Table 1.

Framework analysis across countries

Problem	Context	Policy implementation and required organizational mechanisms	Key observations
Decline in infant MCV coverage	Global rise of antivaccination sentiment; increasing levels of misinformation Increased politicization of immunization Decreasing trust in public health authorities, health-care systems, and governments	Stronger central coordination of immunization programs and local/regional implementation Introduction of mandatory vaccination, where appropriate Introduction of central immunization registry to monitor vaccine coverage HCW-led communication to reduce parental vaccine hesitancy Address public concerns through an ongoing informed debate and education; can involve public interest groups to reduce political aspects	Parents have unmet immunization information needs Public trust in immunization is impacted by broader institutional trust Mandatory immunization can trigger short-term negative public reaction but demonstrates a long-term political commitment to immunization
Increasing disease burden in older age groups	Most immunization programs primarily address infant immunization needs Adult immunization access may be limited	Introduction of adult catch-up campaigns (free-of-charge) Increase immunization access through engaging of additional vaccinators (e.g., community pharmacists)	Outbreaks persist despite high national coverage Increasing disease burden is in adults, ethnic and anthroposophical communities, and may not be reached by routine vaccine services Centralized immunization registries can help monitor uptake
Identify and reduce disease burden in hard-to-reach populations	Susceptible/vulnerable communities are characterized by ethnic, religious, socioeconomic, education, or migration status Identified and targeted only after outbreak Conventional outbreak responses may not address specific community needs	Address the specific needs of underserved communities; greater understanding can guide tailored responses and increase compliance Solutions involve community engagement beyond health-care systems	Outbreaks occur in populations with high nationwide coverage where immunization gaps exist in underserved populations Measles importation is important and international communities may share similar immunization attitudes; and may benefit from similar tailored strategies
Ensure agile response to changing epidemiology and outbreaks	Delays in local implementation of outbreak response measures may reduce their impact Public health decisions are not always evidence-based and may be influenced by political factors Resource constraints can reduce the capacity and ability to adapt to changing needs	Clear division of competencies and responsibilities between central and regional health-care systems and strong central coordination can improve impact of response measures Streamlining diverse stakeholder responsibilities can improve response agility	Agile adjustment of immunization policy can address changing disease burden Decentralized health-care systems require cooperation of regional authorities in implementing central strategies; local engagement is important for local public support Stronger central coordination improves the regional commitment Absence of public representation in policy-making may weaken acceptance and lead to challenges to policy decisions