The equity and poverty reduction benefits of vaccines
Stéphane Verguet (PhD, MS, MPP)
The large public health value of vaccines in preventing disease and death has long been established. Vaccines, and the Expanded Programme on Immunization (or EPI) in low- and middle-income countries (LMICs) in particular, have been recognized as one of the most cost-effective public health interventions in addressing child mortality. 1 But, beyond their sole mortality reduction value and potential for eliminating health care costs, vaccines can bring broad social and economic benefits, including, for example: increasing work productivity by improving physical or mental health, increasing school attendance and investment in education by improving child survival, and community externalities such as disease cases prevented among unvaccinated individuals (e.g. herd immunity). 2,3
Importantly, vaccines can play a large role in promoting equity (or the reduction of health disparities) and in reducing poverty. Firstly, mortality from vaccine-preventable diseases such as measles, rotavirus, or pneumococcal disease remain largely concentrated in LMICs and the world’s poorest countries. 4 For example, measles mortality remains concentrated among a handful of countries such as India, Ethiopia, and Nigeria. Furthermore, vaccine coverage is often unequally distributed, with often those from the highest socioeconomic groups receiving a higher vaccine coverage than those from the lowest socioeconomic groups, as demonstrated by analyses of Demographic and Health Surveys. 5 In Ethiopia, for instance, the coverage of the 3rd dose of Diphtheria-Tetanus-Pertussis vaccine was 36% among the lowest wealth quintile compared to 76% among the highest wealth quintile in 2016. 6 Secondly, vaccine-preventable diseases can lead to high out-of-pocket (OOP) medical expenditure for the treatment of illnesses such as diarrhea, pneumonia, etc., along with substantial transportation costs (to travel and seek care) and possibly significant time losses and wages lost for those with illness or their caretakers. 7 The onset of these incurred illness-related expenditure can generate substantial household impoverishment. Indeed, in a large number of LMICs, high levels of OOP expenditure exist: for example, OOP expenditure as a share of current health expenditure were as high as 65% and 72% in India and Nigeria, respectively, in 2015. 8 As a consequence, the incidence of impoverishing health expenditure – health expenditure pushing households under the poverty line (e.g. international poverty line at $1.90 per day, Purchasing Power Parity) – can be very large in many LMICs. 9 World Bank and World Health Organization researchers estimated cases of impoverishing expenditure to be as high as 100 million cases globally in 2010. 10 Therefore, vaccines, by their preventative nature, can contribute to both decreasing health disparities and reducing medical impoverishment and ultimately poverty.
With the post-2015 United Nations agenda and its Sustainable Development Goals (SDGs) including SDG1 “To end poverty in all its forms everywhere” and the SDG for health (SDG3) “To achieve universal health coverage including financial risk protection for all,” 11 there has been increasing attention given to thinking of how investments in health could be envisioned as investments in reducing health inequality and in providing financial risk protection–the prevention of medical impoverishment. The World Bank, for instance, promotes a dual objective (by 2030) “To end extreme poverty by decreasing the percentage of people living on less than $1.90 a day to no more than 3%” and “To promote shared prosperity by fostering the income growth of the bottom 40% for every country.” 12 In this context, it appears essential to think of which health policy investments could cost-effectively contribute to inequality reduction and poverty alleviation, in addition to decreasing mortality and morbidity. Therefore, extended cost-effectiveness analysis (ECEA) methods 13,14 were developed to assess the consequences of health policy in four domains: (i) the health gains (e.g. deaths averted), (ii) the household costs averted (e.g. elimination of disease treatment costs) by policy and the associated financial risk protection benefits provided to individuals, (iii) the distributional consequences across population subgroups (e.g. per socioeconomic status, geographical setting), and (iv) the costs of policy.
Applying the ECEA methodology, researchers recently developed analytical methods to examine the potential distributional impact (across socioeconomic groups) and poverty reduction impact (decrease in the number of cases of medical impoverishment) of vaccines in LMICs. 15,16 Subsequently, they studied vaccines that prevented diseases caused by ten antigens – measles, hepatitis B, human papillomavirus, yellow fever, Hemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, rubella, Neisseria meningitidis serogroup A, and Japanese encephalitis – that would be rolled out over 2016-2030 in 41 LMICs eligible for funding from Gavi, the Vaccine Alliance. 17 In so doing, they estimated the deaths averted by each vaccine per income quintile of the 41 countries and found that there would be a larger proportion of those deaths averted among the bottom quintiles of those countries’ populations. 18 In particular, they found that on average, those deaths averted would be 2-3 times more important among the lowest than among the highest quintiles. This is in fact expected as the poorest socioeconomic groups have the most to benefit from in the first place, as they often face the largest burden of vaccine-preventable diseases due to a higher concentration of disease risk factors, 19 they often receive the lowest vaccination coverage,5 and they also seek care for treatment and utilize health care services less. Furthermore, they found that investments in vaccines could prevent a large number of cases of medical impoverishment, which would be largely concentrated among the poorest socioeconomic groups. Indeed, even though they would utilize less health care, poorer socioeconomic groups would be more severely impacted by illness-related treatment expenditure as they have a lower disposable income.
As a conclusion, vaccines can have large pro-poor benefits: they can reduce health disparities in populations and provide efficiently financial risk protection to households. In the same way that prepayment mechanisms and social health insurance can buy protection against financial risks, vaccines also, and perhaps cheaply, effectively, and cost-effectively can provide financial protection to populations, and eventually contribute to poverty reduction.
About the Author
Stéphane Verguet is an Assistant Professor of Global Health in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. Dr. Verguet’s multidisciplinary research focuses on health decision science and priority-setting, and the development of mathematical and computational decision-making models to better design health policies.
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- Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF, 2016.
- Memirie ST, Metaferia ZS, Norheim OF, Levin CE, Verguet S, Johansson KA. Household expenditures on pneumonia and diarrhea treatment in Ethiopia: a facility-based study. BMJ Global Health 2017; 1:e000166.
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- United Nations General Assembly. 2015. “Transforming our world: the 2030 Agenda for Sustainable Development.” 25 September. Resolution 70/1.” Available from: https://sustainabledevelopment.un.org/index.php?page=view&type=111&nr=8496&menu=35
- World Bank. Available from: http://www.worldbank.org/en/about/what-we-do
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- Riumallo-Herl C, Chang A, Brenzel L, Clark S, Constenla D, Clark A, Verguet S. Poverty reduction and equity benefits from the introduction or scaling up of measles, rotavirus, and pneumococcal vaccines in low- and middle-income countries: findings from a modeling study. BMJ Global Health 2018; 3:e000613.
- Chang A, Riumallo-Herl C, Brenzel L, Resch S, Salomon JA, Verguet S. Estimating the distribution of morbidity and mortality of childhood diarrhea, measles, and pneumonia by wealth group in low- and middle-income countries. BMC Medicine BMC Medicine 2018; 16:102.
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- Chang A, Riumallo-Herl C, Perales NA, Clark S, Clark A, Constenla D, Garske T, Jackson M, Jean K, Jit M, Jones E, Suraratdecha S, Bullock O, Johnson H, Brenzel L, Verguet S. The Equity Impact Vaccines May Have On Averting Deaths And Medical Impoverishment In Developing Countries. Health Affairs 2018; 37(2):316-324.