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Drawing on current research, this article examines hurdles that malaria immunization may face to reach high-risk children and explores the policy implications. The analysis finds health system related risks with the potential to reduce the ability of malaria vaccines to provide equitable protection. Deployment of effective frameworks to tackle these risks so as to strengthen within-country equity and progress tracking should be entangled with the deployment of the vaccines. To capture more comprehensively disease- and system-related risks to child health and survival, vaccine allocation criteria should expand their data and indicator breadth. Factoring molecular, clinical, and epidemiological features of antimalarial drug resistance into vaccine allocation frameworks is critical to effectively reflect current and future risks to malaria control interventions. It is proposed that approximately 6\u201315 children would need to be vaccinated to prevent a malaria adverse outcome. Vaccine purchasing and delivery costs may overwhelm endemic countries\u2019 health systems given the sizeable number needed to vaccinate, the population of at-risk children, and limited government financing of the health sector. Innovations in health financing are pivotal to ensuring the cost-effectiveness and sustainability of immunization programs aiming to attain and maintain universal and equitable protection.<\/jats:p>","DOI":"10.1186\/s12916-024-03321-2","type":"journal-article","created":{"date-parts":[[2024,3,13]],"date-time":"2024-03-13T02:10:01Z","timestamp":1710295801000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Malaria vaccination: hurdles to reach high-risk children"],"prefix":"10.1186","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1460-9522","authenticated-orcid":false,"given":"Floriano","family":"Amimo","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,3,13]]},"reference":[{"key":"3321_CR1","volume-title":"First malaria vaccine supply allocations May 2023: explanation of process and outcomes","author":"World Health Organization","year":"2023","unstructured":"World Health Organization. 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