Willingness to pay for hypothetical malaria vaccines in rural Burkina Faso

Willingness to pay brand premiums for generic medicines in Kenya: A bidding game experiment

BACKGROUND

Recent growth in the market share of higher priced branded generic medicines in low- and middle-income countries (LMICs) has raised concerns around affordability and access. We examined consumer willingness to pay (WTP) for branded versus unbranded generic non-communicable disease (NCD) medicines in Kenya.

METHODS

We randomly assigned NCD patients to receive a hypothetical offer for either a Novartis Access-branded medicine or for an unbranded generic equivalent. We then analysed WTP data captured using a bidding game methodology.

RESULTS

We found that WTP for Novartis Access medicines was on average 23% higher than for unbranded generic equivalents (p = 0.009). The WTP brand premium was driven almost entirely by wealthier patients.

CONCLUSIONS

Our findings suggest that the dominance of branded generics in LMICs like Kenya reflect in part consumer preferences for these medicines. Governments and other health sector actors may be justified in intervening to improve access to these medicines and equivalent non-branded generics, particularly for the poorest patients who appear to have no preference for branded medicines.

Willingness to Pay for a Coronavirus Vaccine and Its Associated Determinants in Lebanon

OBJECTIVES

This study aimed to investigate the willingness to pay (WTP) for a hypothetical vaccine and its associated determinants among the Lebanese general population during one of the peak episodes during the coronavirus disease 2019 (COVID-19) pandemic in Lebanon.

METHODS

An online survey was developed and delivered to the Lebanese general population. The questionnaire included the participants' sociodemographic characteristics, financial situation, attitude toward vaccination, and WTP for the hypothetical vaccine. The study was based on the contingent valuation method.

RESULTS

Among 500 individuals solicited, 352 individuals agreed to participate (participation rate = 70.4%); among them, 66% were between 18 and 45 years old, and 54% were women. Notably, 78.1% of the respondents were ready to pay for this hypothetical vaccine even if the vaccine will not be covered. The maximum WTP of the Lebanese population was approximately $60 ± $66 (range $3-$500) after excluding extreme values in the sensitivity analysis and ranged between $3 and $500. WTP was associated with the severity of COVID-19 (P<.001), the education level (P=.001), and the place to live during the lockdown (P=.045). There was an association between family income and WTP (P=.004) with a weak correlation.

CONCLUSIONS

The WTP was comparable with other studies and highly associated with the level of education, the household income, living in the city during the lockdown, and the perceived severity of COVID-19. These findings can help in understanding COVID-19 vaccination acceptance and WTP in Lebanon.

“I would have to sell things in order to get the money”: A qualitative exploration of willingness to pay for the RTS,S/AS01 malaria vaccine in the Volta region, Ghana

Background

Malaria morbidity and mortality remain a challenge in Ghana. A promising childhood vaccine is being piloted in Ghana, however with the loss of its low-income status, Ghana is losing associated donor co-funding. User fees have been considered an alternative financing method, so this study utilised qualitative methods and explored caregivers’ willingness to pay for the malaria vaccine (RTS,S/AS01) to inform future service provision.

Methods

The study design was cross-sectional. Twenty in-depth interviews were conducted between February 2020 and March 2020 amongst a purposive sample of caregivers of RTS,S/AS01 eligible children, in the Volta region, Ghana. Interviews were audio-recorded and transcribed into English Language. Thematic analysis followed, using NVIVO12 to organise this data.

Results

Caregivers could distinguish between RTS,S/AS01 and routine vaccines and were willing to pay median GH₵5 (US$0.94), interquartile range GH₵3.75–5 (US$0.71–0.94) per dose of RTS,S/AS01. The maximum amount participants were willing to pay per dose was GH₵10 (US$1.88), interquartile range GH₵6–10 (US$1.13–1.88). Caregivers mentioned that they would work more to cover this cost because they were happy with services rendered to them during the RTS,S/AS01 pilot phase, and preferred vaccines over vector control measures. The results suggest that a willingness to pay was based on beliefs that the vaccine is fully effective. Although no participant declared that they would be unwilling to pay hypothetical user fees, there were still widespread concerns about affordability, with the majority feeling that the government should be responsible to pay for RTS,S/AS01.

Conclusions

Participants expressed a willingness to pay due to an appreciation of vaccines, shaped by personal experiences with immunisations and disease. Participants’ average income was lower than the national average, potentially affecting the perceived affordability of RTS,S/AS01. Because of the belief that RTS,S/AS01 is fully effective, caregivers may pay less attention to other preventative measures, thus unintentionally undermining malaria vector control.

On Imported and Domestic Human Papillomavirus Vaccines: Cognition, Attitude, and Willingness to Pay in Chinese Medical Students

This study aimed to analyze the cognition, attitude, and willingness to pay (WTP) for imported and domestic human papillomavirus (HPV) vaccines in Chinese medical students.

Parents' willingness to pay for a COVID-19 vaccine for themselves and their children in the United States

Differences in obtaining a vaccine vary based on a multitude of factors including perceptions of vaccine safety, efficacy and willingness to pay (WTP). This study focuses on parent perceptions toward a vaccine for COVID-19 including their WTP decisions for their children and themselves. A mixed methods design using a cross-sectional survey was used to assess the perceptions of US parents, with children under 18, in response to the COVID-19 pandemic. The survey was administered online in November 2020 and 584 final responses were collected. The questionnaire consisted of approximately 37 closed and open-ended questions regarding personal background information; awareness, knowledge, and experience of the virus; perception toward vaccines and COVID-19; and the contingent valuation of a hypothetical COVID-19 vaccine. WTP was found to be higher for children and a direct relationship between the number of children and WTP was observed. Parents were willing to pay US$228-$291 for a vaccine for themselves and US$243-US$321 for their children. A positive impact on WTP was found with self-reported parent health status but not children. The findings of this study have important implications for policy programs which require detailed cost-benefit analyses. WTP for a COVID-19 vaccine is crucial to determine the partial benefits of vaccinating to reduce the risk of repetitive widespread outbreaks.

Willingness to Pay for Childhood Malaria Vaccine Among Caregivers of Under-Five Children in Northwest Ethiopia

BACKGROUND

Malaria, a protozoan disease caused by the genus Plasmodium, is responsible for serious illnesses and death across the world. RTS, S/AS01 (Mosquirix™) is a recombinant protein-based malaria vaccine valuable for the prevention and control of the disease. However, studies done so far on the willingness to pay (WTP) malaria vaccine have been inadequate to inform policy-makers.

METHODS

A community-based cross-sectional study was conducted to assess the WTP for childhood malaria vaccine and associated factors among caregivers of under-five children from February to April 2019 in West Dembia district. A multistage stratified systematic sampling technique was used, and the contingent valuation method was used to estimate caregivers' willingness to pay for the vaccine. AOR with 95% CI and less than 0.05 p-values were used to declare factors associated with WTP.

RESULTS

Overall, 60.6% (95% CI: 56.60, 64.40%) of caregivers of under-five children were WTP for the childhood malaria vaccine at a price of US$ 23.11 per full doses. Urban residence (AOR=1.78, 95% CI: 1.04, 3.04), educational status (AOR=3.27; 95% CI: 1.07, 9.94) and vaccination experience for children (AOR= 2.12; 95% CI: 1.29, 3.48) were positively associated with the WTP. WTP for the vaccine was higher among rich households (AOR=3.15; 95% CI: 1.90, 5.22), caregivers who had the previous history of malaria attack (AOR=2.62; 95% CI: 1.68, 4.08), households with fewer members (AOR=1.59; 95% CI: 1.06, 2.40), and families more knowledgeable about malaria prevention and control (AOR=3.56; 95% CI: 1.83, 6.93) compared with their counterparts.

CONCLUSION

The majority of the participants were WTP for the childhood malaria vaccine. A significant rise in willingness to purchase was observed at price below the profile price. Thus, it is of great value to policy-makers to understand the price sensitivity before setting the price of the vaccine.

Acceptance and willingness to pay for a hypothetical vaccine against monkeypox viral infection among frontline physicians: A cross-sectional study in Indonesia

BACKGROUND

A clinical trial is ongoing to evaluate the safety and efficacy of a monkeypox vaccine among healthcare workers (HCWs). The critical question that needs to be addressed is whether HCWs are willing to accept and purchase this vaccine. The objective of this study was to evaluate the acceptance and willingness to pay (WTP) for the vaccine among HCWs.

METHODS

From May to July 2019, a cross-sectional study was conducted among registered general practitioners (GPs) in Indonesia. A contingent valuation method was employed to evaluate the WTP. Besides acceptance and WTP, various explanatory variables were also collected and assessed. A logistic regression and a multivariable linear regression were used to explore the explanatory variables influencing acceptance and WTP, respectively.

RESULTS

Among 407 respondents, 391 (96.0%) expressed acceptance of a free vaccination. The mean and median WTP was US$ 37.0(95%CI:US$ 32.76-US$ 41.23) and US$ 17.90(95%CI:US$ 17.90-US$ 17.90), respectively. In an unadjusted analysis, those 30 years old or younger had 2.94 times greater odds of vaccine acceptance compared to those who were older (95%CI: 1.07-8.08). Location of alma mater, type of workplace, length of individual medical experience, and monthly income of GPs were all significantly associated with WTP.

CONCLUSION

Although the vast majority of GPs would accept a freely provided vaccine, they were also somewhat price sensitive. This finding indicates that partial subsidy maybe required to achieve high vaccine coverage, particularly among GPs at community health centres or those with a shorter duration of medical practice.

Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia

How countries, particularly low- and middle-income economies, should pay the coronavirus disease 2019 (COVID-19) vaccine is an important and understudied issue. We undertook an online survey to measure the willingness-to-pay (WTP) for a COVID-19 vaccine and its determinants in Indonesia. The WTP was assessed using a simple dichotomous contingent valuation approach and a linear regression model was used to assess its associated determinants. There were 1,359 respondents who completed the survey. In total, 78.3% (1,065) were willing to pay for the COVID-19 vaccine with a mean and median WTP of US$ 57.20 (95%CI: US$ 54.56, US$ 59.85) and US$ 30.94 (95%CI: US$ 30.94, US$ 30.94), respectively. Being a health-care worker, having a high income, and having high perceived risk were associated with higher WTP. These findings suggest that the WTP for a COVID-19 vaccine is relatively high in Indonesia. This WTP information can be used to construct a payment model for a COVID-19 vaccine in the country. Nevertheless, to attain higher vaccine coverage, it may be necessary to partially subsidize the vaccine for those who are less wealthy and to design health promotion materials to increase the perceived risk for COVID-19 in the country.

Willingness to pay for oral cholera vaccines in urban Bangladesh

Introduction

Cholera is a highly infectious disease and remains a serious public health burden in Bangladesh. The objective of the study was to measure the private demand for oral cholera vaccines (OCV) in Bangladesh and to investigate the key determinants of this demand, reflected in the household’s willingness to pay (WTP) for oral cholera vaccine.

Methods

A contingent valuation method was employed in an urban setting of Bangladesh during December 2015 to January 2016. All respondents (N = 1051) received a description of World Health Organization (WHO) prequalified OCV, Shanchol^™. Interviews were conducted with either the head of households or their spouse or a major economic contributor of the households. Respondents were asked about how much at maximum they were willing to pay for OCV for their own and their household members’ protection. Results are presented as the average and median of the reported maximum WTP of the respondents with standard deviations and 95% confidence interval. Natural log-linear regression model was employed to examine the factors influencing participants’ WTP for OCV.

Results

About 99% of the respondents expressed WTP for OCV with a maximum mean and median WTP per vaccination (2 doses) of US$ 2.23 and US$ 1.92 respectively. On the household level with an average number of 4.62 members, the estimated mean WTP was US$ 10 (median: US$ 7.69) which represents the perceived demand for OCV of a household to vaccinate against cholera.

Conclusions

The demand of vaccination further indicates that there is a potential scope for recovering a certain portion of the expenditure of immunization program by introducing direct user fees for future cholera vaccination in Bangladesh. Findings from this study will be useful for the policy-makers to make decision on cost-recovery in future oral cholera vaccination programs in Bangladesh and in similar countries.

Willingness to Vaccinate (WTV) and Willingness to Pay (WTP) for Vaccination Against Peste des Petits Ruminants (PPR) in Mali

PPR remains a major challenge to smallholder farmers in Mali. To understand the drivers of low adoption of vaccination by farmers, we analyzed the socio-economic factors influencing farmer WTV during and in the absence of vaccination campaigns. Given that the costs associated with vaccination are largely borne by farmers, we assessed factors that associated with farmer willingness to pay (WTP) more than the current price (150 XOF per dose) by considering two attributes of improvement of the vaccines empirically highlighted as potential leverage points for intervention: access of farmers to vaccines (reducing the distance to the vaccine) and availability of information about the quality of the vaccine (introducing a vaccine viability detector). Data were collected in Mopti and Sikasso regions from 304 producers. Overall (n = 304), 89 percent of respondents vaccinated their herds during official vaccination campaigns. They are associated with receiving information on the campaign calendar more quickly if information is relayed at places of worship and if they have an awareness of the benefits of vaccination, including the protection of third parties. Only 39 percent of respondents vaccinate outside vaccination campaigns. They are positively linked to the credibility of private veterinarians and a recognition of the vital importance of vaccines but are negatively associated with ignorance of vaccination needs and concern about vaccine side-effects. Both distance-effects and quality-tracker effects are associated with farmer willingness to pay more than the current vaccine prices. Farmers practicing semi-intensive production systems are willing to pay 20 percent more than the current vaccine prices, as are users who believe in the beneficial effects of vaccination, users who consider the prices of vaccines as fair, and those who believe that some vaccines are more important than others. Factors that discourage producers from vaccinating or from paying more for vaccination would be more effectively managed with better communication on vaccine benefits through targeted information dissemination campaigns by Malian authorities. Greater price transparency throughout the vaccine production and deployment chain is critical, while timely availability of vaccine tested for viability would increase the willingness to vaccinate while improving access.

Willingness to pay for hepatitis B vaccination in Selangor, Malaysia: A cross-sectional household survey

Background

In Malaysia, one million individuals are estimated to be infected with the hepatitis B virus. A vaccine for infants has been compulsory since 1989, whereas those born before 1989 need to spend their own money to be vaccinated in private clinics or hospitals. The aim of this study was to investigate and ascertain the determinants of willingness to pay (WTP) for adult hepatitis B vaccine in Selangor, Malaysia.

Methods

In 2016, 728 households were selected through a stratified, two stage cluster sample and interviewed. Willingness to pay for hepatitis B vaccine was estimated using the Contingent Valuation Method, and factors affecting WTP were modelled with logit regression.

Results

We found that 273 (37.5%) of the households were willing to pay for hepatitis B vaccination. The mean and median of WTP was estimated at Ringgit Malaysia (RM)303 (approximately US$73) for the three dose series. The estimated WTP was significantly greater in those with higher levels of education, among Malays and Chinese (compared to others, predominantly Indians), and for those with greater perceived susceptibility to hepatitis B virus infection. Other factors–perceived severity, barriers, benefits and cues to action–were not significantly associated with WTP for adult hepatitis B vaccination.

Conclusion

Additional resources are needed to cover the households that are not willing to pay for hepatitis B vaccination. More awareness (particularly in regards to hepatitis B virus susceptibility) could change the national perception towards self-paid hepatitis B virus vaccination and increase hepatitis B vaccine coverage.

Community acceptance and willingness-to-pay for a hypothetical Zika vaccine: A cross-sectional study in Indonesia

BACKGROUND

Understanding people's perceptions of the economic benefits of a potential Zika vaccine (ZV) is critical to accelerating its introduction into either public sector programs or private market. The aim of this study was to assess the acceptance and willingness-to-pay (WTP) for a hypothetical ZV and the associated explanatory variables in Indonesia.

METHODS

We conducted a health facility-based cross-sectional study in Aceh and West Sumatra province from 1 February to 13 June 2018. Patients who visited outpatient departments, have had children or were expecting their first child, were approached and interviewed to collect information on acceptance, WTP, demographic and socio-economic variables and attitudes towards childhood vaccines. Associations of explanatory variables influencing acceptance and WTP were assessed using logistic regression and linear regression analysis, respectively.

RESULTS

In total, 956 respondents were included in the final analysis of acceptance, of whom 338 (35.3%) expressed their WTP. We found that 757 (79.1%) of the respondents were likely to be vaccinated and to recommend their partner to be vaccinated. Higher educational attainment, having a job, having heard about Zika and a good attitude towards childhood vaccination were associated with ZV acceptance in the univariate analyses. In the multivariate analysis, attitude towards childhood vaccination was the strongest predictor for ZV vaccination. We found the geometric mean and median of WTP was US$ 13.1 (95% CI: 11.37-15.09) and US$ 7.0 (95% CI: 4.47-10.98), respectively. In the final model, having heard about Zika, having a job, and higher income were associated with a higher WTP.

CONCLUSION

Although the acceptance rate of the ZV is relatively high in Indonesia, less than 40% of respondents are willing to pay, underscoring the need for a low-cost, high-quality vaccine and public sector subsidies for Zika vaccinations in the country.

Willingness to pay for a dengue vaccine and its associated determinants in Indonesia: A community-based, cross-sectional survey in Aceh

Vaccination strategies are being considered as a part of dengue prevention programs in endemic countries. To accelerate the introduction of dengue vaccine into the public sector program and private markets, understanding the private economic benefits of a dengue vaccine is therefore essential. The aim of this study was to assess the willingness to pay (WTP) for a dengue vaccine among community members in Indonesia and its associated explanatory variables. A community-based, cross-sectional survey was conducted in nine regencies of Aceh province, Indonesia, from November 2014 to March 2015. A pre-tested validated questionnaire was used to facilitate the interviews. To assess the explanatory variables influencing participants' WTP for a dengue vaccine, a linear regression analysis was employed. We interviewed 677 healthy community members; 476 participants (87.5% of the total) were included in the final analysis. An average individual was willing to pay around US-$ 4 (mean: US-$ 4.04; median: US-$ 3.97) for a dengue vaccine. Our final multivariate model revealed that working as a civil servant, living in the city, and having good knowledge on dengue viruses, a good attitude towards dengue, and good preventive practice against dengue virus infection were associated with a higher WTP (P<0.05). Our model suggests that marketing efforts should be directed to community members who are working in the suburbs especially as farmers. In addition, the results of our study underscore the need for low-cost quality vaccines, public sector subsidies for vaccinations, and intensifying efforts to further educate and encourage households regarding other dengue preventive measures, using trusted individuals as facilitators.

Pain Management in Pregnancy: Multimodal Approaches

Nonobstetrical causes of pain during pregnancy are very common and can be incapacitating if not treated appropriately. Recent reports in the literature show that a significant percentage of pregnant women are treated with opioids during pregnancy. To address common pain conditions that present during pregnancy and the available pharmacological and nonpharmacological treatment options, for each of the pain conditions identified, a search using MEDLINE, PubMed, Embase, and Cochrane databases was performed. The quality of the evidence was evaluated in the context of study design. This paper is a narrative summary of the results obtained from individual reviews. There were significant disparities in the studies in terms of design, research and methodology, and outcomes analyzed. There is reasonable evidence available for pharmacological approaches; however, these are also associated with adverse events. Evidence for nonpharmacological approaches is limited and hence their efficacy is unclear, although they do appear to be primarily safe. A multimodal approach using a combination of nonpharmacological and pharmacological options to treat these pain conditions is likely to have the most benefit while limiting risk. Research trials with sound methodology and analysis of outcome data are needed.

The broader economic impact of vaccination: reviewing and appraising the strength of evidence

BACKGROUND

Microeconomic evaluations of public health programmes such as immunisation typically only consider direct health benefits and medical cost savings. Broader economic benefits around childhood development, household behaviour, and macro-economic indicators are increasingly important, but the evidence linking immunization to such benefits is unclear.

METHODS

A conceptual framework of pathways between immunisation and its proposed broader economic benefits was developed through expert consultation. Relevant articles were obtained from previous reviews, snowballing, and expert consultation. Articles were associated with one of the pathways and quality assessed using modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

We found 20 studies directly relevant to one or more pathways. Evidence of moderate quality from experimental and observational studies was found for benefits due to immunisation in improved childhood physical development, educational outcomes, and equity in distribution of health gains. Only modelling evidence or evidence outside the immunization field supports extrapolating these benefits to household economic behaviour and macro-economic indicators.

CONCLUSION

Innovative use of experimental and observational study designs is needed to fill evidence gaps around key pathways between immunisation and many of its proposed economic benefits.

Determinants of willingness to pay for self-paid vaccines in China

BACKGROUND

While vaccines not covered by China's Expanded Program on Immunization can be received voluntarily with out-of-pocket payment, the uptake of self-paid vaccines in China is low.

OBJECTIVE

To investigate willingness to pay (WTP) for self-paid vaccines and its determinants in China.

METHODS

We interviewed 2160 randomly selected households with children 0-3 years old, in 108 communities from three provinces in 2013. A bidding game method was used to elicit WTP for two self-paid vaccines: 7-valent pneumococcal conjugate vaccine and influenza vaccine. We conducted multivariate linear regressions to determine factors affecting the WTP.

RESULTS

Median WTP for pneumococcal conjugate vaccine and influenza vaccine were Chinese Yuan 200 and 60 (10 US Dollars). 92% and 55% of respondents, respectively were not willing to pay the market price for these two vaccines. Lower price barrier and higher ability to pay were associated with higher WTP. Those with better vaccine or disease-related knowledge, higher perceived vulnerability and severity of diseases were willing to pay more. However, perceived effectiveness and safety barriers to vaccination had no significant effects on the WTP. Recommendations from peers and healthcare providers increased the WTP. Fathers and grand parents of children had a higher WTP than their mothers. The WTP decreased with age, but was not affected by education and occupation.

CONCLUSIONS

The majority of individuals, in our study, were not willing to pay the market price for self-paid vaccines against high-burden diseases in China. The economic barriers to vaccination should therefore be removed to increase the demand. Region-specific information about disease burden, fiscal capacity and cost-effectiveness is important for the development of local financing policy in order to cover vaccination costs. Interventions targeting psychosocial factors, such as health education and communication with providers and peers, could also be effective in increasing the uptake of these vaccinations.

A systematic review and meta-analysis of willingness-to-pay values: the case of malaria control interventions

The increasing use of willingness to pay (WTP) to value the benefits of malaria control interventions offers a unique opportunity to explore the possibility of estimating a transferable indicator of mean WTP as well as studying differences across studies. As regression estimates from individual WTP studies are often assumed to transfer across populations it also provides an opportunity to question this practice. Using a qualitative review and meta analytic methods, this article determines what has been studied and how, provides a summary mean WTP by type of intervention, considers how and why WTP estimates vary and advises on future reporting of WTP studies. WTP has been elicited mostly for insecticide-treated nets, followed by drugs for treatment. Mean WTP, including zeros, is US$2.79 for insecticide-treated nets, US$6.65 for treatment and US$2.60 for other preventive services. Controlling for a limited number of sample and design effects, results can be transferred to different countries using the value function. The main concerns are the need to account for a broader range of explanators that are study specific and the ability to transfer results into malaria contexts beyond those represented by the data. Future studies need to improve the reporting of WTP.

Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: a systematic review

BACKGROUND

Public health interventions that prevent mortality and morbidity have greatly increased over the past decade. Immunization is one of these preventive interventions, with a potential to bring economic benefits beyond just health benefits. While vaccines are considered to be a cost-effective public health intervention, implementation has become increasingly challenging. As vaccine costs rise and competing priorities increase, economic evidence is likely to play an increasingly important role in vaccination decisions.

METHODS

To assist policy decisions today and potential investments in the future, we provide a systematic review of the literature on the cost-effectiveness and economic benefits of vaccines in low- and middle-income countries from 2000 to 2010. The review identified 108 relevant articles from 51 countries spanning 23 vaccines from three major electronic databases (Pubmed, Embase and Econlit).

RESULTS

Among the 44 articles that reported costs per disability-adjusted life year (DALY) averted, vaccines cost less than or equal to $100 per DALY averted in 23 articles (52%). Vaccines cost less than $500 per DALY averted in 34 articles (77%), and less than $1000 per DALY averted in 38 articles (86%) in one of the scenarios. 24 articles (22%) examined broad level economic benefits of vaccines such as greater future wage-earning capacity and cost savings from averting disease outbreaks. 60 articles (56%) gathered data from a primary source. There were little data on long-term and societal economic benefits such as morbidity-related productivity gains, averting catastrophic health expenditures, growth in gross domestic product (GDP), and economic implications of demographic changes resulting from vaccination.

CONCLUSIONS

This review documents the available evidence and shows that vaccination in low- and middle-income countries brings important economic benefits. The cost-effectiveness studies reviewed suggest to policy makers that vaccines are an efficient investment. This review further highlights key gaps in the available literature that would benefit from additional research, especially in the area of evaluating the broader economic benefits of vaccination in the developing world.

Systematic review of studies evaluating the broader economic impact of vaccination in low and middle income countries

Background

Most health economic evaluations of childhood vaccination only capture the health and short-term economic benefits. Measuring broader, long-term effects of vaccination on productivity and externalities could provide a more complete picture of the value of vaccines.

Method

MEDLINE, EconLit and NHS-EED databases were searched for articles published between January 1990 and July 2011, which captured broader economic benefits of vaccines in low and middle income countries. Studies were included if they captured at least one of the following categories on broader economic impact: outcome-related productivity gains, behaviour-related productivity gains, ecological externalities, equity gains, financial sustainability gains or macroeconomic benefits.

Results

Twenty-six relevant studies were found, including observational studies, economic models and contingent valuation studies. Of the identified broader impacts, outcome-related productivity gains and ecological externalities were most commonly accounted for. No studies captured behaviour-related productivity gains or macroeconomic effects. There was some evidence to show that vaccinated children 8–14 years of age benefit from increased cognitive ability. Productivity loss due to morbidity and mortality was generally measured using the human capital approach. When included, herd immunity effects were functions of coverage rates or based on reduction in disease outcomes. External effects of vaccines were observed in terms of equitable health outcomes and contribution towards synergistic and financially sustainable healthcare programs.

Conclusion

Despite substantial variation in the methods of measurement and outcomes used, the inclusion of broader economic impact was found to improve the attractiveness of vaccination. Further research is needed on how different tools and techniques can be used in combination to capture the broader impact of vaccination in a way that is consistent with other health economic evaluations. In addition, more country level evidence is needed from low and middle income countries to justify future investments in vaccines and immunization programs. Finally, the proposed broader economic impact framework may contribute towards better communication of the economic arguments surrounding vaccine uptake, leading to investments in immunization by stakeholders outside of the traditional health care sector such as ministries of finance and national treasuries.

Willingness-to-pay for a rapid malaria diagnostic test and artemisinin-based combination therapy from private drug shops in Mukono District, Uganda

In Uganda, as in many parts of Africa, the majority of the population seek treatment for malaria in drug shops as their first point of care; however, parasitological diagnosis is not usually offered in these outlets. Rapid diagnostic tests (RDTs) for malaria have attracted interest in recent years as a tool to improve malaria diagnosis, since they have proved accurate and easy to perform with minimal training. Although RDTs could feasibly be performed by drug shop vendors, it is not known how much customers would be willing to pay for an RDT if offered in these settings. We conducted a contingent valuation survey among drug shop customers in Mukono District, Uganda. Exit interviews were undertaken with customers aged 15 years and above after leaving a drug shop having purchased an antimalarial and/or paracetamol. The bidding game technique was used to elicit the willingness-to-pay (WTP) for an RDT and a course of artemisinin-based combination therapy (ACT) with and without RDT confirmation. Factors associated with WTP were investigated using linear regression. The geometric mean WTP for an RDT was US$0.53, US$1.82 for a course of ACT and US$2.05 for a course of ACT after a positive RDT. Factors strongly associated with a higher WTP for these commodities included having a higher socio-economic status, no fever/malaria in the household in the past 2 weeks and if a malaria diagnosis had been obtained from a qualified health worker prior to visiting the drug shop. The findings further suggest that the WTP for an RDT and a course of ACT among drug shop customers is considerably lower than prevailing and estimated end-user prices for these commodities. Increasing the uptake of ACTs in drug shops and restricting the sale of ACTs to parasitologically confirmed malaria will therefore require additional measures.

Estimating the economic impact of climate change on cardiovascular diseases--evidence from Taiwan

The main purpose of this study was to investigate how climate change affects blood vessel-related heart disease and hypertension and to estimate the associated economic damage. In this paper, both the panel data model and the contingent valuation method (CVM) approaches are applied. The empirical results indicate that the number of death from cardiovascular diseases would be increased by 0.226% as the variation in temperature increases by 1%. More importantly, the number of death from cardiovascular diseases would be increased by 1.2% to 4.1% under alternative IPCC climate change scenarios. The results from the CVM approach show that each person would be willing to pay US$51 to US$97 per year in order to avoid the increase in the mortality rate of cardiovascular diseases caused by climate change.

Willingness to pay for three hypothetical malaria vaccines in Nigeria

BACKGROUND

Unlike some African countries that have reported a approximately 50% reduction in malaria deaths in recent years, Nigeria has shown no evidence of a systematic decline in malaria burden. An important and sustainable reduction in malaria burden cannot be achieved unless an effective and inexpensive malaria vaccine becomes available.

OBJECTIVES

The goals of this study were to determine the willingness to pay (WTP) for 3 hypothetical malaria vaccines with different levels of protection (in years), effectiveness, and adverse effects; and to identify factors that influence the price that people are willing to pay in Nigeria.

METHODS

With the aid of a questionnaire, a contingent valuation method using payment cards was used to elicit WTP values for 3 hypothetical malaria vaccines. Payment cards contained both a description of the features of the vaccine being evaluated and price options. The 3 hypothetical vaccines had the following characteristics: vaccine A was 75% effective, protected for 3 years, and was well tolerated; vaccine B was 85% effective, protected for 6 years, and was less well tolerated than vaccine A; and vaccine C was 95% effective and protected for 12 years, but was the least well tolerated. Participants consisted of a convenience sample of individuals who were at the pharmacy waiting area of the state-owned hospitals located in Benin City and Warri, Nigeria. Every third patient or caregiver who was in the pharmacy to fill a prescription was asked to take part in the study as they waited to see the pharmacist. If consent was not granted, the next person in line was approached to be interviewed. Linear multiple regression analysis and nonparametric Kruskal-Wallis, Mann-Whitney, or chi(2) test was applied in inferential analysis, where necessary, to investigate the effects of sociodemographic factors on WTP. Prices on payment cards were expressed in Nigerian naira (NGN 150.00 approximately US $1.00), but study results were expressed in US dollars.

RESULTS

A total of 359 individuals aged > or =18 years of 500 who were approached agreed to participate in the study, giving a response rate of 71.8%. Most of the participants (216/359; 60.2%) were women, and 48 of them were pregnant. Most respondents (299/359; 83.3%) had at least one malaria attack within the last year, and 27.3% (98/359) were hospitalized for malaria. The mean WTP for vaccine A was $6.77 and that for vaccine B was $6.70. Vaccine C was the least well accepted with a mean WTP of $5.06. Respondents were willing to pay significantly more for vaccine A (95% CI, $5.96-$7.57); thus, the WTP was significantly different for the 3 hypothetical malaria vaccines (P < 0.001; Kruskal-Wallis statistic [kw] = 84.304). Dunn's multiple comparison test also indicated that the WTP values for vaccines A and B were significantly different from each other (P < 0.05). There was also a significant difference between vaccine A or B versus C (P < 0.001). All workers and those with a higher monthly income were willing to pay significantly more for vaccines A and B, but less for C (P < 0.003). Those who preferred vaccine A (198/359; 55.2%) were willing to back their choice with a higher WTP (P < 0.001).

CONCLUSIONS

It appears that although malaria is a serious disease, the Nigerian people in this sample preferred and were willing to pay more for a vaccine that was well tolerated, even if its effectiveness and duration of protection against malaria were lower than those of a product that caused severe adverse effects. Interpretation of this study should be guided by the knowledge that differences exist between the study sample and the general population.

The Health and Demographic Surveillance System (HDSS) in Nouna, Burkina Faso, 1993-2007

The Nouna Health and Demographic Surveillance System (HDSS) is located in rural Burkina Faso and has existed since 1992. Currently, it has about 78,000 inhabitants. It is a member of the International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), a global network of members who conducts longitudinal health and demographic evaluation of populations in low- and middle-income countries. The health facilities consist of one hospital and 13 basic health centres (locally known as CSPS). The Nouna HDSS has been used as a sampling frame for numerous studies in the fields of clinical research, epidemiology, health economics, and health systems research. In this paper we review some of the main findings, and we describe the effects that almost 20 years of health research activities have shown in the population in general and in terms of the perception, economic implications, and other indicators. Longitudinal data analyses show that childhood, as well as overall mortality, has significantly decreased over the observation period 1993–2007. The under-five mortality rate dropped from about 40 per 1,000 person-years in the mid-1990s to below 30 per 1,000 in 2007. Further efforts are needed to meet goal four of the Millennium Development Goals, which is to reduce the under-five mortality rate by two-thirds between 1990 and 2015.

Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania

BACKGROUND

Household ownership of insecticide-treated mosquito nets (ITNs) is increasing, and coverage targets have been revised to address universal coverage with ITNs. However, many households do not have enough nets to cover everyone, and the nets available vary in physical condition and insecticide treatment status. Since 2004, the Government of Tanzania has been implementing the Tanzania National Voucher Scheme (TNVS), which distributes vouchers for ITNs through antenatal clinics to target pregnant women and their infants. This analysis aimed to determine the following: (1) coverage patterns of bed nets within households according to physical condition and treatment status; (2) who might be at risk if mosquitoes were diverted from occupants of untreated nets to those not using nets? (3) the degree to which those at highest risk of malaria use the most protective nets.

METHODS

Data from the 2006 TNVS household survey were analysed to assess within-household distribution of net use. The associations between net characteristics and net user were also evaluated. Multivariate analysis was applied to the relationship between the number of holes per net and user characteristics while adjusting for confounders.

RESULTS

In households with a net:person ratio better than 1:4 (one net for every four household members), more than 80% of the people in such households reported using a net the previous night. ITNs were most likely to be used by infants, young children (1-4 y), and women of childbearing age; they were least likely to be used by older women (>or=50 y), older children (5-14 y), and adult men. The nets used by infants and women of childbearing age were in better-than-average physical condition; the nets used by older women and older children were in worse-than-average condition; while young children and adult men used nets in intermediate (average) condition. When adjusted for confounders, the nets used by young and older children had more holes than nets used by infants.

CONCLUSIONS

Infants and other vulnerable groups were most likely to sleep under the most protective nets. Nevertheless, more communication efforts are needed to increase use of intact ITNs within households for children. Further research is necessary to fully understand motivations influencing within-household net distribution.

Community perceptions of bloody diarrhoea in an urban slum in South Asia: implications for introduction of a Shigella vaccine

Understanding local perceptions of disease causation could help public health officials improve strategies to prevent bloody diarrhoea. A cross-sectional survey was conducted in Dhaka, Bangladesh to elicit community beliefs about the causes of and prevention strategies for bloody diarrhoea. Between March and June 2003, we interviewed 541 randomly selected respondents. Overall, 507 (93%) respondents perceived that a vaccine could prevent bloody diarrhoea. If a vaccine provided lifetime protection, 445 (83%) respondents stated that they would opt to get the vaccine and would pay a median of $0·05 (range U.S.$0·01-0·15) for it, equivalent to <1% of their median weekly income. There was almost universal perception that an effective vaccine to prevent bloody diarrhoea was highly beneficial and acceptable. While respondents valued a vaccine for prevention of bloody diarrhoea, they were only willing to pay minimally for it. Therefore, achieving a high rate of Shigella vaccine coverage may require subsidy of vaccine purchase.

Willingness to pay for maternal health outcomes: are women willing to pay more than men?

BACKGROUND

Only a limited number of studies have specifically sought to analyse and try to understand sex differences in willingness to pay (WTP).

OBJECTIVE

To identify the role of sex in determining monetary values placed upon improvements in maternal health in Burkina Faso, West Africa.

METHODS

A contingent valuation survey using the bidding game method was conducted in the district of Nouna in 2005; a sample of 409 male heads of households and their spouses were asked their WTP for a reduction in the number of maternal deaths in the Nouna area. Ordinary least squares regression analysis was employed to examine the determinants of WTP.

RESULTS

Men were willing to pay significantly more than women (3127 vs 2273 West African francs), although this represented a significantly smaller proportion of their annual income (4% vs 11%). In the multivariate analyses of all respondents there was a significant positive relationship between WTP values and both starting bid and whether there had been a previous maternal complication in the respondent's household. However, there was a significant negative relationship between WTP and female sex. Once interactions between sex and income were taken into account, income did affect valuations, with a positive relationship between higher-income women and WTP values.

CONCLUSION

In absolute terms, men were willing to pay more than women, while women were willing to pay a greater proportion of their income. Differences between men and women in their WTP, both in absolute terms and in terms of proportion of income, can be explained by a household effect. Future studies should distinguish between individual income and command over decision making with respect to use of individual and household income, and gain further insight into the strategies used by respondents in answering bidding game questions.

Perceived health six months after delivery in women who have experienced low back pain and pelvic pain during pregnancy

BACKGROUND AND OBJECTIVES

A majority of women suffer from low back pain and pelvic pain (LBPP) during pregnancy. The aim of the study was to investigate perceived health, sexual life, social situation, sick leave and use of medical services 6 months after pregnancy in women with LBPP during pregnancy.

RESEARCH METHODS

In a previous questionnaire study, 72% (n = 639) of the respondents had reported LBPP during pregnancy. These respondents were sent a second questionnaire approximately 6 months after delivery. The respondents were divided into three groups: 'no pain', 'recurrent pain' and 'continuous pain'. Pearson's chi-squared test was used to test the difference between groups.

RESULTS

Perceived health status 6 months after pregnancy was less favourable for women with persistent LBPP compared to women with remission of LBPP. Family situation, change of relationship and sexual life did not differ among women with remission of LBPP or persistent LBPP after pregnancy. Four of 10 women with persistent LBPP had sought medical care, and two of 10 had been on sick leave because of LBPP after pregnancy.

CONCLUSIONS

Perceived health status was less favourable for women with persistent LBPP after pregnancy. Use of medical services among women with persistent LBPP was prevalent.