{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,4,24]],"date-time":"2025-04-24T04:30:29Z","timestamp":1745469029460,"version":"3.40.4"},"reference-count":60,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2025,4,23]],"date-time":"2025-04-23T00:00:00Z","timestamp":1745366400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV006046"],"award-info":[{"award-number":["INV006046"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Despite the well-documented life-saving potential of pneumococcal conjugate vaccines (PCV) and global efforts to widen vaccine availability, access to PCV in middle-income countries (MICs) has remained suboptimal due, in part, to vaccine pricing and limited external funding opportunities. To understand gaps and opportunities for improving vaccine equality, this qualitative study engaged leaders from governments, medical institutions, and health agencies who were based in MICs that did not currently have PCV in their national immunization programs to explore their perspectives on decision-making contexts and constraints related to PCV introduction. In-depth interviews with 17 participants from Egypt, Jordan, Sri Lanka, and Thailand in 2023 documented that, despite high immunization coverage and commitment toward equitable health systems, implementing new vaccines such as PCV has remained challenging. Among the six thematic areas that emerged, two were strong enablers to vaccine implementation: 1) the existence of strong primary healthcare systems; and 2) established policy processes for vaccine decision-making. Three themes that emerged have hindered PCV introduction, including; 1) limited information on disease burden and available vaccine products; 2) competing country health priorities; and 3) financing challenges. The interplay of these thematic areas has documented a paradox unique to MICs, further contributing to inequalities in vaccine access. While a subset of MICs recently became eligible for support from Gavi, the Vaccine Alliance for introducing new vaccines, the marketplace has historically lacked tiered vaccine pricing that MICs could sustain for the long term. This is despite the great need with existing inequities and a substantial proportion of the world\u2019s low-income and displaced populations. Finally, participants said barriers may be alleviated with support from global and regional actors providing technical capacity-strengthening, advocacy, and strategic financial support. These findings are informative for strengthening equality in access to vaccines and developing strategies to introduce and sustain life-saving vaccines, including PCV.<\/jats:p>","DOI":"10.1371\/journal.pgph.0004473","type":"journal-article","created":{"date-parts":[[2025,4,23]],"date-time":"2025-04-23T17:23:24Z","timestamp":1745429004000},"page":"e0004473","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Bridging the gap in pneumonia prevention: Qualitative insights on vaccine implementation from health leaders in middle-income countries"],"prefix":"10.1371","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0171-5043","authenticated-orcid":true,"given":"Rose","family":"Weeks","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5021-3432","authenticated-orcid":true,"given":"Baldeep K.","family":"Dhaliwal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jasmine","family":"Huber","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4942-2508","authenticated-orcid":true,"given":"Sarah","family":"Nabia","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3844-7292","authenticated-orcid":true,"given":"Ala\u2019a F.","family":"Al-Shaikh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0140-4600","authenticated-orcid":true,"given":"Kulkanya","family":"Chokephaibulkit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"LaKKumar","family":"Fernando","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8197-6237","authenticated-orcid":true,"given":"Ehssan","family":"Baghagho","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anita","family":"Shet","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,4,23]]},"reference":[{"issue":"4 Suppl","key":"pgph.0004473.ref001","first-page":"S12-5","article-title":"Introducing new vaccines into developing countries: obstacles, opportunities and complexities","volume":"11","author":"J Clemens","year":"2005","journal-title":"Nat Med"},{"key":"pgph.0004473.ref002","author":"UNICEF"},{"key":"pgph.0004473.ref003"},{"key":"pgph.0004473.ref004","author":"IA2030 Working Group on Middle-Income Countries","year":"2024"},{"key":"pgph.0004473.ref005"},{"key":"pgph.0004473.ref006","author":"World Bank"},{"key":"pgph.0004473.ref007","author":"World Bank. World Bank Country and Lending Groups \u2013 World Bank Data Help Desk [Internet]"},{"key":"pgph.0004473.ref008","author":"Immunization Agenda (IA2030) Scorecard. IA2030 Scorecard for Immunization Agenda 2030 [Internet]"},{"key":"pgph.0004473.ref009","author":"Immunization Agenda 2030 Work Group on MICs","year":"2020"},{"key":"pgph.0004473.ref010","author":"International Development Association"},{"key":"pgph.0004473.ref011","author":"Gavi, the Vaccine Alliance","year":"2022"},{"key":"pgph.0004473.ref012","unstructured":"Gavi, the Vaccine Alliance. Gavi Middle Income Countries Approach: Overview [Internet]. 2023. Available from: Personal communication"},{"issue":"12","key":"pgph.0004473.ref013","first-page":"93","article-title":"Pneumococcal conjugate vaccine for childhood immunization--WHO position paper","volume":"82","author":"World Health Organization.","year":"2007","journal-title":"Wkly Epidemiol Rec"},{"issue":"1","key":"pgph.0004473.ref014","doi-asserted-by":"crossref","first-page":"2281065","DOI":"10.1080\/16549716.2023.2281065","article-title":"Closing the pneumococcal conjugate vaccine (PCV) introduction gap: an archetype analysis of last-mile countries","volume":"16","author":"P Banerjee","year":"2023","journal-title":"Glob Health Action"},{"issue":"S","key":"pgph.0004473.ref015","first-page":"S98-106","article-title":"Opportunities to accelerate immunization progress in middle-income countries","volume":"42","author":"J Zhu","year":"2024","journal-title":"Vaccine"},{"issue":"1","key":"pgph.0004473.ref016","doi-asserted-by":"crossref","first-page":"e47","DOI":"10.1016\/S2214-109X(18)30408-X","article-title":"Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis","volume":"7","author":"DA McAllister","year":"2019","journal-title":"Lancet Glob Health"},{"issue":"1","key":"pgph.0004473.ref017","doi-asserted-by":"crossref","first-page":"010408","DOI":"10.7189\/jogh.06.010408","article-title":"Cost of management of severe pneumonia in young children: systematic analysis","volume":"6","author":"S Zhang","year":"2016","journal-title":"J Glob Health"},{"key":"pgph.0004473.ref018"},{"key":"pgph.0004473.ref019","author":"Gavi, the Vaccine Alliance","year":"2023"},{"key":"pgph.0004473.ref020"},{"issue":"6","key":"pgph.0004473.ref021","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups","volume":"19","author":"A Tong","year":"2007","journal-title":"Int J Qual Health Care"},{"key":"pgph.0004473.ref022","first-page":"ii62-76","article-title":"National decision-making on adopting new vaccines: a systematic review","author":"HED Burchett","year":"2012","journal-title":"Health Policy Plan"},{"key":"pgph.0004473.ref023","first-page":"284","article-title":"Up the anthropologist: perspectives gained from studying up.","volume-title":"Reinventing anthropology [Inte","author":"L Nader","year":"1972"},{"issue":"1","key":"pgph.0004473.ref024","doi-asserted-by":"crossref","first-page":"2314828","DOI":"10.1080\/21645515.2024.2314828","article-title":"Introduction of the pneumococcal conjugate vaccine in humanitarian and fragile contexts: perspectives from stakeholders in four African countries","volume":"20","author":"BK Dhaliwal","year":"2024","journal-title":"Hum Vaccin Immunother"},{"key":"pgph.0004473.ref025","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1186\/1471-2288-13-117","article-title":"Using the framework method for the analysis of qualitative data in multi-disciplinary health research","volume":"13","author":"NK Gale","year":"2013","journal-title":"BMC Med Res Methodol"},{"key":"pgph.0004473.ref026","author":"A Al-Shaikh","year":"2023"},{"key":"pgph.0004473.ref027"},{"key":"pgph.0004473.ref028","author":"Gavi, the Vaccine Alliance"},{"key":"pgph.0004473.ref029","unstructured":"Middle Income Country Task Force. Sustainable Access to Vaccines in Middle-Income Countries (MICs): A Shared Partner Strategy Report of the WHO-Convened MIC Task Force. 2015 Mar."},{"key":"pgph.0004473.ref030"},{"key":"pgph.0004473.ref031","unstructured":"Immunization Agenda 2030 Working Group on Middle-Income Countries. Performance Of Middle-income Countries: Impact Goals, Baseline-2021 Immunization Agenda 2030. 2023."},{"issue":"1","key":"pgph.0004473.ref032","article-title":"Worldwide child routine vaccination hesitancy rate among parents of children aged 0-6 years: A systematic review and meta-analysis of cross-sectional studies","volume":"12","author":"M Abenova","year":"2023","journal-title":"Vaccines (Basel)"},{"key":"pgph.0004473.ref033","author":"United Nations Children\u2019s Fund.","year":"2023"},{"issue":"suppl_3","key":"pgph.0004473.ref034","doi-asserted-by":"crossref","first-page":"S368-77","DOI":"10.1093\/cid\/cix101","article-title":"The effect of antibiotic exposure and specimen volume on the detection of bacterial pathogens in children with pneumonia","volume":"64","author":"A Driscoll","year":"2017","journal-title":"Clin Infect Dis"},{"issue":"4","key":"pgph.0004473.ref035","doi-asserted-by":"crossref","DOI":"10.3390\/microorganisms9040742","article-title":"Global landscape review of serotype-specific invasive pneumococcal disease surveillance among countries using PCV10\/13: The Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project","volume":"9","author":"M Deloria Knoll","year":"2021","journal-title":"Microorganisms"},{"issue":"3","key":"pgph.0004473.ref036","doi-asserted-by":"crossref","first-page":"426","DOI":"10.3390\/vaccines8030426","article-title":"Pneumococcal vaccination for children in Asian Countries: A systematic review of economic evaluation studies","volume":"8","author":"N Zakiyah","year":"2020","journal-title":"Vaccines (Basel)"},{"issue":"6","key":"pgph.0004473.ref037","doi-asserted-by":"crossref","first-page":"2114252","DOI":"10.1080\/21645515.2022.2114252","article-title":"Cost-utility and cost-benefit analysis of pediatric PCV programs in Egypt","volume":"18","author":"JP Sevilla","year":"2022","journal-title":"Hum Vaccin 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Ezoji","year":"2019","journal-title":"East Mediterr Health J"},{"issue":"26","key":"pgph.0004473.ref041","doi-asserted-by":"crossref","first-page":"2839","DOI":"10.1016\/j.vaccine.2013.03.047","article-title":"Cost-utility analysis of 10- and 13-valent pneumococcal conjugate vaccines: protection at what price in the Thai context?","volume":"31","author":"W Kulpeng","year":"2013","journal-title":"Vaccine"},{"issue":"21","key":"pgph.0004473.ref042","doi-asserted-by":"crossref","first-page":"6998","DOI":"10.3390\/ijerph20216998","article-title":"Understanding HPV vaccination policymaking in Rwanda: a case of health prioritization and public-private-partnership in a low-resource setting","volume":"20","author":"E Asempah","year":"2023","journal-title":"Int J Environ Res Public Health"},{"issue":"1","key":"pgph.0004473.ref043","doi-asserted-by":"crossref","first-page":"1624","DOI":"10.1186\/s12889-021-11642-7","article-title":"Ensuring sustainability of polio immunization in health system transition: lessons from the polio eradication initiative in Indonesia","volume":"21","author":"L Azizatunnisa\u2019","year":"2021","journal-title":"BMC Public Health"},{"key":"pgph.0004473.ref044"},{"issue":"4","key":"pgph.0004473.ref045","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1093\/ije\/dyac107","article-title":"Large variation in the epidemiological transition across countries: is it still valuable as a mortality theory","volume":"51","author":"N Sudharsanan","year":"2022","journal-title":"Int J Epidemiol"},{"issue":"7806","key":"pgph.0004473.ref046","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1038\/s41586-020-2238-4","article-title":"Childhood vaccines and antibiotic use in low- and middle-income countries","volume":"581","author":"JA Lewnard","year":"2020","journal-title":"Nature"},{"key":"pgph.0004473.ref047","author":"PATH"},{"key":"pgph.0004473.ref048","author":"S Nebehay","year":"2021"},{"key":"pgph.0004473.ref049","author":"Gavi, the Vaccine Alliance"},{"key":"pgph.0004473.ref050","doi-asserted-by":"crossref","first-page":"100158","DOI":"10.1016\/j.lansea.2023.100158","article-title":"Local distribution infrastructure and robust vaccine manufacturing facilities in LMICs should be prioritised to tackle ongoing and future pandemic risk","volume":"11","author":"HM Reza","year":"2023","journal-title":"Lancet Reg Health Southeast Asia"},{"key":"pgph.0004473.ref051","author":"PATH"},{"issue":"2","key":"pgph.0004473.ref052","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1080\/21645515.2015.1084450","article-title":"The potential impact of pneumococcal conjugate vaccine in Africa: considerations and early lessons learned from the South African experience","volume":"12","author":"SA Madhi","year":"2016","journal-title":"Hum Vaccin 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