Malawi was one of the first countries in Africa to introduce vaccines against rotavirus, the leading cause of severe and fatal diarrhea in young children. The World Health Organization (WHO) made the global recommendation for rotavirus vaccines in 2009 and Malawi introduced the vaccine in 2012, becoming the fourth country in Africa to do so with support from Gavi, the Vaccine Alliance.
The first two years after introduction saw quick declines in diarrhea hospitalizations—a pattern seen in all countries where rotavirus vaccines are introduced. While health benefits were a top priority, decision-makers in Malawi also wanted to know if the program was cost-effective. Based on the way the program was going so far, would the costs be balanced by the benefits? Could Malawi afford the program in the long term, even without Gavi’s financial support? Just how much impact would the program have?
Sounds like a job for health economists.
A clear decision for Malawi
To help answer these questions, PATH’s health economics experts teamed up with economists and clinicians from Malawi, the University of Liverpool, the US Centers for Disease Control and Prevention, and other experts to conduct a cost-effectiveness analysis starting in 2013. The team of scientists utilized a mathematical Excel-based modeling tool called TRIVAC, which allows users to plug in country- and disease-specific information to predict long-term outcomes. Because Malawi was already using the rotavirus vaccine in routine immunization, the analysis collected and used post-introduction health system and household costs in the modeling. In other words, the economists plugged in actual data on real-world vaccine costs and effectiveness from the existing rotavirus vaccination program, instead of projections of what they thought might happen. With the analysis informed by real-world data, Malawi’s decision-makers could have more confidence in the results.
“Over 20 years, Malawi's rotavirus vaccination program would prevent 1,026,000 cases of rotavirus gastroenteritis; 78,000 hospitalizations; 4,300 deaths; and 136,000 disability-adjusted life years.”
The results confirmed what the team predicted—Malawi’s rotavirus vaccination program was highly cost-effective after introduction. The analysis estimated that, over 20 years, the program would prevent 1,026,000 cases of rotavirus gastroenteritis; 78,000 hospitalizations; 4,300 deaths; and 136,000 disability-adjusted life years (DALYs) in Malawi. DALYs, or healthy years lost due to disease, are a commonly used measure in health economics because they account for time lost due to early death as well as time spent in a hospital instead of working, learning, or playing. This information helped health officials in Malawi determine that the rotavirus vaccination program was a strong investment and should continue to be supported.
Then, in 2018, two new rotavirus vaccines were prequalified by WHO: ROTAVAC and ROTASIIL. With new options to choose from, Malawi was interested in an updated cost-effectiveness analysis for all available rotavirus vaccines. PATH's updated analysis found that the new rotavirus vaccine options would also be cost-effective compared to no vaccination in Malawi as well as Ghana and Bangladesh. Determining which product is the least costly option is highly dependent on country-specific variables. As the PATH economists Clint Pecenka and Frederic Debellut comment, "a periodic assessment of current product availability, product characteristics, and prices can help ensure an effective, affordable, and sustainable rotavirus vaccination program."
An important responsibility, a useful tool
Health economics tools, such as the cost-effectiveness analysis in Malawi, help country decision-makers determine the best use of limited resources and help the global health community identify which vaccines will have the greatest impact. Public officials have an important responsibility to spend public funds in a way that brings the greatest benefit to their populations.
While vaccines in general are one of the best buys in global health, specific vaccines and vaccination strategies can have differing degrees of cost-effectiveness in different areas and populations. So, when a country health official must make an important decision around introducing a vaccine in his or her national immunization program, it helps to have as much information as possible. Health economics is one really useful tool in these decision-makers’ toolbox for predicting the financial and health impacts of such a big change.
Tools such as cost-effectiveness analyses can also help inform global priorities, recommendations, and donor spending. For example, PATH-led analyses on the cost-effectiveness and health impact of the RTS,S malaria vaccine helped inform the WHO recommendation of this historic vaccine in 2021.
“Public officials have an important responsibility to spend public funds in a way that brings the greatest benefit to their populations.”
Economists on a mission
While health economics is complex and often full of uncertainties, a few things are certain: vaccines work to save lives and improve health, and decisions are best made based on evidence. We’re proud to work with so many partners to contribute to countries’ vaccine decision-making through economic analyses. PATH’s health economists use a variety of tools to assess the cost-effectiveness and return on investment of vaccines—both before and after introduction—in districts, countries, and regions around the world.
When country leaders are making the decision to introduce a new vaccine and need evidence on the potential costs and health benefits of the vaccine within the target population and area, we conduct cost-effectiveness and other health economic analyses to compare the costs and health effects of alternative courses of action. The alternatives could be introducing a new vaccination program versus no vaccination, or introducing a certain vaccine under various vaccination strategies. PATH's Vaccine Cost Calculators allow decision-makers to estimate the costs associated with vaccination programs before an introduction or product switch.
When decision-makers need confirmation of cost-effectiveness and updated projections for cost savings and health impact after a vaccine is introduced, we conduct post-introduction vaccine cost-effectiveness and costing studies. With evidence of the vaccine’s observed impact, countries can continue to prioritize the vaccine, maintain high coverage rates, and show results to other country decision-makers, donors, and manufacturers.
Additional resources
- PATH's Vaccine Cost Calculator Excel tools (available for rotavirus, pneumococcal conjugate, and HPV vaccines)
- Are rotavirus vaccines a good investment for middle-income countries? brief
- Economic implications of Switching Rotavirus Vaccine Products in Palestine's Immunization Program brief
- The case for investment in enterotoxigenic Escherichia coli vaccines report
- DefeatDD website
- Moving the Needle e-newsletter
- Immunization Matters e-newsletter
