2. How is the economic assessment of vaccines performed today?

Figures & data

Table 1. Overall and specific evaluation under medical attention only; and comparison of QoL-loss avoided for a cohort of 100,000 subjects by specific treatment versus vaccine prevention (hypothetical example).

				No specific treatment		Specific treatment		Vaccine prevention
	Impact (Vaccine Efficacy)					0.9		0.9
			QoL-loss	Days	QoL/year	Days	QoL/year	Days	QoL/year
Overall evaluation	Pre-medical	Disease	−0.1	4	−0.0011	4	−0.0011	0.4	−0.00011
	Medical	Disease 1st day	−0.2	1	−0.00055	1	−0.0005	0.1	−0.000055
		Disease subsequent days	−0.3	7	−0.00575	0.7	−0.0006	0.7	−0.0006
	Post-medical	Recovery	−0.1	3	−0.00082	1	−0.0003	0.3	−0.0001
	Total				−0.00822		−0.0025	−0.0007
			Proportion^a
	Pre-medical	Disease	0.3		−32.87671		−32.877		−3.2877
	Medical	Disease 1st day	0.15		−8.21918		−8.2192		−0.8219
		Disease subsequent days	0.15		−86.30137		−8.6301		−8.6301
	Post-medical	Recovery	0.1		−8.21918		−2.7397		−0.8219
	Total				−135.6164		−52.466	−13.5616
	Gain in less QoL-loss					83.1506		122.0548
	Additional gain in less QoL-loss							38.9041
			QoL-loss	Days	QoL/year	Days	QoL/year	Days	QoL/year
Specific evaluation under medical attention only	Pre-medical	Disease	0	0	0	0	0	0	0
	Medical	Disease 1st day	−0.2	1	−0.00055	1	−0.0005	0.1	−0.000055
		Disease subsequent days	−0.3	7	−0.00575	0.7	−0.0006	0.7	−0.0006
	Post-medical	Recovery	0	0	0	0	0	0	0
	Total				−0.0063		−0.0011	−0.00065
			Proportion^a
	Pre-medical	Disease	0		0		0		0
	Medical	Disease 1st day	0.15		−8.21918		−8.2192		−0.8219
		Disease subsequent days	0.15		−86.30137		−8.6301		−8.6301
	Post-medical	Recovery	0		0		0		0
	Total				−94.52055	−16.849			−9.452
	Gain in less QoL-loss					77.671		85.0686
	Additional gain in less QoL-loss							7.3973

^aProportion of the total population cohort.

QoL, quality of life.

Figure 1. Comparison of treatment versus prevention: hypothetical example (a) Assessing the individual quality of life (QoL) gain or loss with prevention and treatment; (b) Impact difference between treatment and prevention at a population level (cohort of 100,000 subjects). QoL, quality of life

Figure 2. Schematic view of the different levels of vaccine benefit.

Figure 3. Incremental cost-utility ratio (ICUR) per QALY gained versus intervention cost (CostI) comparing treatment (blue line) versus vaccine (green line). ICUR, incremental cost-utility ratio; CostI, intervention cost; QALY, quality-adjusted life-years. (A) Cost-offset when two treatments are compared; (B) The difference in cost between the cost-neutral point (Cn1) and the cost where the line reaches the threshold (Cm1) for a treatment compared with another treatment; (C) Cost-offset when a vaccine is compared with a treatment; (D) The difference in cost between Cn2 and the cost where the line reaches the threshold (Cm2) for a vaccine compared with a treatment; T, threshold value.

Table 2. Evaluation tools for assessing the economic value of vaccines.

Name	Benefit	Cost	Summary	Value	References
Cost-effectiveness using cost-utility gain	Expressed as QALY gained	All different cost items to be considered	Ratio of the cost-difference divided by a QALY difference being under or equivalent to a local threshold	Incremental cost-effectiveness result expressed in money terms	[45]
ECEA	Expressed in QALYs gained + financial risk protection (reduction in out of pocket payment)	All different cost items to be considered	Cost effectiveness ratio for the health gain and % of financial risk protection achieved	Combines economic and social indicators to prioritise new interventions at household level	[46]
Cost-Benefit	All benefits are expressed in monetary terms	All different cost items to be considered	Select the intervention with the highest cost value for society	Every benefit is evaluated in monetary terms and equal money weight is given to each item in the equation	[25,47]
Cost-Consequence	Selects an item of importance to be improved with the new intervention	Medical and non-medical cost	Example is the payment made per hospitalisation avoided, or medical visit avoided	No value is given to events that have been avoided.	[48]
Portfolio management	Specific health goal to optimise through the use of different vaccines in a specific sequence over time	Budget constraint in the analysis, but other constraints can be included as well such as logistics	List of vaccine introduction in a multi-year, multi-budget plan with the highest health outcome benefit to be achieved within a specific time frame	Answers questions on the order in which vaccines should be implemented and what budget plan guarantees the highest health benefit within a specific time frame	[49]
Optimisation modelling	Evaluates a single vaccine introduction in terms of reaching a certain health goal within a time and budget frame	Budget limitation will identify how to reach the health goal	Optimisation is different from cost-effectiveness. Optimisation makes the link between budget and health goals to be reached within a time frame	Many decision makers prefer optimisation analysis above cost-effectiveness analysis because it uses the normal budget framework and it allows better combination of options	[24,50,51]
Return on investment	What is the return in tax payment if the population is kept healthy through vaccination?	Investment in vaccination, cost-offsets, extra payment in education, pension	Ministry of Plans and Finance are comfortable with the approach because of the terminology used (IRR)	Open the dialogue with decision-makers other than Ministry of Health	[42,52]
Poverty trap avoidance	Proportion of households staying above the income threshold of poverty	Household spending per time unit	The new intervention avoids sick conditions in households which improves productivity and reduces cost for medical care which avoids the fall into the poverty trap without openings of recovery	If more households stay away from the poverty trap, it may improve the local economic and welfare condition of the community under study	[53–55]
RSA	Mitigating financial risk with access to vaccines; cost-based deals instead of performance based	Payer’s budget is at risk with high investment at start	Financial risk through uncertainty in effectiveness, safety, uptake, supply, real-world implementation	Assessment through dose schemes, target population, herd protection and delayed benefit	[56]
Macro-economic assessment	Impact of a vaccination program on the improvement of macro-economic indicators such as GDP	GDP per capita and vaccine cost	Extended control of infectious diseases in children with vaccination programmes may impact the whole economy of a country	Not many health interventions are able to demonstrate a real impact on the economy through better specific disease control	[43]

ECEA, extended cost-effectiveness analysis; GDP, gross domestic product; IRR, internal rate of return; QALY, quality-adjusted life-years; RSA, risk sharing agreements.

Drummond M, Sculpher M, Torrance G, et al. Cost-utility analysis. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005. p. 137–210.

 Google Scholar

Verguet S, Kim JJ, Jamison DT. Extended cost-effectiveness analysis for health policy assessment: a tutorial. Pharmacoeconomics. 2016;34(9):913–923.

 PubMed Web of Science ®Google Scholar

Bala MV, Zarkin GA, Mauskopf JA. Conditions for the near equivalence of cost-effectiveness and cost-benefit analyses. Value Health. 2002;5(4):338–346.

 Web of Science ®Google Scholar

Barnighausen T, Bloom DE, Canning D, et al. Rethinking the benefits and costs of childhood vaccination: the example of the Haemophilus influenzae type b vaccine 2. Vaccine. 2011;29(13):2371–2380.

 Web of Science ®Google Scholar

Mauskopf JA, Paul JE, Grant DM, et al. The role of cost-consequence analysis in healthcare decision-making. Pharmacoeconomics. 1998;13(3):277–288.

 PubMed Web of Science ®Google Scholar

Topachevskyi O, Standaert B, Van Bellinghen L, et al. Can a Multi-Criteria Decision (MCD) optimisation model help decision makers in the optimal selection of vaccines when expanding their universal mass vaccination programme? The case of Poland. Value Health. 2013;16(7):A615.

 Web of Science ®Google Scholar

Standaert B, Curran D, Postma J. Budget constraint and vaccine dosing: a mathematical modelling exercise. Cost Eff Resour Alloc. 2014;12(1):3.

 Web of Science ®Google Scholar

Demarteau N, Breuer T, Standaert B. Selecting a mix of prevention strategies against cervical cancer for maximum efficiency with an optimization program. Pharmacoeconomics. 2012;30(4):337–353.

 Web of Science ®Google Scholar

Earnshaw SR, Dennett SL. Integer/linear mathematical programming models: a tool for allocating healthcare resources. Pharmacoeconomics. 2003;21(12):839–851.

 Web of Science ®Google Scholar

Connolly MP, Topachevskyi O, Standaert B, et al. The impact of rotavirus vaccination on discounted net tax revenue in Egypt: a government perspective analysis. Pharmacoeconomics. 2012;30(8):681–695.

 Web of Science ®Google Scholar

Kotsopoulos N, Connolly MP, Postma MJ, et al. Fiscal consequences of changes in morbidity and mortality attributed to rotavirus immunisation 1. Vaccine. 2013;31(46):5430–5434.

 PubMed Web of Science ®Google Scholar

Somi MF, Butler JR, Vahid F, et al. Economic burden of malaria in rural Tanzania: variations by socioeconomic status and season. Trop Med Int Health. 2007;12(10):1139–1147.

 Web of Science ®Google Scholar

Su T, Kouyate B, Flessa S. Catastrophic household expenditure for health care in a low-income society: a study from Nouna District, Burkina Faso. Bull World Health Organ. 2006;84(1):21–27.

 PubMed Web of Science ®Google Scholar

Adamski J, Godman B, Ofierska-Sujkowska G, et al. Risk sharing arrangements for pharmaceuticals: potential considerations and recommendations for European payers. BMC Health Serv Res. 2010;10:153.

 PubMed Web of Science ®Google Scholar

Sachs J, Malaney P. The economic and social burden of malaria. Nature. 2002;415(6872):680–685.

 PubMed Web of Science ®Google Scholar