sanitation

0.10930.1397GDP per capita

0.00000.3017

Immunisation readiness0.16190.0210©Economist Impact 2023

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HALE

Figure 12. Healthy life expectancy (HALE) of the populations of the thirty Index countries vstheir overall immunisation readiness performance20

Immunisation Readiness performance

Using the Index to improve country readiness levels
Overall immunisation readiness varied widely among the Index countries. Some countries have low
rates of diseases that can be prevented by immunisations, however their vaccine ecosystems cannot
withstand unanticipated health pressures; this was evidenced by the increase in the number ofchildren worldwide who missed their routine immunisations due to the covid-19 pandemic, which can
result in an increased incidence of the diseases that vaccinations would have prevented.
The Index was specifically designed to examine the inputs (policies) to determine how well a country
is able to respond to changes in epidemiology or disruptions in distribution and supply chains,
vaccine hesitancy and the emergence of epidemics of endemic diseases (and novel pathogens withthe potential for causing epidemics). Looking at disease rates at any point in time gives a snapshotof how the vaccine ecosystem is performing, which can be useful if the infrastructure of the vaccine
ecosystem is known to be robust. A strong vaccine ecosystem should be able to withstand the threats
posed by vaccine-preventable diseases, but our understanding of the vaccine ecosystem indicates that
this point has not been achieved – yet.
Attention must be paid to the disparities between countries in terms of domains and Index
performance and real-world performance. The Index assesses a country’s ability to respond to
threats that are amenable to vaccination, and these findings can aid understanding of how individual
countries can improve immunisation readiness.
One goal of this research was to identify substantive actions that policymakers can undertake to make
improvements. The assessment of overall performance of countries across all domains revealed thatno country performed at the highest level and only three achieved the second-highest tier. In addition,
opportunities for improvement were the greatest in low-income countries.
The following chapters examine the findings relating to each domain, providing insights into whichcountry policies worked well and suggesting opportunities for improvement.

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Domain 1: Planning

The Planning domain examines national immunisation plans—including mechanisms for coordination,
monitoring and evaluation­—to support and facilitate adequate availability of vaccines to immunise
the population. Because diseases do not recognise national borders, a concerted national and global
effort is necessary for ensuring control of communicable diseases. Such planning requires years ofwork and foresight from national governments, in collaboration with partners, to build resilient androbust vaccination strategies. Partners might include global organisations and non-governmentalorganisations, such as WHO, and industry.
The Immunisation Readiness Index includes fourteen indicators for analysing the current ability of
the Index countries to implement sufficient planning and coordination (Table 5). All indicators were
weighted equally. The review of planning revolved around the extent to which a country has a national
immunisation strategy or plan and whether it has explicitly defined targets for vaccination coverage.
The Index measures whether there is an established national taskforce with dedicated budgets forfunding the implementation of the plan to meet defined goals. The Index also measures the extent towhich a given country has active monitoring and evaluation policies and procedures for measuring thelevel of disease surveillance and identifying adverse vaccination events. The Index only notes whether
these strategies or plans were in place; it did not measure the impact or outcomes of the policies,
highlighting the need for further research.

“Plans are essential but we must
remember that they are living
documents … they need to be tested
often, looking at small manageable
sections. From these exercises,
lessons need to be learned andincorporated into an updated plan.
Then you can be sure that they will
always work when you need them.”
Nigel Lightfoot, CBE
Advisory Council Member©Economist Impact 2023

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Table 5. Indicators in Domain 1: Planning of the Immunisation Readiness Index
Sub-domain

Indicator

Strategy andplanning

1.1.1aExistence of a national immunisation strategy/plan

1.1.1bNational immunisation strategy: vaccine coverage targets

1.1.1cNational immunisation strategy: evidence-based rollout strategy

1.1.1dNational immunisation strategy: inclusiveness1.1.1eNational immunisation strategy: vaccine equity

1.1.1fNational immunisation strategy: dedicated budget

1.1.1gNational immunisation strategy: contingency plans

1.2.1

National task force

1.2.2

National immunisation technical advisory group (NITAG)

1.2.3

Health sector coordination

1.3.1

Surveillance of vaccine-preventable diseases

1.3.2

Health management committee

1.3.3

Pharmacovigilance

1.3.4

Commitment to surveillance data-sharing

Coordination andengagement

Monitoring andevaluation

Overall, countries performed better in Domain 1 than in the other domains. More countries (ten out ofthirty; 33%) achieved Tier 2 performance in this domain than in any other domain. For Domain 1, theminimum level of performance was 37.3 (out of 100) and the maximum was 97.6, with an average of
75.9. In general, the best-performing countries share similar features, such as having comprehensive
national immunisation strategies/plans, long-term mechanisms for disease surveillance, and wellestablished monitoring and evaluation processes.

Figure 13. Country performance in Domain 1: Planning
Improving readiness

Tier 6Tier 5Tier 4Tier 3Tier 2Tier 1

Senegal

Egypt
GuatemalaSouth Africa

BrazilIran
Japan
PakistanSouth Korea
Spain
ThailandNigeria
Tanzania
TurkeyVietnamBangladesh
China
FranceGermany
Indonesia
Kenya
Philippines
PolandRussiaUSA

Colombia
Ethiopia
India
MexicoUK©Economist Impact 2023

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Key findings
Having a national immunisation plan shows a country recognises the importance of vaccinations—but the plan must have a dedicated budget
The highest-performing indicator in the planning and coordination domain (all-country average100) looked at the existence of a national vaccine strategy or plan. All of the Index countries havenational vaccine plans or strategies to guide their approaches to immunisation readiness, and thebest-performing countries in this domain have comprehensive national immunisation plans in place,indicating that their governments recognise the importance of planning and have taken steps toorganise national approaches.
Many countries design plans with the entire population of their country in mind, recognising that their
populations are heterogeneous in terms of ethnicity, language and religion, among other factors.
Their strategies often contain specific ways to promote equity so that immunisations reach everyone.
The routine and emergency vaccination plans require specific planning and coordination thatcountries must budget appropriately. Indeed, the most effective plans include a budget for routine
21,22
vaccinations, which is distinct from plans for public health emergencies such as epidemics.
Planning for contingencies promotes responsivenessThe indicator yielding the poorest country performance in Domain 1 considers contingency plansfor public health emergencies. The average country score was 43.3. To improve, countries must havecontingency plans that provide guidance and insights enabling them to adapt to changing events
22in real time. Better-performing countries are better able to anticipate and address problems; forexample, Ethiopia’s National Expanded Programme on Immunisation has contingency plans for publichealth emergencies that aim to effectively integrate immunisation programmes into humanitarian
emergency responses as part of its efforts to “to save lives and reduce morbidity, disability and23
mortality due to vaccine-preventable diseases”.
Supplementary immunisation initiatives are critical parts of contingency plans. They involve pooling23
resources and capacities, and have been used for outbreaks of polio and measles in several regions.
Robust epidemiological surveillance systems improve readinessCountries that perform better in Domain 1 have mechanisms in place for robust disease surveillancesystems covering the entire country, and including multiple sources of data collection. Suchmechanisms were associated with Tier 1 performance (as opposed to Tier 2). For a country to movefrom Tier 6 to Tier 1, it must develop disease surveillance systems that incorporate all regions, subregions and municipalities in the country and collect data from all jurisdictions. Only one Index
country did not have a surveillance system in place for monitoring the occurrence of vaccinepreventable disease. Improvement in surveillance systems includes having the ability to detect the
emergence of new pathogens; currently, seventeen of the thirty countries (57%) conduct this type ofhorizon scanning.
Constant and consistent monitoring and evaluation of surveillance systems improves flexibility,
thus allowing adaptation to emerging information. Countries performing well in this domain
have established national and sub-national mechanisms for planning, evaluating, adjusting andimplementing strategies to strengthen the breadth and accessibility of their vaccination plans. They
also revise their immunisation programmes according to surveillance data. Separate surveillancesystems that track adverse events related to immunisations (similar to the Vaccine Adverse Events
24
Reporting System in the US) also improve overall performance.

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Examples of best practices
The research uncovered many examples of best practices that lead to good performance; thefollowing initiatives encompass unique and innovative approaches for addressing the issues
within Domain 1 and can be adapted for use by other countries to improve their performancein this domain.
PAKISTAN—Mobile services
The National Expanded Program on Immunisation and Strategic Guidelines (revised 2015)
places an emphasis on socially disadvantaged and marginalised communities. Its measures
25
include mobile vaccination services for reaching underserved and vulnerable populations.
UK—Equity impact assessments
A key theme of the National Immunisation Programme is equity, with objectives such as
helping to ‘reduce health inequalities’. It mandates Health Equity Impact Assessments ofimmunisation programmes, relating to equality characteristics, socioeconomic factors andlocal vulnerable populations, and these were used to make recommendations for programme
26
improvement.

Actions to improve performance in PlanningThis domain covers the breadth of work that should be included in effective national immunisationplans or strategies, including mechanisms for coordination, monitoring and evaluation to support
vaccine availability and enable population-wide immunisation. Planning and coordination must be
equitable, adaptable, far-sighted and regularly evaluated to accommodate emerging needs. To achieve
Tier 1 performance in this domain, it is necessary to have a national vaccination plan with protectedbudgets and goals to obtain population equity, coordination across the health sector and strong
monitoring and evaluation of the national vaccination plan. Most index countries perform well in thisdomain. Performance can be improved by:• ensuring plans have adequate ring-fenced budgets that ensure they can be effectively
operationalised• strengthening responsiveness by planning for contingencies• increasing readiness by having robust epidemiological surveillance systems
These improvements are important for making sure national immunisation plans are fit-for-purpose
and can be implemented effectively, thus meeting the needs for vaccinations to prevent endemic
diseases and public health emergencies.

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Domain 2: Regulation

Regulation relates to the laws governing the approval of vaccines in a country, whether thosevaccines are manufactured within that country or imported. It also covers how a country evaluates
vaccine data, R&D and manufacturing information from outside agencies and foreign sources.
Concerted efforts at national and global levels are necessary to ensure that regulatory standards are
streamlined in order to create a regulatory environment that allows for timely yet safe responses tospreading communicable diseases.
There are five indicators for analysing the ability to develop and utilise regulatory standards in the
Index (Table 6). They look for the presence of a specific agency tasked with vaccine approvals, formechanisms for adopting regulations based upon universally recognised standards developed byexpert organisations (such as WHO), for an expedited approval process for vaccines required during
a public health emergency, for an agency responsible for monitoring vaccine manufacturing. The
indicator relating to the latter (2.1.1a) is especially important – whether or not the country has its own
manufacturing capability – because it demonstrates an understanding of the manufacturing process.
The Index also studies the extent to which a country engages with the wider global community tocoordinate vaccine regulations and standards, specifically seeking evidence of agreements withoutside organisations on data-sharing for vaccine approval and of engagement between national
regulatory agencies and vaccine developers and manufacturers.

“Thoughtful, coordinated and robust regulatory
practices—driven by science—must be acornerstone of the vaccine ecosystem, enabling
acceleration of R&D, appropriate and timely
review of product safety and efficacy, and theongoing oversight of vaccines post-approval so
as to ensure quality, monitor risks and benefits,
and support appropriate use.”
Dr Margaret Hamburg
Advisory Council Member©Economist Impact 2023

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Table 6. Indicators in Domain 2: Regulation of the Immunisation Readiness Index
Sub-domain

Indicator

Regulatory
approval
and standards

2.1.1aRegulatory approval mechanism for new human vaccines

2.1.1b

Expedited approval process for public health emergencies

2.1.2

Oversight of vaccine manufacturing standards

2.2.1

Regional or international data-sharing related to the vaccine-approval
process

2.2.2

Engagement with vaccine R&D companies and/or manufacturers

Engagement

Overall, countries recognise the importance of regulation as evidenced by good performance inthis domain. More countries (eleven of thirty; 37%) achieved Tier 1 status in this domain than in any
other. The minimum level of performance was 12.5 (out of 100) and the maximum was 100 (allcountry average 75.4). The best-performing countries generally have efficient and rigorous regulatory
agencies and national processes for approving vaccines for routine immunisations (and public healthemergencies) and engage with the international community, with R&D and with manufacturers.

Figure 14. Country performance in Domain 2: Regulation
Improving readiness

Tier 6Tier 5Tier 4Tier 3Tier 2Tier 1

Kenya
Nigeria
SenegalSouth Africa
Tanzania

Egypt
Ethiopia
Iran
Pakistan
Philippines

Bangladesh
China
Indonesia
PolandThailandTurkeyUK
VietnamIndia

BrazilColombia
FranceGermany
GuatemalaJapan
MexicoRussiaSouth Korea
Spain
USA

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Key findings
Vaccine regulatory processes were in place
All thirty countries maintain policies for routine vaccine approval. This indicates that all of thenational governments understand the importance of regulatory vaccine-approval mechanisms.
The best-performing indicator (2.1.1a) in this domain, with an all-country average of 100 out of100, examines the existence of regulatory mechanisms for approving new vaccines for human use.
However, regulatory processes must be actively reviewed, with continued investment, to ensure they
are adequately maintained and up-to-date. Exploring the operationalisation of these processes was
beyond the scope of the Index, but may benefit from further research.
Data-sharing accelerates vaccine approval and rollout
Only fourteen of the thirty Index countries (47%) had existing agreements to participate in datasharing. This indicator (2.2.1) is the lowest performing in the domain, suggesting that there is significant
room for improvement. A lack of transparent data-sharing can cause unnecessary bottlenecks in thevaccine approval process in many countries, and ultimately slows the rollout of vaccinations. The
covid-19 pandemic saw an unprecedented level of data-sharing across the global scientific community
and regulators, and this encouraged rapid progress in research and emergency authorisation for use of
the new vaccines. When governments, manufacturers and other stakeholders communicate and sharedata, they can expedite the authorisation process, which is especially important during public healthemergencies. Progress on this indicator is indicated by transparent evidence of how a government
works with manufacturers and other stakeholders.

Examples of best practices
The following examples are highlighted because they demonstrate unique and innovative
approaches for addressing the issues within Domain 2 and they can be adapted by othercountries to improve their performance.
INDONESIA—Engagement with R&D and manufacturers
In April 2021, Indonesia provided various supports for vaccine R&D initiatives during the covid-19
pandemic, including the publication of ‘vaccine development tools’ at research facilities like theInstitute for Molecular Biology Eijkman (where the national Red and White vaccine research
initiative originated). This support extended to directly overseeing the development of a vaccine
27
by domestic vaccine and serum manufacturer, Bio Farma, showing how government and privatecompanies can coordinate and, thereby, benefit from R&D investment.
USA—Vaccine development guidance
The USA has a history of engaging with R&D manufacturers, but nothing to the extent seen
during the covid-19 pandemic. Early on, the US Food and Drug Administration provided
guidance for accelerating vaccine development, enabling the use of data from research onother vaccines that use identical platforms, which helped expedite research while ensuring
28,29
vaccine safety and efficacy.

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Actions to improve performance in Regulation
The Regulation domain analyses the comprehensiveness of vaccine regulatory standards, the agencies
responsible for those standards and what steps can be taken to improve the efficiency of the vaccineapproval process. In order to achieve Tier 1 in this domain, countries must have regulatory approval
standards for routine and emergency approvals along with regular engagement, including datasharing between R&D and regulatory bodies at national and international levels. Overall, the analysis
found significant room for improvement in:• ensuring the maintenance of effective, rigorous vaccine regulatory processes and creating active
review and continued investment• streamlining data-sharing to allow quicker and more accurate characterisation of effectiveness andsafety to improve efficiency of the approval processes
Taking such opportunities can help countries keep pace with the need for immunisations to prevent
endemic diseases and improve performance during public health emergencies. Furthermore, bybuilding and maintaining effective and rigorous regulatory processes and streamlining data-sharing,countries can work together to combat vaccine-preventable diseases.

©Economist Impact 2023

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Domain 3: Procurement

The Procurement domain covers mechanisms for procuring and financing vaccinations. Every country
must be able to procure and finance vaccines and ancillary supplies, such as needles and syringes. In
the past, procurement was a slow and uneven process. Streamlined and efficient vaccine procurement
mechanisms, along with adequate and reliable financing, are critical for obtaining sufficient vaccine
supplies, and improvements here will ensure populations are adequately protected.
Five indicators have been used to assess vaccine procurement and financing (Table 7), and served todetermine whether a country has annual demand projections for national vaccine requirements todevelop both short- and long-term forecasts, whether sufficient annual budgets were allocated andmaintained for delivering the vaccines recommended in the national immunisation plan, and to what
extent a country has a dedicated emergency financing mechanism for procuring vaccines during
public health emergencies.

“It is hard to overstate the benefits of vaccination
to public health and global development. In
many ways, vaccination programmes have been
victims of their own success. By committing
many diseases to distant collective memory,
vaccination has made it all too easy to forgetthat those diseases - not to mention diseases
that we have not yet encountered - remain agrave threat to human flourishing.”
Dr Vivek Muthu
Academic Advisor©Economist Impact 2023

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Table 7. Indicators in Domain 3: Procurement of the Immunisation Readiness Index
Sub-domain

Indicator

Procurement
mechanisms

3.1.1

Demand forecasts for national vaccine requirements

3.1.2

Procurement strategy that considers factors other than price

3.2.1

Sufficient budget for procurement and delivery

3.2.2

Dedicated emergency vaccine financing mechanism

3.2.3

Current Health Expenditure (CHE) per capita

Financing

There is room for improvement in this domain for all countries in the Index. None fulfil all the criteria,
although some perform better than others and appear to understand the need for strong procurement
and financing mechanisms (of course, many countries do understand this need but may be unable toimplement or prioritise development in the area). No country achieved Tier 1 status and most wereclustered in Tier 6. The lowest-performing country scored 16.7 out of 100 and the highest scored83.3 (average 49.4). National immunisation strategies must include dedicated budgets to ensure
procurement and delivery of vaccines and sufficient financing during public health emergencies.
However, more of the countries had dedicated funds for vaccines for use in public health emergencies
than for vaccines to counter routine childhood and adult diseases.

Figure 15. Country performance in Domain 3: Procurement
Improving readiness

Tier 6Tier 5Tier 4Tier 3Tier 2

BrazilChina
Germany
Guatemala
India
Iran
MexicoNigeria
Pakistan
SenegalSpain
ThailandBangladesh
Egypt
Ethiopia
Japan
Kenya
Philippines
South Africa
Tanzania
TurkeyRussiaSouth Korea

Colombia
Indonesia
PolandVietnam
USA

FranceUK

Tier 1©Economist Impact 2023

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Key findings
Dedicated budgets must be part of the national immunisation planInterventions to improve procurement must consider vaccines that are used during public healthemergencies, as well as those for preventing infectious childhood and adult diseases, and both must
be properly funded. Improved financing often leads to equitable and timely access to vaccines, which
is necessary for achieving immunisation goals. Proper planning and budgeting are also required for
vaccines and ancillary supplies (e.g. needles, syringes, alcohol swabs, personal protective equipment)
to support all of a country’s immunisation programmes, whether routine or emergency.
Only seventeen of the Index countries (57%) were found to have a sufficient annual budget for
procuring and delivering the vaccines included in their national strategy or plan (Indicator 3.2.1). In
thirteen of them (43%), there was misalignment between the goals set out in the strategy and thebudget allocated for implementation.
Dedicated emergency financing mechanisms for securing vaccines during public health emergencies
were present in twenty-four of the countries (80%). Indicator 3.2.2 had the highest average country
performance (80.0), partly because public health emergencies receive more public attention andgenerate greater political will, even though funding for routine immunisation programmes is just as
important for public health.
National immunisation strategies must include dedicated budgets, and it is important toconsider the costs of vaccines and ancillary supplies when budgeting, planning and implementing
programmes, to enhance overall readiness. If funding is inadequate, then planning is a theoretical
exercise. Improvements in this area require full funding of immunisation strategies and theirassociated programmes to properly support vaccination efforts against routine disease threats andpublic health emergencies.
In some higher-income countries, high costs affect the ability to fund immunisation programmes
equitably and can prevent some communities from having adequate access to necessary vaccines.
Therefore, to ensure success, procurement strategies must consider factors other than price. For
Indicator 3.1.2, twenty-one of the thirty countries (70%) considered such factors when making
procurement decisions, such as equity, safety and place of manufacture, as demonstrated by South
Africa – one of the top ten performers in Domain 3 with its five-pillar procurement strategy (see Best
Practices below).
The Index does not explore complex issues related to budgeting and pricing beyond this indicator,
but points this out as an important area for further research. Similarly, further research is requiredon the policies for procurement of ancillary supplies (such as needles and syringes) to enable vaccine
administration.
Forecasting improves procurement
When government officials and policymakers understand the processes involved in forecasting
vaccine demand, they are more likely to use limited budgets more efficiently and make better
decisions about the quantity and frequency of the procurement of vaccines and ancillary supplies.
According to Gavi, the Vaccine Alliance, demand forecasting is important for understanding
30
markets and planning annual immunisation programmes. For this reason, Gavi creates forecasts
30
spanning periods of up to 20 years. Without proper forecasting, vaccination supplies can either beinsufficient or can exceed the required demand; in either scenario, valuable vaccines are wasted or
the population is not adequately protected.

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Indicator 3.1.1 examines demand forecasts for national vaccine requirements and has the lowest allcountry average (23.3). Fourteen of the Index countries (just under half; 47%) develop annual demand
forecasts for required vaccines. Our experts consider a five-year forecast to be the minimum timeframe for long-term planning, but no countries routinely create a forecast of this length to inform
immunisation readiness, reducing their ability to make long-term projections for national vaccine
requirements for routine immunisations. Thus, substantial improvements are needed in this area tobetter prepare for future vaccination needs.

Examples of best practices
These examples of best practices are given because they offer unique and innovative
approaches to address issues encompassed by Domain 3 and can be usefully adapted by othercountries to improve their performance in this domain.
EGYPT—Emergency financing
In 2014, Egypt initiated an account for public funding. One of the main focuses of the Long
Live Egypt Fund is a disaster and crisis response programme. From the start of the covid-19
pandemic, it provided medical equipment to health facilities, financially supported poor
31
families and crowdfunded to expand covid-19 vaccine coverage.
SOUTH AFRICA—A procurement strategy that actively promotes equity
South Africa is among the top ten performers in Domain 3 with its five-pillar procurement
strategy. The Government General Procurement Guidelines prescribe a minimum setof standards: value for money, open and effective competition, ethics and fair dealing,accountability and reporting, and equity. The guidelines are supplemented by individual
accounting officer’s procurement procedures issued under the general authority contained in32
the Public Finance Management Act 1999. As outlined on the Department of Health website,
33
the department ‘always awards bids in accordance with the treasury’s procedures’.

Actions to improve performance in Procurement
The Procurement domain relates to mechanisms for ensuring the efficient supply of vaccinations
for routine and emergency vaccination efforts. Streamlined and efficient procurement mechanisms,
along with adequate and reliable financing, are critical for ensuring sufficient supplies of all available
vaccines. To be in Tier 1 for this domain, a country must have a strong procurement strategy, demand
forecasting and sufficient financing allotted to cover both routine and emergency procurement.
Performance for all thirty Index countries could be enhanced by:• improving the budgeting process to ensure national immunisation plans include sufficient dedicatedresources for all vaccinations, whether for routine use or public health emergencies• improving forecasting to promote effective procurement©Economist Impact 2023

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Domain 4: Delivery

The Delivery domain encompasses many factors involved in creating and maintaining robust
systems to enable population-wide vaccination efforts. Countries must have an appropriate publichealth infrastructure, including mechanisms to track vaccine stockpiles and vaccine distribution andmaintain accurate vaccination records. A sufficient number of properly trained personnel is required
to implement vaccination campaigns, with enough flexibility to shift to the provision of immunisations
during public health emergencies. In any country, the percentage of the population with accessto vaccinations is significant, including hard-to-reach populations. Also of concern is whether any
difficulties stem from challenges in geography or poor health literacy.
There are fourteen indicators in the domain (Table 8), which assess, for example, individual country
infrastructure, personnel and distribution systems for vaccination delivery, integration with theprimary healthcare system, digitalisation of vaccination records, vaccine inventory management
systems, and access to healthcare (access affects the potential to reach immunisation goals). Eachcountry’s healthcare workforce and national training mechanisms for health workers who administer
vaccines were also reviewed. This domain captures the extent to which countries have culturally
appropriate distribution practices in place and notes whether the functionality of distribution systems
was tested via a functional exercise.

“This report describes how effective vaccination
demands attention to an interconnected systemof policy instruments, technological and scientificinnovation, complex logistics and sophisticatedsociological interventions. It also describes - in very
concrete and specific ways - how this system can be
improved. Ultimately, I hope that this report, and theinitiative of which it forms a part, helps to ensurethat vaccination remains an active global priority,
demanding political attention and investment, which isrightly regarded as central to securing and sustaining abrighter future for all.”
Dr Vivek Muthu
Academic Advisor©Economist Impact 2023

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Table 8. Indicators in Domain 4: Delivery of the Immunisation Readiness Index
Sub-domain

Indicators

Health systeminfrastructure

4.1.1aNational immunisation infrastructure integration

4.1.1b

Non-traditional vaccine delivery strategies

4.1.2

Digital vaccination records (integrated with national health information
system)4.1.3

Vaccine inventory management

4.2.1

Universal Health Coverage (UHC) Service Coverage Index

4.2.2aGeneral medical practitioners (GPs)

4.2.2bPharmacists

4.2.2cNurses and midwives

4.2.3aData on health-worker competency in immunisation

4.2.3bNational health-worker training programme for immunisation

4.2.3cEmergency workforce strategy for public health emergencies

4.3.1

Vaccine delivery and storage infrastructure (cold chain)

4.3.2

Culturally appropriate distribution practices

4.3.3

Delivery system testing

Access tohealthcare

Distribution
systems

Overall, there is room for improvement in every Index country. Most of the countries (ten; 33%) werein Tier 3, with none in Tiers 1 or 2. The lowest-performing level in this domain was 43.4 out of 100, andthe highest was 85.2 (all-country average 64.0). A common feature of the best-performing countries
in this domain is a reliable physical and health infrastructure that is integrated with the primary
healthcare system.

Figure 16. Country performance in Domain 4: Delivery
Improving readiness

Tier 6Tier 5Tier 4Tier 3

China
GuatemalaNigeria
SenegalIndia
IranPakistan
Philippines
South Africa
Spain
ThailandBangladesh
BrazilEgypt
Ethiopia
Kenya
PolandRussiaTanzania

Colombia
Germany
Indonesia
Japan
MexicoSouth Korea
TurkeyUK
USA
VietnamTier 2Tier 1©Economist Impact 2023

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Key findings
Infrastructure is a prerequisite for effective immunisation delivery
The best-performing indicator in this domain was 4.1.1a, relating to national integration of theimmunisation infrastructure into the public health system. All of the countries met this goal (allcountry average 100). The term ‘physical infrastructure’ relates to internet access, cellphone networks,
roads and electricity grids, while ‘health infrastructure’ relates to clinics, hospitals and healthinstitutions that are key to vaccination delivery. A reliable infrastructure (comprising both these
aspects) allows public health systems to successfully deliver immunisations to the population. Everycountry demonstrated this ability to some extent, but the reliability and resilience of the physicalinfrastructure were not examined (e.g. digital networks or road quality). This was beyond the scope of
the Index and offers an opportunity for further research.
Health personnel require training for effective vaccine delivery
Countries that perform well in this domain make efforts to maintain an adequate health workforce
and a robust vaccine distribution system. There is comprehensive training for health workers, which
typically covers vaccinology and injection training, and ways to improve delivery strategies andaddress public concerns. Sub-domain 4.2 looks at access to healthcare and national health systems
with the personnel required to immunise their populations. High-performing countries train
healthcare personnel in vaccine delivery for both routine diseases and public health emergencies,
and they also provide continuing and up-to-date training regarding best practices for vaccine
delivery. Indicator 4.2.3a, the lowest-performing indicator in the domain, considers the availabilityof data on health worker competency in vaccine administration (all-country average 13.3) throughthe collection and publication of figures on the number of health workers trained to administer
vaccines. Only four of the countries (13%) made this information available to the public. Most do
not collect or publish the data. Countries can improve in this indicator by making information about
their healthcare workforce publicly available.
Delivery systems must be sufficiently robust and well maintained
National immunisation plans and strategies for delivering immunisations are of little value unlessthey can be properly operationalised and adapted to meet specific needs. A well-developed
system will deliver vaccines to all areas of a country. Indicator 4.3.1 focuses on the ability to meetand maintain the temperatures required to transport and store vaccines safely to at least 80%
of districts. Only nineteen of the thirty countries (63%) demonstrated the ability to ensure thatvaccines were kept within their required temperature-controlled environments, so these delivery
systems must be expanded and updated. Plans must also be validated regularly, by testing andevaluation, with updates and revisions made as needed. Note that nationwide exercises, such as the27
WHO Joint External Evaluation, had been conducted in 90% of the countries; good performanceon this indicator (4.3.3) should be maintained to prevent readiness levels from falling, and countries
are encouraged to conduct regular monitoring of vaccine delivery systems via functional exercises
to maintain – or improve – performance in this area.

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Examples of best practices
The following three countries demonstrate unique and innovative approaches for addressing
the issues in Domain 4, which can be usefully adapted by other countries to improve theirperformance. Brazil worked to improve the delivery of vaccines among hard-to-reachcommunities; France worked to broaden the range of health workers able to administer
immunisations during public health emergencies; and Iran worked to provide training tocommunity health workers.
BRAZIL—Culturally appropriate vaccine distribution
Operation Droplet promotes the ability of vaccination programmes to be offered insocioeconomically disadvantaged, hard-to-reach geographic areas, including indigenous areas
such as the Amazon, Amapa, Para and Acre. Supported by the Division of Public Health forindigenous populations, the programme aims to vaccinate people in communities using non34
traditional delivery strategies and culturally appropriate practices.
FRANCE—Extended range of healthcare providers for administering vaccines during
public health emergencies
The wide range of health professionals authorised to administer vaccines during public healthemergencies now includes vets, dentists and firefighters, meaning there are far more people
35
who can administer injections to expedite vaccine rollout throughout the population.
IRAN—Training programme for health personnel
Part of Iran’s national community healthcare programme relates to remote rural and small
urban communities, and a key component of the public health system is the use of trained
community health workers to provide or supplement primary healthcare services in these36communities. A 2018 WHO study noted that rural communities are at the core of primary
healthcare delivery, and that community health workers provide ‘a broad range of services,
including annual censuses, health education, family planning, maternal and child healthcare,
37
care for elderly populations, oral healthcare and occupational health’.

Actions to improve performance in Delivery
In order to achieve Tier 1 in this domain, which analyses how vaccines are delivered by examining
health system infrastructure, personnel capacity and vaccine distribution systems, a country needsa reliable infrastructure (both physical and health aspects), sufficiently trained health personnel,
and a robust vaccine distribution system (with temperature-controlled environments and culturally
appropriate delivery methods). Performance in this area can be improved by:• improving the reliability of the national infrastructure• ensuring health personnel are adequately trained to deliver vaccines• ensuring ongoing validation of immunisation plans through active evaluation and maintenance sothey can be effectively operationalised and adapted to meet changing needs• creating and maintaining vaccine distribution systems capable of delivering vaccines to all areas,
equitably and sustainably
Immunisation readiness depends on effectiveness in each of these areas, whereby maintaining andimproving performance enhances the efficiency of vaccine delivery, to achieve better vaccine uptake
for endemic diseases and ensure preparedness for dealing with novel pathogens.
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Domain 5: Outreach

The Outreach domain involves public education and outreach measures to provide insights into thereceptiveness of a particular population to a recommended vaccine. Adequate public awarenessleads to increased knowledge and transparency, which is key because no matter how well a particularcountry performed in Domains 1–4, it is meaningless if the population refuses to be immunised.
The Index includes four indicators on immunisation education programmes and public outreachactivities (Table 9) that look for publicly funded health literacy programmes, including digital
health literacy, and risk communications strategies for vaccines and vaccine-preventable diseases.
The indicators consider the aspects of such strategies that are intended to overcome barriers tovaccination and reflect national efforts to understand public attitudes towards vaccination, using
measures such as surveys of public opinion.

“Public trust is essential for any successful
vaccination campaign. The Economist
Group’s Vaccine Ecosystem materials arecomprehensive, extensive and include important
information regarding informed decisionmaking and public communication and are vitalfor policymakers responsible for public health.”
Dr Laura Kahn
Advisory Council Member©Economist Impact 2023

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Table 9. Indicators in Domain 5: Outreach of the Immunisation Readiness Index
Sub-domain

Indicator

Education programmes

5.1.1

Public education programme on immunisation

Public outreach

5.2.1

Risk-communications strategy

5.2.2

Communication strategies to overcome barriers to vaccination

5.2.3

Research into public attitudes towards vaccines

Overall, there is significant room for improvement across the Index countries in Domain 5. Thisdomain has the greatest spread in performance, covering the entire range of possibilities (fromzero to 100; all-country average 47.5), with sixteen countries (53%) falling into Tier 6. The highestperforming indicator in this domain (5.2.1) relates to the existence of a risk-communications
strategy specifically for vaccine-preventable diseases (all-country average 63.3). The indicatorfor public education programmes that support immunisation (5.1.1) showed the lowest level of
performance (average 38.3). Taken together, these findings reflect a significant disconnect between
the existence of policy and its successful operationalisation into actionable effective results. Publichealth communications should be improved in all countries to ensure that no one is disenfranchised
and that everyone has access to clear and easily understandable information. In general, the bestperforming countries for this domain share characteristics such as long-term public communication
strategies that aim to overcome inequities, vaccination-focused public education campaigns andclear strategies for gauging attitudes towards vaccination.

Figure 17. Country performance in Domain 5: Outreach
Improving readiness

Tier 6Tier 5Tier 4Tier 3Tier 2Tier 1

Bangladesh
Colombia
Guatemala
Egypt
India
Japan
Nigeria
Pakistan
Philippines
RussiaSenegalSouth Africa
South Korea
Tanzania
Thailand
Vietnam

China
Ethiopia
Kenya
MexicoUSA

PolandSpain

BrazilFranceIndonesia
UK

TurkeyGermany
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Key findings
Optimising uptake requires specific investment, expertise and strategies
To make improvements in this domain, governments must prioritise investment in programmes
and systems that optimise public acceptance and uptake, such as vaccination literacy programmes.
Investment must be increased in a few key areas, such as identifying groups who may be marginalisedor have a history of poor vaccination uptake, and working to address their needs. Culturally targeted
outreach measures allow public health organisations to engage with communities and explain therationale behind vaccination, which is especially relevant where there is vaccine hesitancy, that often
arises due to a lack of information and understanding – or mistrust – of the health system. According
to Indicator 5.2.3, sixteen of the Index countries (53%) have conducted surveys to gauge attitudes
towards vaccines in the last five years.
Improving health literacy through comprehensive programmes that address structural and societal
barriers that impede participation in health decision-making, leads to more effective education andoutreach programmes. There were funded public education programmes on immunisation to improvehealth literacy (Indicator 5.1.1) in eighteen countries (60%), but only five of them (17%) include digital
health literacy in their programmes.
Efforts to improve public communications, and thus shared decision-making, must address thecomplexities associated with vaccines and vaccination programmes. There were risk-communication
strategies for vaccine-preventable diseases in nineteen of the thirty countries (63%) (Indicator 5.2.1).
Strategies specifically aimed at overcoming socioeconomic inequalities, geographic barriers, culturaldifferences and other obstacles to vaccination (Indicator 5.2.2) were found in sixteen countries (53%).
It is important for all vaccine-related information to be clear and comprehensive but concise andculturally appropriate, and delivered in multiple formats using appropriate and accessible language.
It is also best if community leaders and trusted organisations work in alignment with public healthefforts to deliver messages about vaccination, thus promoting understanding and uptake.
To improve in this area, the needs and concerns of specific population groups must be addressed,
and it is essential to have communication techniques that incorporate active listening, as well as
disseminating evidence-based information. While there was evidence that countries conductedsurveys to gauge attitudes and had programmes for improving health literacy and developing risk
communications, the impact of these surveys and programmes on outreach and vaccine uptake wasbeyond the scope of this Index, providing a further opportunity for research.
Impactful and trusted leadership can improve immunisation uptake
Strong and effective leadership from government, key stakeholders and policy experts at international,
national and community levels is essential for achieving robust education and outreach. Indicators
relating to the quality of governance are important for context and were included in Domain 6:
Society. They relate to government effectiveness, political stability and corruption. None of the Index
countries were in Tier 1 for this domain, but it is acknowledged that the effectiveness of leadershipand governance is an ongoing requirement of successful vaccination programmes, and key to better
performance in this area.
To positively impact immunisation, effective leadership must come from all levels of government(international, national, regional and local). Clear communication about infectious disease threats andvaccination programmes must be based on scientific evidence, which promotes trust. Elected officials
must be informed, engaged and prepared to lead effective emergency responses and motivate their38
constituents to participate in life-saving vaccination programmes. To ensure equity in vaccination
outreach and education, such programmes must involve a broad range of trusted and influential
stakeholder groups to act as ambassadors, including politicians, government leaders, professionalorganisations, health workers, religious and traditional community leaders, among other respected©Economist Impact 2023

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6community members.

Examples of best practices
These examples showcase unique and innovative approaches for addressing the issues in thisdomain and can be adapted by other countries to improve in this area.
KENYA—Cultural considerations in risk communications
The National Policy Guidelines on Immunisation (2013) include communications strategies
specifically aimed at overcoming socioeconomic inequalities, geography, cultural and linguistic
differences, or gender barriers to vaccination. Health workers are mandated to conduct
outreach in areas known to have ‘high numbers of unreached children and pregnant women’,and all communication strategies and supplemental immunisation activities include cultural
39
considerations. In 2021, the Ministry of Health recruited religious leaders to widen the40
campaign against covid-19.
PHILIPPINES—Community engagement
A risk-communication strategy for vaccine-preventable diseases can be found in Booklet 8 of
the National Immunisation Programme Manual of Procedures, which discusses engaging withthe community to raise awareness about the risks of not getting children vaccinated, and theuse of interviews, focus groups and print media, for example, to encourage behaviours relating41
to routine immunisations, with clear behavioural objectives. The National Deployment and
Vaccination Plan for Covid-19 Vaccines contains a chapter on a risk-communication strategy
and crisis management. It specifies the creation of a Task Group for Demand Generation
and Communications that is responsible for activities such as advocacy, ongoing community
engagement, trust building, active hesitancy prevention, regular national assessment of
42
vaccine concerns and crisis-response planning.

Actions to improve performance in Outreach
Vaccines are a major public health achievement, but the full benefits of immunisation cannot be
obtained without proper education and outreach. Greater knowledge helps to mitigate apprehension
and unease that some people feel about being vaccinated or getting their children vaccinated, andhigher health literacy levels improve knowledge and competencies, making it easier for people to find,43
understand, assess and apply information, thus allowing better interactions with the health system.
Effective activities in these areas lead to better acceptance of vaccinations and result in a higher
percentage of fully immunised people. In order to be in Tier 1 of this domain, a country needs strong
outreach to improve public understanding of vaccinations, robust immunisation outreach campaigns
and a well-articulated disease risk-communication strategy. Many countries performed poorly in thisdomain, but there are several ways in which their performance can be improved, such as by:• making greater investment in programmes to optimise vaccine uptake
in disenfranchised and one word, no hyphen populations• strengthening trust in all levels of leadership (international,
national, regional and local) to increase vaccine uptake
To have a meaningful impact on vaccine uptake, governments must invest in communication
programmes aimed at improving understanding, knowledge, and trust, while also attempting
to dispel myths associated with immunisation.
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Improving immunisation readiness:building a resilient future
Two decades ago, the US Centers for Disease Control and Prevention (CDC) declared vaccinations
one of the major public health achievements of the twentieth century, placing them first in the top ten
44of its public health achievements. Vaccinations reduce the burden of disease in humans and lower
morbidity and mortality rates on a huge scale.
The Immunisation Readiness Index was conceived to take the principles and framework established by
The Vaccine Ecosystem Initiative and translate them into a qualitative and quantitative tool. Policies
across thirty Index countries were researched and analysed to identify any gaps or opportunities
for improvement as governments around the world look to become more resilient to threats posedby diseases that are amenable to prevention or treatment through vaccination. The analysis of thefindings from the Index build upon a previous report, Towards a stronger Vaccine Ecosystem: Building
1
2–6
resilience beyond covid-19, and several policy briefing papers that consider ways to improvestructural approaches for strengthening global health security.
The aim of the Index is to highlight variability and inequalities across countries while providing clear
and actionable insights with potential for making improvements, that can also promote dialogue
between countries and help them learn from each other. The discrepancies observed between
countries help to identify important gaps that would benefit from more work. The Index allows us
to look beyond research laboratories and understand how different countries can maximise theavailability, and therefore the utility, of vaccines for people living within their borders.
Since it began, The Vaccine Ecosystem Initiative endeavoured to explore the possibilities for bothradical and incremental changes that might improve health-system preparedness and work acrossbroader society to harness the full potential of current and future vaccines. A meaningful structure
has been developed since 2020, to define what was initially an amorphous construct into fiveinterdependent core pillars, including research and development; manufacturing; procurement,
pricing and finance; distribution, logistics and supply chain management; and user acceptance anduptake. The Immunisation Readiness Index builds on this work by quantitatively and qualitatively
mapping actions taken by individual countries in the field of immunisation, to identify opportunities
to enhance preparedness.

Immunisation Readiness Index demonstrates need for improvement
across all countries and all domains
The Index is a statistically significant predictor of a country’s healthy life expectancy, highlighting how
improvements in immunisation readiness can enhance health outcomes. It reveals that none of thethirty countries studied performed to the highest level across all domains – clearly indicating that each
one still has room to improve.
The countries performed well in the first two domains, covering the legal and regulatory structures
underlying national immunisation plans or strategies, and examining the policy and planningmechanisms that govern immunisation efforts. All the Index countries have a national immunisation©Economist Impact 2023

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strategy/plan for guiding vaccine programming. In general, the domains related to policies guiding
operationalisation of such plans are where the countries fell short, because they may not havedeveloped the steps that guide implementation. Consequently, performance was lower overall forthe three domains on Procurement, Delivery and Outreach. The lowest levels of performance
related to Procurement and Outreach, thus revealing that these aspects of immunisation readiness
require the greatest attention.

“The need for building stronger partnerships, among public
and private players, is common to all domains analysed in
the Immunisation Readiness Index and this report. We need
to work as partners towards a sustainable vaccine ecosystem
to restore and strengthen immunisation programmes withprimary healthcare along the life course.”
Mr Thomas Cueni
Advisory Council Member

All of the Index countries recognised the importance of planning, as evidenced by good performancein Domain 1: Planning. However, they need to strengthen their national immunisation plans or
strategies to ensure they have the capacity and capability to address routine endemic diseases aswell as emerging disease threats. Mechanisms for coordinating, monitoring and evaluating vaccine
availability and promoting population-wide immunisation must be part of the national approach, andplanning and coordination must be equitable, far-sighted, regularly evaluated and flexible enough toaccommodate emerging needs. Active evaluation, maintenance and funding of the strategy is required
to maximise immunisation readiness.
Within Domain 2: Regulation, all countries were found to have regulatory authorisation mechanisms
for approving new vaccines for human use. Streamlining the sharing of data enhances the speed
and accuracy with which information on vaccine effectiveness and safety can be disseminated andassessed during the vaccine-approval process, which can be particularly helpful during public healthemergencies. Further research opportunities include analysing the operationalisation of regulation
processes to ensure that they meet evolving needs.
More can also be done regarding Domain 3: Procurement, to prioritise mechanisms for vaccine
procurement to protect population health. National immunisation plans and strategies often
overlook the inclusion of forecasting and dedicated budgets, but good forecasting is critical for all
downstream planning, budgeting and operationalisation. No plan can be operational unless it has adedicated source of funding. Our experts considered a five-year forecast as the minimum time frame
for adequate planning to protect public health from diseases, whether those diseases are routineor the cause of a public health emergency. Note that a more thorough understanding of pricing and
its impact on budgeting, planning and procurement was beyond the scope of the Index, but suchknowledge might help countries improve vaccine availability and access.
Domain 4: Delivery demonstrates that better operationalisation of national immunisation
strategies improves readiness because it helps ensure the resilience of a country’s physical and healthinfrastructure. National plans for delivering immunisations are of little value unless they can beproperly utilised and adapted to meet specific needs. They must be regularly validated through testingand evaluation, and require updating and revisions as appropriate.

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Information on the competency of health workers to administer immunisations is helpful forassessing readiness. All countries met the indicator criteria on infrastructure, but measuring thereliability of the infrastructure would be even more valuable and presents an opportunity forfurther research. Note that responsiveness requires investment and validation to ensure national
immunisation plans can be effective.
Countries must prioritise investment in programmes and systems that optimise public acceptance anduptake of vaccinations by addressing health literacy, vaccine hesitancy, mistrust and other concerns. Thissituation is explored in Domain 5: Outreach. Outreach must be culturally appropriate to facilitate
engagement with groups who may be marginalised or may have a history of poor vaccine uptake.
Trusted leadership is key to this and is best when drawn from international, national, local andcommunity stakeholders. Trust improves understanding and knowledge and dispels health myths.
Countries showed evidence of surveys conducted to gauge attitudes, of programmes for improving
health literacy and of risk-communication strategies, but their impact on outreach and immunisation
uptake was beyond the scope of the Index. Further research in this area is recommended.

A strengthened vaccine ecosystem
Overall, the Index has highlighted the need to build stronger partnerships and involve a broader rangeof stakeholders, such as forging alliances between ministries of health and public health, finance,social services and education, health professionals and cross-sector leaders at community, national
and international levels. There is much more work to be done and wider discussion is invited as partof the ongoing Vaccine Ecosystem Initiative, to examine and reimagine elements that were critical for
vaccine development, deployment and adoption, and thus promote a sustainable vaccine ecosystem.
The key message remains: none of us is safely protected until everyone is safely protected.

“Every year, vaccines prevent 4-5 million deaths in all age
groups and have the potential to fight some of the biggest
threats to global public health. During the covid-19
pandemic, health systems administered more vaccines thanin any year in history and we are now seeing the largest
decline in vaccination coverage in a generation.”
Mr Thomas Cueni
Advisory Council Member©Economist Impact 2023

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Appendices©Economist Impact 2023

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Appendix A: The pillars of The Vaccine Ecosystem Initiative
The Immunisation Readiness Index is just one part of an overarching research programme called
The Vaccine Ecosystem Initiative. The Initiative was established in November 2020 to promotea sustainable global vaccine ecosystem by examining and reimagining elements that are criticalfor vaccine development, deployment and adoption. This involved extensive research on how
to maximise the utility of and equitable access to vaccines in order to promote the availability of
immunisations for people worldwide.
To operationalise the cross-cutting themes within the ecosystem, working with experts in theInitiative’s Advisory Council, five key pillars of the vaccine ecosystem were identified: research anddevelopment (R&D); manufacturing; procurement, pricing and finance; distribution, logistics andsupply chain management; and user acceptance and uptake. The pillars represent the key stages in thelife cycle of a vaccine, from surveillance and research to administration to individual people. Althougheach pillar has been examined individually, they are not ’silos’– any progress or failure in just one ofthem has an impact on the others. For example, information gaps in the R&D process can lead to the
spread of unintended (or deliberate) misinformation that influences public uptake of a vaccine.
Great efforts have been taken to break down the critical aspects of the entire system into more easily
understood elements by applying recently lived-experience of the covid-19 pandemic. This was theentry point to wider discussions of all aspects of the vaccine ecosystem, and it allowed explorationof the potential for both radical and incremental changes capable of improving global preparedness
within health systems and across societies. The work has always centred on systemic readiness rather
than covid-19 response.

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Figure A1. Framing The Vaccine Ecosystem: five pillars support a successful vaccine ecosystem

The Vaccine Ecosystem

Research andDevelopment

Manufacturing

Procurement
Pricing and
Finance

Distribution,
Logisitics andSupply Chain
Management

User
Acceptanceand Uptake

Critical pillars are the foundation of a viable ecosystem

The following paragraphs describe what the five pillars entail. They are further defined in the
1
Framework Report Towards a stronger Vaccine Ecosystem: Building resilience beyond covid-19.
Pillar 1: Research and development (R&D)
R&D incorporates the vaccine research process from the earliest stages of laboratory researchthrough to Phase III (human) clinical trials. It covers the regulatory oversight necessary for supporting
vaccine development and innovations that can improve the characteristics of existing vaccines. It
also addresses the type of R&D needed for supporting the delivery of vaccine services, including
disease surveillance and monitoring, as well as the enabling policies, infrastructure, investments and2partnerships that can promote success.
Pillar 2: Manufacturing
The second pillar relates to the factors involved in manufacturing vaccines and ancillary equipment
in a timely fashion, together with regulatory oversight and the use of good manufacturing practices
at a scale necessary to meet demand. It covers the infrastructure, human resources and conditions
required to manufacture vaccines and the strict quality-control standards that must be met to ensure
3
production of safe and effective vaccines.
Pillar 3: Procurement, pricing and financeThis pillar focuses on the policies, mechanisms and partnerships involved in the purchasing and pricing
of vaccines, as well as the financing of both vaccine R&D and the implementation of immunisation
programmes. It deals with procurement, pricing and finance systems that promote quicker and more
equitable access to vaccines globally, not only by supporting the development and production of
4
vaccines, but also by meeting global immunisation needs.

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Pillar 4: Distribution, logistics and supply chain management
The fourth pillar covers the mechanisms that enable safe distribution of vaccines from manufacturing
facilities to the sites where the vaccinations are administered. It encompasses the logistics,
infrastructure and systems required to distribute vaccines both within and between countries, andrecognises that consistently strong and resilient distribution networks, logistics capabilities andglobal supply chain management are needed to ensure equitable and rapid worldwide protection of5
populations against vaccine-preventable diseases.
Pillar 5: User acceptance and uptake
The fifth pillar covers the factors that encourage individuals to choose to be vaccinated and the factorsthat enable them to get vaccinated easily. It includes health literacy, education and awareness, andthe ways in which improvements can be made at each point to improve public trust in vaccines. It
examines vaccination programmes and the services that aim to combat these challenges, as well as
6
the reasons for delays in vaccine uptake.

Creating the Immunisation Readiness Index
Having defined the components of The Vaccine Ecosystem, the Immunisation Readiness Index
analyses the policies and systems within a country that have been established to address public healththreats that are amenable to prevention or treatment through immunisation. It explores the enabling
environment for equitable and sustainable immunisation across a total of thirty countries by collecting
information across six domains, consisting of a total of fifty indicators. In this way, the Index enables us
to understand system-wide readiness within individual countries for dealing with disease threats andhighlights the need to address disparities urgently.
The development of the Index was driven by the creation of a theoretical framework, informed by The
Vaccine Ecosystem Initiative report Towards a stronger Vaccine Ecosystem: Building resilience beyond
1covid-19. This described the concept for the entire Initiative. While the five pillars of the Initiativeencompass aspects of the global vaccine ecosystem, the first five of the six domains of the Index
capture the country-specific policy levers and mechanisms that can be used to develop, implement
and maintain immunisation strategies to achieve immunisation readiness. These five domains weredistilled from the five pillars to include only the components necessary for an individual country toachieve immunisation readiness (see example below). Thus, the domains of the Index are distinct fromthe pillars of the overarching Initiative, but they are intentionally aligned.

Manufacturing (Pillar 2) of The Vaccine Ecosystem Initiativeand Regulation (Domain 2) of the Immunisation Readiness Index
Manufacturing relates to the factors involved in manufacturing vaccines and ancillaryequipment in a timely fashion, together with regulatory oversight and the use of good
manufacturing practices at a scale necessary to meet demand. Country-level immunisation
strategies often rely on regional or international manufacturing processes to create thevaccines and related supplies required to carry out national immunisation efforts. However, it is
not necessary for an individual country to build and maintain its own manufacturing facilities.
Thus, Domain 2 of the Index focuses on the ability to regulate the manufacture of vaccines andengage with manufacturers; it does not assess a country’s capacity or ability to manufacture
vaccines domestically.

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Appendix B: Methodology
The following details the methods used to develop and construct the composite scores of the
Immunisation Readiness Index (including domains, sub-domains and indicators). We invite
suggestions and observations related to the project’s methodology (contact the Economist Impact
team at vaccineecosystem@economist.com). Although this is the first iteration of the Index, we
hope that future versions will expand the countries studied: thus any feedback can be used to makeadjustments as necessary. The specific stages of the Index research programme were as follows:
Literature review: a pragmatic review to identify conceptual indicators witha sound intellectual basis for assessing the immunisation readiness of individual countries
Expert engagement: the selection of appropriate experts for a roundtable discussion on project
scope and methods and preliminary findings from the literature
Framework creation: the creation of an initial framework for the Index,
involving the definition of specific indicators and the selection of countries
Data collection: the identification of key sources of information, generating
and reviewing justifications for qualitative measures, and gathering relevant data
to develop the Index and support the analysis
Country outreach: confirmation of findings with the health ministries(or comparable agencies) of every Index country to validate the research findings
Index construction and analysis: building the Index, conducting further analysis
and presenting the findings via an interactive Data Dashboard, a white paper andvisualisation for The Vaccine Ecosystem website.

Literature review
The literature review informed the overarching work of The Vaccine Ecosystem Initiative and the
Immunisation Readiness Index. Its findings, and the methods described below, can be found in
our Framework Report, entitled Towards a stronger Vaccine Ecosystem: Building resilience beyond
1covid-19.
The original research questions were:• How did the vaccine ecosystem facilitate such rapid development of vaccines against covid-19?
• What unexpected obstacles were there to the rapid development of these vaccines?
• What gaps in the vaccine ecosystem hinder more equitable vaccination efforts across the world?
• Which approaches within the vaccine ecosystem are successful and might be adapted for long-term
use to help maintain its structural integrity?
• Which foundations within the vaccine ecosystem require improvement?
A multi-pronged approach was adopted with a focus on indexed databases such as Medline and
EMBASE, as well as the grey literature, and supplemental searching of Google Scholar, Scopus andother resources. The websites of key organisations were searched for relevant media releases,
including government, regulatory and industry agencies such as WHO, ECDC, CDC, Gavi (the Vaccine
Alliance), CEPI and the Bill and Melinda Gates Foundation.

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Given the wide variety of search terms – and databases – there was no central search taxonomy;
thus a structured triangulation approach was applied across a set list of search terms. The search
was conducted and filtered down by three individual researchers to make sure the most accurate
and up-to-date information was captured. Furthermore, in-depth discussions with experts in diverse
areas were held to supplement and validate the findings of the literature review.
The search produced over 600 relevant results, of which 170 sources included in the report. Not all of
1them were cited in the Framework Report, but they were all were reviewed extensively in the creationof the evidence review and were useful as the research progressed.
Limitations and mitigations
The objective of this research was to obtain an overview of the key aspects of the covid-19 pandemic
response from the point it began, as well as the key components of the entire vaccine ecosystem. The
1
Framework Report was largely compiled in the first nine months of 2021, amid the rapidly evolving
situation and the urgent development and rollout of many different vaccines throughout the world.
Great efforts were made to ensure the timely nature of the research used to inform this work andkeep abreast of developments, which was challenging because new information and evidence were
emerging constantly.
The original research questions, as outlined above, were not suitable for conducting a rigid systematic
literature review, which meant that some relevant literature may not have been identified. To mitigate
this problem, the search was supplemented by seeking expert opinion. Furthermore, there was alack of relevant systematic reviews on the subject, which may have provided more certainty on someissues and been a useful ‘sense check’, although this was not surprising given the broad field and therapidly changing situation.

Expert engagement
Since its inception, a variety of experts have been involved in the Index, which has always sought toengage key opinion leaders, to facilitate dialogue with policymakers and health professionals andprovide actionable insights that stakeholders can use globally to improve immunisation strategies.
The Advisory Council first convened in March 2021 and was instrumental in guiding the developmentof both the Initiative and the Index. For the Index, we engaged seven subject-matter experts toparticipate in a roundtable in September 2021. Their contributions related to the scope, frameworkand findings of the Index. They also reviewed the choice of indicators and data sources and provided
input on the construction of the Index. Follow-up meetings were conducted at critical project
milestones in July 2022 and April 2023.

Framework creation
The development of the Index was driven by the creation of a theoretical framework, as informedby The Vaccine Ecosystem Initiative report Towards a stronger Vaccine Ecosystem: Building resilience1beyond covid-19, which underpinned the concept of the research programme, with indicators that
demonstrate the policies governments can use to develop, implement and maintain immunisation
strategies to improve readiness. The top level framework includes six core domains (Planning,
Regulation, Procurement, Delivery, Outreach, Society); the resulting framework combines fifteen subdomains, broken down into fifty indicators of which thirteen were quantitative and thirty-seven werequalitative) (see Table B1).

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Table B1. Domains and sub-domains of the Immunisation Readiness Index
Domain 1
Planning

Domain 2
Regulation

Domain 3
Procurement

Domain 4
Delivery

Domain 5
Outreach

Domain 6
SocietyStrategy andplanning

Regulatory
approval andstandards

Procurement
mechanisms

Health systeminfrastructure

Education
programmes

Access to
education

Coordination
andengagement

Engagement

Financing

Access tohealthcare

PublicoutreachCommunications
infrastructure

Monitoringand evaluation

Distribution
systems

Quality of
governanceDomains 1–4 include indicators relating to policies and processes relevant to the development of anational approach to getting vaccinations to the population. These domains reflect a chronologicalprocess, from developing an immunisation strategy and approving new vaccines, to ensuring thevaccines can be delivered under the correct temperature-controlled environment and be administeredby a qualified health professional.
Domain 5 includes concepts relevant to building the public’s trust in vaccines and reaching all
members of the population through outreach activities. Because these activities take place throughout
the process of national vaccine preparation, outreach is regarded as a component of the entire vaccine
ecosystem, occurring simultaneously with Domains 1–4, and facilitating the specific actions thatcomprise these domains.
Domain 6 represents the governance and societal context, providing contextualisation to our overallfindings. It enables us to develop insights that increase understanding of the unique conditions indifferent countries and how they contribute to overall readiness. Because the indicators in Domain
6 provide necessary context but are not necessarily indicative of a country’s level of readiness, thisreport focuses primarily on findings from Domains 1–5.
Country selection
Economist Impact selected the following thirty countries, which represent
76% of the global population:• East Asia and Pacific—China, Indonesia, Japan, Philippines, South Korea, Thailand, Vietnam• Europe and Central Asia—France, Germany, Poland, Russia, Spain, Turkey, United Kingdom• Americas—Brazil, Colombia, Guatemala, Mexico, United States• Middle East and North Africa—Egypt, Iran
• South Asia—Bangladesh, India, Pakistan• Sub-Saharan Africa—Ethiopia, Kenya, Nigeria, Senegal, South Africa, Tanzania.

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Data collection
A total of thirty-seven qualitative indicators were designed for this study to analyse factors forwhich no across-country data were readily available. These indicators were scored according todetailed criteria, carried out by researchers with expertise in the individual countries, including indepth justification and relevant references. The data collected during the process are available in aninteractive Data Dashboard, and you will find more on the indicators and the raw scoring scheme andranges in Appendix C.
Quantitative indicators
The quantitative indicators leverage existing metrics from reputable third-party databases such as
those of WHO, the World Bank and OECD, as well as academic studies, national statistical agencies
and proprietary databases of The Economist Group.
Qualitative indicators
The qualitative factors relate to different aspects of each country’s vaccine ecosystem. The indicators
were scored according to publicly available data, and were mostly binary, whereby ‘Yes’ responses
scored 1 and ‘No’ responses scored 0. This approach minimised subjectivity in the scoring, and makes it
easier to make comparisons between countries. A tiered scale was used for indicators requiring morenuanced responses (Table B2).

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Table B2. Types of qualitative scoring used for the Index
Type of qualitative
scoring

Example questions

Binary scoring (0–1)

Is there a national immunisation strategy or plan?
1 = Yes
0 = NoTiered scoring (0–2)

Is there a national immunisation technical advisory group (NITAG), and does itsatisfy all six WHO criteria (information about which is publicly available)?
2 = Yes
1 = Yes (but the NITAG does not satisfy all six WHO criteria)
0 = NoBackground indicators
Additionally, data were collected for a set of background indicators to permit correlation analysis. They
are included in the interactive Data Dashboard, but were not incorporated into the Index scores. They
include national vaccination rates for many of the vaccines mentioned in the Index, the prevalence ofvaccine-preventable diseases and other related health-outcome indicators.
Taking covid-19 into account
The Index is intended to provide a tool to aid understanding on the extent to which national
immunisation policies, systems and practices are able to leverage the potential of vaccines to prevent
and/or treat diseases now and in the future. As such, any measure of immunisation readiness would
be incomplete without proper consideration of the challenges faced by individual countries in their
response to the spread of covid-19 infections. When scoring the indicators, great care was taken toaccount for covid-specific actions by:• We studied how each country implemented long-lasting policies or practices because of, or during,the covid-19 pandemic. Points were allotted to countries for indicators where there was evidence
that the policy or practice would continue beyond covid-19.
• We considered policies or practices that were implemented only in direct response to the covid-19
pandemic but without evidence of consideration of future vaccination needs. For indicators where
there was insufficient evidence that the policy or practice would continue, or could be harnessedin the future, countries were not given points. We recognise that some countries demonstrated anability to mobilise resources to respond to covid-19 without having pre-existing mechanisms in place
to do so. For this reason, information about covid-specific policies and practices has been included
in our Data Dashboard.
Example: Emergency financing in IranWe examined whether individual countries have a dedicated emergency financing mechanism
or fund that can be accessed in the face of a public health emergency to procure vaccines(Indicator 3.2.2). For example, Iran was able to allocate funds to purchase covid-19 vaccines,
but there was insufficient evidence to indicate the presence of a dedicated fund or funding
mechanism that can be used in the event of an emergency to purchase vaccines. As a result,
Iran scores 0 out of 100 possible points for this indicator. More information about the fundingused for Iran’s covid-19 vaccine procurement is available under the Notes for Iran for Indicator
3.2.2 in the Data Dashboard.

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Calibration
Individual indicator scores were calibrated during an iterative process that allowed us to identify andcorrect data anomalies.

Country outreach
The Index is intended to be a rigorous collaborative tool to aid understanding of individual country
readiness to achieve equitable and sustainable immunisation. To ensure that it reflects the most upto-date information, the research team invited stakeholders from all thirty countries to participate ina feedback process and review the data ahead of publication. This included the sharing of calibrated
country data and an explanation of the scoring scheme with their ministries of health (or an equivalentgroup). However, only two countries responded with feedback comments. We evaluated this andincorporated the information as appropriate.

Index construction and analysis
The Index incorporates composite scores, created by normalising, weighting and combining all
indicators for each country by domain. A total of 50 individual indicators are weighted, reflecting theirlevel of importance relative to other indicators. Sub-domains have been included as components ofoverall domains, to organise the indicators contained within each.
Normalisation of scores
All indicator scores have been presented on a normalised scale, from 0 to 100, where 100 represents
the highest possible level of immunisation readiness and 0 the lowest. Normalisation allows raw data
to be assessed on a common scale, allowing data points to be easily compared and aggregated. The
method is simple and does not require a large sample size. Most importantly, it allows comparisonsof the relative performance measures of diverse countries at both ends of the vaccine-capability
spectrum. The normalisation methods were:
For qualitative datasets where countries are scored on a stepped scale, scores are normalised between
the minimum and maximum possible values for each indicator.
ExampleFor Indicator 1.1.1, Existence of a national immunisation strategy/plan, countries werescored using a qualitative rating of zero (no strategy exists) to one (a strategy exists). On thenormalised scale, countries with evidence of a national immunisation strategy receive a scoreof 100 and countries with no evidence of a strategy receive a zero for this indicator.

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For pre-existing quantitative datasets presenting discrete, linear values, scores were normalised
between the minimum and maximum values possible.  
ExampleFor Indicator 4.2.1, Universal Health Coverage (UHC) Service Coverage Index, which provides
a composite score (0-100) sourced from WHO, the minimum score (39%) is equal to 39 on thenormalised scale and the maximum score (87%) is equal to 87.
For pre-existing quantitative datasets with continuous data values, scores were normalised between
the minimum and maximum values for countries included in the Index. We used Tukey’s method
to adjust for any outliers (information about specific outliers for each dataset can be found in ourinteractive Data Dashboard). With this method, the highest-scoring country (or countries) score 100.
ExampleFor Indicator 3.2.3, Current Health Expenditure (CHE), the minimum score (US$ 26.7) is equal
to zero on the normalised scale and the maximum score (US$ 6,143.1) is equal to 100.
Weighting
Following normalisation, scores were compiled to create performance levels, in which:• Sub-domain scores = weighted sum of individual indicator scores• Domain scores = weighted sum of sub-domain scores• Overall scores = weighted sum of domain scores
The weightings assigned to individual indicators and domains typically reflect different assumptions
about their relative importance. Through consultation with the Expert Panel, it was determined thatthe default would be neutral weighting, which implies they are of equal importance (Table B3).

Table B3. Domain and sub-domain weighting profile
Level

Weight (%)

Domain 1: Planning

16.7%

1.1 Strategy and planning

33.3%

1.2 Coordination and engagement

33.3%

1.3 Monitoring and evaluation

33.3%

Domain 2: Regulation

16.7%

2.1 Regulatory approval and standards

50%

2.2 Engagement

50%©Economist Impact 2023

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Domain 3: Procurement

16.7%

3.1 Procurement mechanisms

50%

3.2 Financing

50%

Domain 4: Delivery

16.7%

4.1 Health system infrastructure

33.3%

4.2 Health workforce capacity

33.3%

4.3 Distribution systems

33.3%

Domain 5: Outreach

16.7%

5.1 Education programmes

50%

5.2 Public outreach50%

Domain 6: Society

16.7%

6.1 Access to education

33.3%

6.2 Communications infrastructure

33.3%

6.3 Quality of governance

33.3%

Limitations of the Index
This type of index has limitations, thus it should be used only as a tool for improving understanding about
individual countries’ vaccination capacities and their enabling environments for achieving equitable
and sustainable immunisation of their populations – it is not intended to be predictive of immunisation
outcomes. A variety of political, social and economic variables impact all countries’ abilities to translatereadiness into outcomes, and while great care has been taken to incorporate as many of these factors as
possible, the indicators used in the Index are not necessarily the only relevant measures.

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Appendix C: The Index framework
The Immunisation Readiness Index includes 50 indicators: 37 qualitative indicators created
for this research and 13 quantitative indicators from existing sources.

Table C1. All indicators used in individual domains of the Immunisation Readiness Index
Indicator number

Indicator questions/descriptions

Scoring scheme

Unit

SourceDomain 1: Planning
1.1 Strategy and planning
1.1.1

National immunisation strategy/plan

1.1.1aExistenceof national
immunisation
strategy/plan

Does the country have anational immunisation strategy
or plan?

0 = No
1 = Yes

0–1

Economist Impact
country research

1.1.1bNational
immunisation
strategy/plan:vaccine coveragetargets

Does the country's national
immunisation strategy/plan havetarget rates for vaccine coverage
across the life course?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes (but only
one target group isincluded)
2= Yes (and it includes
multiple target
immunisation rates
across the life course)

0–1–2

Economist Impact
country research

1.1.1cNational
immunisation
strategy/plan:
evidence-based
rollout strategy

Does the country's national
immunisation strategy/plan
have evidence-based guidelines
specifying which groups should
be vaccinated and when?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes

0–1

Economist Impact
country research

1.1.1dNational
immunisation
strategy/plan:
inclusiveness

Does the country's national
immunisation strategy/plan
have evidence of considerationof socioeconomic inequalities,
geography, cultural/linguistic
differences and/or genderbarriers?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes

0–1

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1.1.1eNational
immunisation
strategy/plan:vaccine equity

Does the country's national
immunisation strategy/plan
have vaccine equity as a statedpriority?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes

0–1

Economist Impact
country research

1.1.1fNational
immunisation
strategy/plan:
dedicated budget

Does the country's national
immunisation strategy/plan
identify a dedicated budget for
immunisation programmes?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes

0–1

Economist Impact
country research

1.1.1gNational
immunisation
strategy/plan:
contingency plans

Does the country's national
immunisation strategy/plan
have contingency plan(s) for
public health emergencies?

0 = No (or there is nonational immunisation
strategy/plan)
1 = Yes (there is acontingency planfor public healthemergencies, but it
is not included in thenational immunisation
strategy/plan orits supporting
documents)
2 = Yes

0–1–2

Economist Impact
country research

1.2 Coordination and engagement
1.2.1

National task force

Does the country have anational task force (or similar)
to oversee vaccine programmerollouts?

0 = No
1 = Yes

0–1

Economist Impact
country research

1.2.2

National
immunisation
technical advisorygroup (NITAG)

Does the country have a
National Immunisation
Technical Advisory Group(NITAG)?

0 = No
1 = Yes (but it does
not satisfy all six WHO
criteria)
2 = Yes

0–1–2

Economist Impact
country research

1.2.3

Health sector
coordination

Is there evidence of coordination
mechanisms/partnerships forhealth sector stakeholders
to participate in planning,
implementation and monitoringof immunisation programmes?

0 = No
1 = Yes

0–1

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1.3 Monitoring and evaluation
1.3.1

Surveillanceof vaccinepreventablediseases

Does the country have asurveillance system for vaccinepreventable diseases that
includes the ability to detectoutbreaks and new pathogens?

0 = No
1 = Yes (but there isinsufficient evidenceof a system that can
detect outbreaks andnew pathogens)
2 = Yes

0–1–2

Economist Impact
country research

1.3.2

Healthmanagement
committee

Does the country have a healthmanagement committee(or equivalent) to review
immunisation performance?

0 = No
1 = Yes

0–1

Economist Impact
country research

1.3.3

Pharmacovigilance

Does the country have a system
to track, report and investigate
vaccine-related adverse eventsin a timely and consistentmanner?

0 = No
1 = Yes (but not in atimely or consistentmanner)2 = Yes

0–1–2

Economist Impact
country research

1.3.4

Commitment tosurveillance datasharing

Has the country committed
to share surveillance data on
vaccine-preventable diseases
with other countries?

0 = No
1 = Yes

0–1

Economist Impact
country research

Domain 2: Regulation
2.1 Regulatory approval and standards
2.1.1 Regulatory approval mechanisms
2.1.1aRegulatory
approvalmechanism for
new vaccines forhumansIs there a government agency
responsible for approving
new vaccines for humans, or alegal mechanism for adopting
regulatory decisions from othercountries or WHO for the use of
new vaccines?

0 = No
1 = Yes

0–1

Economist Impact
country research

2.1.1b

Expedited
approval process
for public healthemergencies

Is there an expedited process
for approving vaccines forhuman use during public healthemergencies?

0 = No
1 = Yes

0–1

Economist Impact
country research

2.1.2

Oversightof vaccine
manufacturing
standards

Is there an agency that provides
oversight of manufacturing
standards for vaccines usedwithin the country?

0 = No
1 = Yes

0–1

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2.2 Engagement
2.2.1

Regional orinternational datasharing related tovaccine-approval
process

Is there evidence of anagreement to participate inregional or international datasharing related to the vaccineapproval process?

0 = No
1 = Yes

0–1

Economist Impact
country research

2.2.2

Engagement withvaccine R&D
companies and/or
manufacturers

Is there evidence that therelevant regulatory agency
that engages with vaccine
R&D companies and/or
manufacturers?

0 = No
1 = Yes

0–1

Economist Impact
country research

Domain 3: Procurement
3.1 Procurement mechanisms
3.1.1

Demandforecasts fornational vaccine
requirements

Is there an annual demand
forecast for national vaccine
requirements that includes longterm forecasts extending 5 years
or more?

0 = No
1 = Yes (but it does
not include long-term
forecasts extending 5
years or more)
2 = Yes

0–1–2

Economist Impact
country research

3.1.2

Procurement
strategy thatconsiders factors
other than price

Does the national procurement
strategy consider factors otherthan price in its decisionmaking?

0 = No
1 = Yes

0–1

Economist Impact
country research

3.2 Financing
3.2.1

Sufficient budget
for procurementand delivery

Is there a sufficient annual
budget for procuring anddelivering the vaccines
recommended in the national
strategy?

0 = No
1 = Yes

0–1

Economist Impact
country research

3.2.2

Dedicated
emergency
vaccine financing
mechanism

Is there a dedicated emergency
financing mechanism or fundthat the country can access to
procure vaccines during publichealth emergencies?

0 = No
1 = Yes

0–1

Economist Impact
country research

3.2.3

Current HealthExpenditure (CHE)
per capita

What is the current healthexpenditure per capita?

Quantitative indicatorusing existing dataset

US$

World Bank

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Domain 4: Delivery
4.1 Health system infrastructure
4.1.1

Delivery infrastructure for vaccines

4.1.1aNational
immunisation
infrastructure
integration

Is the national immunisation
infrastructure integrated into
primary healthcare and/or publichealth services?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.1.1b

Non-traditional
vaccine delivery
strategies

Is there evidence that nontraditional delivery strategies areused to deliver vaccines?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.1.2

Digital vaccination
records(integrated withnational healthinformation
system)Are there interoperable digital
vaccination records, and are they
integrated with a national healthinformation system?

0 = No
1 = Yes (but they are
not integrated orinteroperable)
2 = Yes

0–1–2

Economist Impact
country research

4.1.3

Vaccine inventory
management

Is there a national management
system for monitoring vaccine
stocks?

0 = No
1 = Yes

0–1

Economist Impact
country research

What is the average coverage ofessential health services?
(Universal health coverage isan index based on indicatorsthat measure reproductive,
maternal, newborn and childhealth, infectious diseases,
non-communicable diseases
and service capacity and access,among the general and the mostdisadvantaged populations.)

Quantitative indicatorusing existing dataset%

WHO: UHC Service
Coverage Index

4.2 Access to healthcare
4.2.1

Universal Health
Coverage (UHC)
Service Coverage
Index

4.2.2

Healthcare workforce

4.2.2aGeneralpractitioners (GPs)

What is the reported number of
GPs?

Quantitative indicatorusing existing dataset

Per 1,000
population

World Bank

4.2.2bPharmacists

What is the reported number ofpharmacists?

Quantitative indicatorusing existing dataset

Per 10,000
population

WHO©Economist Impact 2023

Immunisation Readiness Index

4.2.2cNurses andmidwives

What is the reported number ofnurses and midwives?

73

Quantitative indicatorusing existing dataset

Per 1,000
populationWHO

4.2.3 Health workforce capacity
4.2.3aData onhealth worker
competency inimmunisation

Is data collected and publishedon the number of healthstaff that are competent in
immunisation?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.2.3bNational healthworker training
programme for
immunisation

Is there a national healthworker training programme for
immunisation?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.2.3cEmergency
workforce strategy
for public healthemergencies

Is there a strategy for
deploying human resources for
vaccination during public healthemergencies?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.3 Distribution systems
4.3.1

Vaccine delivery
and storage
infrastructure(cold chain)

Is there evidence of sufficientvaccine delivery (the ability
to meet and maintaintemperatures required totransport and store vaccines)
in more than 80% of counties/
districts in the country?

0 = No
1 = Yes

0–1

Economist Impact
country research

4.3.2

Culturally
appropriate
distribution
practices

Is there a system for reachingmarginalised and hard-to-reach
populations using culturally
appropriate practices, withevidence that the country
recognises that training andplanning are necessary to reachtargeted communities?

0 = No
1 = Yes (there isa plan to reachspecific marginalisedcommunities, but it
does not specify thattraining and planning
are necessary toaccomplish this goal)
2 = Yes

0–1–2

Economist Impact
country research

4.3.3

Delivery system
testing

Is vaccine delivery tested via
a nationwide campaign orfunctional exercise?

0 = No
1 = Yes

0–1

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Domain 5: Outreach
5.1 Education programmes
5.1.1

Public education
programme on
immunisation

Is there a funded public
education programme on
immunisation for improving
health literacy, including digital
health literacy?

0 = No
1 = Yes (but it does notinclude digital healthliteracy)
2 = Yes

0–1–2

Economist Impact
country research

5.2 Public outreach
5.2.1.

Riskcommunications
strategy

Is there a risk-communication
strategy for vaccine-preventablediseases?

0 = No
1 = Yes

0–1

Economist Impact
country research

5.2.2

Communication
strategies toovercome barriers
to vaccination

Does the national immunisation
strategy/plan include
communication strategies
specifically aimed at overcoming
socioeconomic inequalities,
geography, cultural/linguistic
differences and/or genderbarriers to vaccination?

0 = No
1 = Yes

0–1

Economist Impact
country research

5.2.3

Research into
public attitudes
towards vaccines

Has the country conducteda survey of the population
to gauge attitudes towards
vaccines or vaccination in thepast 5 years (2018–2022)?

0 = No
1 = Yes

0–1

Economist Impact
country research

Domain 6: Society
6.1 Access to education
6.1.1

Adult literacy rate

What percentage of thepercentage of people aged 15
and above can both read andwrite in their everyday life?

Quantitative indicatorusing existing dataset% ofpopulation>15 years

UNESCO Institute for
Statistics

6.1.2

Mean duration ofschooling

What is the average number ofcompleted years of education
for those aged 25 years andabove?

Quantitative indicatorusing existing dataset

Years

World Bank

6.1.3

Primary school
attendance rate

What percentage of eligible
students are enrolled in a
primary school programme?

Quantitative indicatorusing existing dataset% ofpopulation

World Bank

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6.2 Communications infrastructure
6.2.1

Households with
Internet

What percentage of households
reported access to the internet?

Quantitative indicatorusing existing dataset% ofhouseholds

International
Telecommunication
Union

6.2.2

Mobile cell-phoneuseWhat is the total number ofmobile cell-phone subscriptions?

Quantitative indicatorusing existing dataset

Subscriptions
per 100
inhabitants

International
Telecommunication
Union

6.3 Quality of governance
6.3.1

Government
effectiveness

What is the country's score on
the Government EffectivenessIndex?
(The World Bank's World
Governance Indicators define
government effectiveness as"capturing perceptions of thequality of public services, thequality of the civil service andthe degree of its independence
from political pressures, thequality of policy formulationand implementation, and thecredibility of the government's
commitment to such policies.")Quantitative indicatorusing existing dataset

Standard
deviations
from mean(positive= aboveaverage)

World Bank, WGI

6.3.2

Corruption
Perception Index

What is the country's scoreon the Corruption Perception
Index?
(The Corruption Perception
Index measures the perceived
level of public sector
corruption.)

Quantitative indicatorusing existing dataset

0–100(100 = lowest
perceived
level ofcorruption)

Transparency
International

6.3.3

Political stability

What is the country's score on
the Political Stability Index?
(The Political Stability Index"measures perceptions of thelikelihood of political instability
and/or politically-motivatedviolence, including terrorism.")

Quantitative indicatorusing existing dataset

Standard
deviations
from mean(positive= aboveaverage)

World Bank, WGI©Economist Impact 2023

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Appendix D
Case studies: selected countries over-performing relative to
expectations
Some countries performed better than one expected based on their reported immunisation rates. The
following three case studies provide more context with respect to country-specific performances, anddraw attention to discrepancies between immunisation readiness and immunisation rates. Each casestudy includes a:• a country profile illustrating the level of immunisation readiness• population vaccination rates for:- covid-19

18- the third dose of a diphtheria, tetanus and pertussis vaccine (DTP3)- the final dose of a measles-containing vaccine (MCV2)

1515• a rationale for the country’s performance• recommendations for improvements in immunisation readiness
It is our hope that highlighting areas in which countries do well (as well as those where improvements
can be made) will enable policymakers and other stakeholders to focus their efforts on improving
immunisation throughout their populations while creating an environment that is conducive toachieving immunisation goals.
For more information about any specific country policies and practices, or immunisation rates for theroutine vaccines below, please see the interactive Data Dashboard.

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Colombia
Figure D1. Immunisation Readiness in Colombia

Colombia’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries
All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

Index measure

Table D1. Vaccination rates for vaccines against covid-19, diphtheria, tetanus and pertussis(DTP3) and measles (MCV2) in Colombia, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
71.4%

15

86.0%

15

86.0%

MCV2

Rationale for performance
Despite reported vaccination rates that were below immunisation targets, Colombia performed wellin the Planning and Regulation domains, which are essential for a robust immunisation programme.
Colombia’s Extended Programme on Immunisation has well-developed policy and regulatory structures,alongside several agencies and institutions that support efforts related to vaccination and vaccine45
preventable diseases. The agencies include Columbia’s National Institute of Health, the National Foodand Drug Surveillance Institute and the Agency for Integrated Management of Immuno-preventable
Diseases. Most importantly, this interconnected web of institutions is properly backed by legislation,46
ensuring legal support for their respective activities. Despite the opportunities for improvement
described below, Colombia performed above the average observed across the thirty Index countries.

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Building better Immunisation Readiness in Colombia
Colombia has much lower performance in the Outreach and Society domains than in the Planningand Regulation domains, with the potential for improvement in the Procurement and Delivery
domains. The lower performance in Outreach relates to its public education programme, which lacks
consistency and structure, and there are socioeconomic and demographic factors that may act asbarriers to its immunisation efforts, including low performance on the Corruption Perception Index
and Political Stability Index (in the Society domain). Similarly, research suggests that barriers to routine
vaccination include factors relating to parents (e.g. a lack of time), adverse events concerns, andreligious and cultural beliefs, and such a combination of factors may contribute to the below-target
vaccination rates.

FranceFigure D2. Immunisation Readiness in France
France’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries

All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

Index measure

Table D2. Vaccination rates for covid-19, diphtheria, tetanus and pertussis (DTP3)
and measles (MCV2) in France, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
78.4%

15

96.0%

15

86.0%

MCV2

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Rationale for performance
France had above-average performance in all domains, with its best performance in the Regulation
domain. It has a robust immunisation programme covering nearly all analysed aspects within the
Immunisation Readiness Index, including a dedicated budget, target rates for vaccination, and a47
significant focus on preventing diseases amenable to vaccination. There is also a strong emergency
48
mechanism that allows it to attain immunisation goals in public health emergencies, consistent with
reports from late 2021 detailing the success of the French Health Pass. It did little to decrease hesitancy
49
for covid-19 vaccines, but it successfully increased vaccine uptake, with the share of individuals
receiving both doses of the initial regimen increasing from 49% in July 2021 to 89% in mid-December
50
2021. This demonstrates France’s ability to harness the potential of vaccines in public healthemergencies.
Building better Immunisation Readiness in France
In 2022, research began to show the shortcomings of the Health Pass programme, including a failure
51
to address inequities related to vaccination as reported in the media. The delivery system in France
also lacked distribution efficiency. There was no system for reaching marginalised populations and it
does not appear that over 80% of the country’s districts have been reached. The country scores wellin Regulation and the Finance area of Procurement, but there are opportunities to improve in the
Planning and Delivery domains and the operationalisation and implementation of vaccination policy.

Indonesia
Figure D3. Immunisation Readiness in Indonesia
Indonesia’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries
All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

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Table D3. Vaccination rates for covid-19, diphtheria, tetanus and pertussis (DTP3) and measles(MCV2) in Indonesia, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
62.7%

15

67.0%

15

50.0%

MCV2

Rationale for performance
Indonesia performed above average for all domains except the Regulation domain, which wasslightly below the all-country average. Its best performance was in the Planning domain, because its
52
National Immunisation Plan satisfies most of indicators studied. The Ministry of Health coordination
mechanisms with other public programmes and sectors, with a well-developed level of community
empowerment that involves religious and community leaders in supporting vaccination, as assessed in53
its Joint External Evaluation.
Building better Immunisation Readiness in Indonesia
During the last decade, Indonesia has been committed to building immunisation readiness, including
the establishment of the National Immunisation Technical Advisory Group (NITAG) and immunisation
53
performance reviews. However, there was a time lag between the establishment of groups andprogrammes focused on the immunisation infrastructure and the increased rates of immunisationof the population. Vaccination coverage rates increase each year, but remain below the WHO
53
immunisation targets, due to inequality in access due to socioeconomic and demographic factors. Its
lowest performance was in the Society domain, which covers socioeconomic factors.

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Appendix E
Case studies: selected countries under-performing relative to
expectations
Some countries did not perform as well as expected based on their reported immunisation rates. The
following three case studies provide more context related to country-specific performance, and draw
attention to discrepancies between immunisation readiness and immunisation rates. Each case study
includes:• a country profile illustrating the level of immunisation readiness• population vaccination rates for:18

- covid-19

15- the third dose of a diphtheria, tetanus and pertussis vaccine (DTP3)
15- the final dose of a measles-containing vaccine (MCV2)• a rationale for the country’s performance• recommendations for improvements in immunisation readiness
It is our hope that highlighting areas in which countries do well (as well as those where improvements
can be made) will enable policymakers and other stakeholders to focus their efforts on improving
immunisation throughout their populations while creating an environment that is conducive toachieving immunisation goals.
For more information about any specific country policies and practices, or immunisation rates for theroutine vaccines below, please see the interactive Data Dashboard.

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Japan
Figure E1. Immunisation Readiness in Japan
Japan’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries
All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

Index measure

Table E1. Vaccination rates for covid-19, diphtheria, tetanus and pertussis (DTP3) and measles(MCV2) in Japan, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
83.4%

15

96.0%

15

95.0%

MCV2

Rationale for performance
Japan performed well in the Regulation and Society domains, indicating that its approach is conducive
to supporting immunisation efforts and achieving immunisation goals. There is a contingency plan for
public health emergencies, and there are evidence-based guidelines that state which groups should54
be vaccinated and when. Furthermore, performance was above average in the Procurement and55
Delivery domains. The healthcare workforce is capable of vaccinating the population and the country
56
scores high on the Universal Health Coverage Index.

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Building better Immunisation Readiness in Japan
While its immunisation rates exceed immunisation targets, Japan’s performance in the Planningdomain indicates that more can be done to ensure that its policies are structured to promote thesustainability of immunisation success in the long term. The immunisation strategy does not include
a dedicated budget, or target rates for vaccination, or a focus on equity. There are opportunities
to improve the national immunisation strategy by updating it to include these important factors.
Performance in the Outreach domain can also be enhanced by developing educational programmesthat support the use of vaccination to combat vaccine-preventable diseases and promote knowledge
and uptake across the population.

SenegalFigure E2. Immunisation Readiness in Senegal
Senegal’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries
All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

Index measure

Table E2. Vaccination rates for covid-19, diphtheria, tetanus and pertussis (DTP3) and measles(MCV2) in Senegal, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
8.3%

15

85.0%

15

75.0%

MCV2

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Rationale for performance
57

Senegal has been regarded as a leader in developing immunisation programmes due to its successes
in vaccinating the public and reducing mortality rates among children under 5 years of age. However,these successes were not reflected within national policy; examination of its existing policies revealed
below-average performance across all domains. Key pieces of national immunisation policies
and strategies are missing, that are known to be essential for achieving equitable and sustainable
58
immunisation programmes. Despite having many opportunities for improvement, Senegal
demonstrates an ability to provide population-wide vaccination that improves health outcomes andindicates its commitment to providing access to immunisations. This is reflected by its performance in
the indicators measuring the use of community health workers to promote vaccination over the last57
few decades.
Building better Immunisation Readiness in Senegal
To improve readiness level, Senegal can codify its commitment within its policies, to formally endorse
vaccinations within national policy and further support the infrastructure necessary to promote its
immunisation efforts. Detailed national immunisation policies and strategies are helpful for promoting
the improvement of immunisation programmes, and policies must be published in the public domain– not only for the benefit of the public but also for those who are able to provide support to thecountry or learn from its success.

USA
Figure E3. Immunisation Readiness in the USA
USA’s overall and domain performance in the Immunisation Readiness Index compared tothe averages for all Index countries
All countires (average)
100
90
80

Performance

70
60
50
40
30
20
10
0

Immunisation
Readiness(1)
Planning(2)
Regulation(3)
Procurement(4)
Delivery(5)
Outreach(6)Society

Index measure©Economist Impact 2023

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Table E3. Vaccination rates for covid-19, diphtheria, tetanus and pertussis (DTP3) and measles(MCV2) in the USA, as included in the Data Dashboard
Type of vaccine
18

Covid-19
DTP3

Vaccinated population
69.5%

15

93.0%

15

95.0%

MCV2

Rationale for performance
While the USA consistently performed above the all-country average, its overall immunisation
readiness score was lower than expected based on its ability to meet and exceed vaccination targets.
It performed best in the Regulation domain, and has regulatory approval processes for new vaccines,
59,60
including an emergency approval mechanism that can be used in public health emergencies.
61
It also engages with a variety of stakeholders, including vaccine manufacturers. Furthermore, its
performance is above average in the Procurement and Delivery domains, particularly with respect tovaccine financing.
Building better Immunisation Readiness in the USA
Under the US system, public health – including vaccination – is not a federal government
62,63
responsibility; rather, individual state governments are responsible.
Some state programmes satisfy
the indicators in the Index, but the international guidance recommends that policies and programmes
are best carried out with specific guidance, funding and support at a national level. There havebeen challenges for many decades because of the separation of roles and responsibilities between
63federal and state governments in the health arena. Without an overarching federal government
responsibility, the national government lacks an ability to manage programmes across state lines
and consequently, cannot guarantee that access, education, and outreach are being carried out in asustainable or equitable manner. This lack of a national approach to delivery infrastructure impacts
the success of immunisation programmes and the ability to provide vaccinations to the entire
population, which is reflected in performance relating to procurement, health system infrastructure,and the Outreach domain. Opportunities to improve outreach include the federal government
providing more detailed guidelines and funding for states to use in creating their own individual
outreach programmes.

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