Integrated vaccine economics for countries transitioning from Gavi support
Authors: Maarten van Wijhe, Lone Simonsen
Journal: The Lancet Global Health (2019)

Rotavirus is a leading cause of childhood deaths from diarrhoea and one for which vaccines are fortunately available. In The Lancet Global Health, Frédéric Debellut and colleagues1Debellut F Clark A Pecenka C et al.Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling study.Lancet Glob Health. 2019; 7: e1664-e1674Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar evaluate the cost-effectiveness of rotavirus vaccines in 73 countries that now or recently had received financial support from Gavi, the Vaccine Alliance, for their childhood vaccine programmes. The evaluation is timely for at least two important reasons. First, two new rotavirus vaccines are now available at less than half the cost of the original two. Second, paediatric diarrhoeal mortality burden has declined dramatically in low-income countries worldwide in the past decade. This last point is important to emphasise as this reduction is partly due to factors other than rotavirus vaccines. Such factors include the effects of improving sanitation, medical care, maternal education, and other factors linked to an improving economy.2GBD 2016 Diarrhoeal Disease CollaboratorsEstimates of the global, regional, and national morbidity, mortality and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Infect Dis. 2018; 18: 121-128PubMed Google Scholar, 3Do carmo GMI Yen C Cortes J et al.Decline in diarrhea mortality and admission after routine childhood rotavirus immunization in Brazil: a time-series analysis.PLoS Med. 2011; 8e1001024Crossref PubMed Scopus (191) Google Scholar, 4Kanyuka M Ndawala J Mleme T et al.Malawi and Millennium Development Goal 4: a countdown to 2015 country case study.Lancet Glob Health. 2016; 4: 201-214Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 5Burstrom B Macassa g Oberg L et al.Equitable child health interventions: the impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925.Am J Public Health. 2005; 95: 208-216Crossref PubMed Scopus (46) Google Scholar This effect has also been shown in other areas, like the profound decline in respiratory paediatric mortality in the decades before pneumococcal vaccines were in use.6Schuck-Paim C Taylor RJ Alonso WJ et al.Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study.Lancet Glob Health. 2019; 7: e249-e256Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar In terms of cost-effectiveness, these two factors pull in opposite directions: on the one hand, an expensive vaccine becomes cheaper, while on the other hand, the potential health effect declines. Debellut and colleagues' study is therefore a much needed update on this issue, and the key message is that, despite these changes, rotavirus vaccine remains highly cost-effective in most Gavi-supported countries. Debellut and colleagues address the changing and varying landscape of rotavirus cost-effectiveness by accounting for the different vaccine choices made in each country and the background decline in childhood mortality that is expected even in the absence of a vaccine. Still, rotavirus vaccine was projected to be strongly cost-effective for the decade 2018–27 in all but four of the 73 Gavi-supported countries, and might avert about 80 million outpatient visits, around 8 million hospitalisations, and over half a million deaths. From a government perspective with Gavi support, the vaccine was highly cost-effective at an overall US$264 per disability-adjusted life year (DALY) averted, corresponding to one sixth of the per-capita gross-domestic product (GDP). WHO considered interventions up to 1 times GDP per capita per DALY to be highly cost-effective, but nowadays have shifted to recommend country specific thresholds.7World Health OrganizationThe world health report 2002—reducing risks, promoting healthy life. Geneva.https://www.who.int/whr/2002/en/whr02_en.pdf?ua=1Date: 2002Date accessed: October 16, 2019Google Scholar, 8Marseille E Larson B Kazi D et al.Thresholds for the cost-effectiveness of interventions: alternative approaches.Bull World Health Organ. 2015; 93: 118-124Crossref PubMed Scopus (500) Google Scholar, 9Betram MY Lauer JA De Joncheere K et al.Cost-effectiveness thresholds: pros and cons.Bull World Health Organ. 2016; 94: 925-930Crossref PubMed Scopus (394) Google Scholar A key question that still needs addressing is the economics of rotavirus vaccination programmes for countries that have already or will soon graduate from Gavi support because their national economy has improved and passed the Gavi threshold of $1580 GDP. For such countries, the case was less compelling as these must pay an increasing part of vaccine price and typically have a lower disease burden; cost-effectiveness estimates ranged from $108 per DALY averted in the African region to $1081 in the European region. Indeed, as countries transition away from Gavi support, the relative costs of rotavirus vaccines might increase several-fold (figure). Four countries (Armenia, Honduras, Moldova, and Ukraine) who have graduated from Gavi support had less than 50% probability of vaccine cost effectiveness at the 1 times GDP per capita threshold.1Debellut F Clark A Pecenka C et al.Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling study.Lancet Glob Health. 2019; 7: e1664-e1674Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Therefore, Debellut and colleagues rightfully recommend that Gavi-graduating countries should look at the newer, less expensive rotavirus vaccines to offset the loss of Gavi support. This issue ties into another key one that needs more attention; namely, that of affordability. A national vaccine programme might have a considerable effect on a country's health-care budget such that other options for spending are foregone. Thus, even in the case of a cost-effective rotavirus vaccine programme, the question must be asked as to the opportunity costs in terms of alternative health investments. This query is particularly pertinent for countries transitioning out of Gavi support and looking at a new large investment in rotavirus, and probably several other expensive paediatric vaccines, such as the pneumococcal, meningococcal, and human papillomavirus vaccines. Will the health-care budget allow for the new expense for all of these vaccines at market prices? Will the costs disallow other investments in paediatric health? How do we define such opportunity costs, and what time horizon should be included in assessments? Can investments in other areas perhaps be more worthwhile in the long term, such as structurally improving access to health care, improvements in hygiene and maternal education, and so on? A first step would be to consider multiple vaccines in economic analyses and relate this to a nation's health-care budget spending. This would provide a more complete picture of the impact of transitioning from Gavi relevant for policy makers. Such an analysis should also consider what will happen if a country, after years of Gavi support, decides to discontinue rotavirus, and other relatively expensive, vaccines. Will hospitalisation and mortality rates soar, and if so, on what time scale? These questions are still open and need to be addressed in order to allow truly informed policy decisions. Updates of the cost-effectiveness of vaccines, such as those elegantly presented in this issue by Debellut and colleagues, are an important tool for policy makers. Their value can be increased further by considering more than one vaccine at the time. We look forward to studies that provide a broader understanding of the effect of transitioning through Gavi and increasing economic self-reliance, its effect on regional health-care budget, and the opportunity costs incurred. We declare no competing interests. Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling studyRotavirus vaccination continues to represent good value for money across most Gavi countries despite lower rotavirus mortality estimates and more stringent willingness-to-pay thresholds. Full-Text PDF Open Access