Table 1.

Summary table of studies reporting PCV implementation in MICs

Reference	Country	Issues	Solutions
Blau et al. [14]	Albania, Azerbaijan, Georgia, Croatia	Lack of local expertise in health economic and economic evaluation. Lack of available national data on disease burden and cost of treatment of disease preventable by new vaccines.	• to use cost-effectiveness analysis to strengthen decision making in immunization policy and to ensure the sustainability of vaccine introduction • to provide economic evidence to help decide if introducing new vaccine should be prioritized along with other public health programs • to maximise the commitment and support of existing advisory bodies in the country: National Immunization Technical Advisory Group (NITAG) or Interagency Coordination Committee (ICC) • to provide scientific recommendations to support final decisions of introducing PCV
Bonner et al. [16]	LICs and MICs (list of countries not specified)	The cost of PCV can be prohibitive, discouraging countries from including it in their EPI schedules.	• GAVI and its donors should respond to WHO recommendations and countries’ needs and expand the vaccine subsidy window for vaccination in children up to age five • policy should be formulated to ensure that PCV is used in emergency contexts, including in extended age groups, as a rapid intervention to limit IPD-related morbidity and mortality • the global immunization community should address the obstacles to systematically using PCV as part of the health service package in emergencies
Gordon et al. [18]	LICs and LMICs (list of countries not specified)	Lack of economic expertise and an explicit desire to include economists in their NITAGs and interagency co-ordinating committees. The availability and consistency of financing was uniformly reported to be the greatest challenge.
Levine et al. [20]	Global		• the need for post-introduction surveillance to monitor vaccine impact and any shifts in the serotype distribution
Moon et al. [17]	Developing countries (list of countries not specified)	No mechanism is in place ensuring that poorer countries get the lowest possible prices. This case underscores the difficulty in determining what is a “fair” price for MICs.
Philippe et al. [13]	Global	Limited access to international support is resulting in LMICs beginning to lag behind the poorest countries in protecting their populations from vaccine-preventable diseases using newer vaccines and combination vaccines. Strong disease surveillance and programme monitoring systems are required.	• to seek more suitable formulations and presentations of new vaccines • surveillance of diseases targeted by new vaccines including enhanced laboratory networks and centres of excellence • supporting the establishment/strengthening of National Immunization Technical Advisory Committees • to ensure evidence-based decision at country level, which is particularly needed in view of the complexity of the immunization programs and cost of new vaccines
Saxenian et al. [19]	GAVI graduating countries: Indonesia, Sri Lanka, Angola, Bolivia, Azerbaijan, Honduras, Georgia, Congo, Moldova, Armenia, Mongolia, Guyana, Bhutan, Kiribati	Countries had not carried out detailed financial projections of vaccine costs by funding source.	• Ministry of Health should ensure that vaccine procurement methods result in competitive prices for high quality products • need to build specialised market knowledge and skills • a well-functioning national regulatory agencies (NRA) • to maximise the commitment and support of existing advisory bodies in the country (NITAG)
Shen et al. [15]	Developing countries (list of countries not specified)	(1) policy, standards, and guidelines; (2) governance, organization and management; (3) human resources; (4) vaccine, cold chain, and logistics management; (5) service delivery; (6) communication and community partnerships; (7) data generation and use; (8) sustainable financing. An enabling environment, even in the poorest countries, depends on the political will of decision-makers.	• a strong routine immunization platform to benefit the overall health system by generating policy and skilled human resources • NITAGs is to guide the development of national immunization policies, guidelines, and standards • NRAs are necessary if countries are to self-procure and ensure a reliable supply of quality vaccines • to improving governance, organization, and management of routine immunization include • to invest to build the capacity and professional development of an appropriately trained health care • educating and mobilising the public to support immunization and to use immunization services is central to EPI • the generation of high-quality immunization data is important to informing programmatic decisions • sustainable financing