When Are Health Systems Ready for New Vaccines? The Introduction of Pneumococcal Vaccine in Malawi

Abstract

Increasing coverage of routine immunisation and new vaccines is key to reaching Millennium Development Goal number four (MDG 4) on reducing child mortality. Malawi, despite a weak health system, is on track to achieve MDG 4, partly because of its high-performing immunisation programme. Among the early adopters of new vaccines, with major support from Global Alliance for Vaccines and Immunisation, Malawi introduced pneumococcal vaccine in 2011 during a time of severe political and economic crisis. This exploratory case study (part of a larger research project on explaining differential immunisation coverage, conducted in 2010 and 2011, using primarily qualitative methods including in-depth interviewing) looks at the decision-making and policy process for vaccine introduction within the broader political–economic context. Based on a framework of benchmarks on preparedness of immunisation systems and assessments of integration with health systems, the study findings suggest that pneumococcal vaccine introduction was more integrated with key health system functions the closer it got to the point of service delivery. Furthermore, although the vaccine introduction succeeded in relation to immunisation targets and prevention of disease, it may have had substantial indirect costs to other targeted health interventions and broader health systems functions at times when basic amenities are in short supply or unavailable. For a donor-dependent country such as Malawi, policy choices are limited to what is on offer – and new vaccines were on offer; other crucial necessities were not. Further research could establish with more certainty the conditions under which vaccine introduction strengthens health systems that are already weak, and when they push systems further into crisis.

Keywords:

• vaccines
• immunisation
• health systems
• development assistance
• political economy

Notes on contributors

Lot Jata Nyirenda is a Ph.D. candidate at the Institute of Health and Society, Faculty of Medicine, University of Oslo, and a Research Fellow at the Centre for Development and the Environment, University of Oslo. With a background in Medical Sociology he has carried out health systems and health service delivery research since 2005. In his Ph.D. work, he seeks to understand how Malawi achieves relatively high immunisation coverage in a context of a weak health system.

Kristin Ingstad Sandberg, Ph.D., has been Associate Professor at the Center for Development and the Environment, University of Oslo. Her research interests include the dynamics of global public policy and governance, and its interface with national political processes. This interest is in conjunction with a focus on global health as an issue area. She has published papers on the politics of global child immunisation initiatives and the GAVI Alliance in addition to global health as a foreign policy issue.

Judith Justice is a professor of medical anthropology and health policy at the University of California at San Francisco. She has conducted research in South and Southeast Asia and Africa, and served as an evaluator for foundations and international organisations, in addition to working with the United Nations and UNICEF/India. Key research interests include global health policy, foreign assistance to the health sector, the cultural context of infectious disease, and long term multi-country studies on immunisation and adoption of new vaccines.

Notes

¹References to respondents consisted of the following: the respondent number which corresponds to his/her name, the month and the year of interview. For instance, 1 (October 2010) refers to an interview with respondent number 1, conducted in October 2010.

²This is a WHO/UNICEF policy to establish a budget line in the MoH budget, with the expectation that the contribution would be increased in the future – but this has not yet happened with pentavalent vaccines introduced in 2002.

³See http://www.nyasatimes.com/2011/12/01/abomination-malawi-women-paying-to-give-birth/ (accessed 30 September 2013).

⁴See http://www.nyasatimes.com/malawi/2012/04/07/doctors-no-drugs-narrowed-mutharikas-survival/ (accessed 12 July 2012).