{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,11]],"date-time":"2026-10-11T14:08:03Z","timestamp":1791727683869,"version":"4.3.4"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"11","license":[{"start":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T00:00:00Z","timestamp":1762214400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100001125","name":"GAVI Alliance","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100001125","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000265","name":"UK Medical Research Council","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Poverty alleviation is a major global development goal. Vaccines have the potential to provide financial risk protection (FRP) by preventing illnesses and associated healthcare costs. We estimate the lifetime FRP benefits generated by major vaccines among individuals vaccinated between 2000 and 2030 in low- and middle-income countries (LMICs).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods and findings<\/jats:title>\n                    <jats:p>\n                      We developed a microsimulation model to quantify the number of cases of catastrophic health expenditure (CHE) averted by a range of vaccines in 52 Gavi-eligible countries, stratified by wealth quintile. Vaccines protecting against five pathogens were considered, i.e., hepatitis B (routine and birth dose vaccine),\n                      <jats:italic>Haemophilus influenzae<\/jats:italic>\n                      type B, rotavirus, measles (routine and supplementary campaign vaccine), and\n                      <jats:italic>Streptococcus pneumoniae<\/jats:italic>\n                      . Model inputs were obtained from secondary data sources, including infection reduction rates under various immunization coverage scenarios, out-of-pocket health expenditures, transportation costs, wage losses, and healthcare utilization associated with disease treatment and consumption expenditures. CHE cases were defined as exceeding 10% of annual consumption, with sensitivity analyses conducted using thresholds of 25% and 40%, as well as impoverishing health expenditures were estimated. All vaccines, singly and collectively, showed a large impact on FRP and could avert ~200 million CHE cases across 52 Gavi-eligible countries from 2000 to 2030. Importantly, about half of all CHE cases were prevented among the poorest quintiles. When evaluated at a 10% threshold for CHE, the first dose of measles vaccine stood out in averting around 1,400 CHE cases per 10,000 vaccinated individuals in the poorest quintile, that is a total of 44 million CHE cases averted. A key limitation is the assumption of uniform disease risks in the absence of vaccination across quintiles, which may underestimate benefits for poorer groups.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Vaccines can provide substantial FRP benefits, particularly among the most disadvantaged populations. Sustained investments to ensure vulnerable populations receive vaccinations in LMICs can therefore not only improve health outcomes but also contribute to poverty reduction.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pmed.1004764","type":"journal-article","created":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T18:31:51Z","timestamp":1762281111000},"page":"e1004764","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Financial risk protection from vaccines in 52 Gavi-eligible low- and middle-income countries: A modeling study"],"prefix":"10.1371","volume":"22","author":[{"given":"Boshen","family":"Jiao","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryoko","family":"Sato","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua","family":"Mak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5180-3626","authenticated-orcid":true,"given":"Bryan","family":"Patenaude","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margaret","family":"de Villiers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0427-241X","authenticated-orcid":true,"given":"Aniruddha","family":"Deshpande","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3843-670X","authenticated-orcid":true,"given":"Ivane","family":"Gamkrelidze","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3734-9081","authenticated-orcid":true,"given":"Katy A. M.","family":"Gaythorpe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9681-0424","authenticated-orcid":true,"given":"Timothy B.","family":"Hallett","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6658-8255","authenticated-orcid":true,"given":"Mark","family":"Jit","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiang","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9238-0068","authenticated-orcid":true,"given":"Benjamin","family":"Lopman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shevanthi","family":"Nayagam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Devin","family":"Razavi-Shearer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yvonne","family":"Tam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4618-8267","authenticated-orcid":true,"given":"Kim H.","family":"Woodruff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Hogan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3475-3599","authenticated-orcid":true,"given":"Tewodaj","family":"Mengistu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4128-0849","authenticated-orcid":true,"given":"St\u00e9phane","family":"Verguet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,11,4]]},"reference":[{"key":"pmed.1004764.ref001","unstructured":"The United Nations Department of Economic and Social Affairs. The 17 goals [cited 2023 June 5]. Available from: https:\/\/sdgs.un.org\/goals"},{"key":"pmed.1004764.ref002","unstructured":"World Bank Group. Sustainable Development Goals and Targets. In: The Atlas of Sustainable Development Goals 2020 [Internet]. [cited 5 June 2023]. Available from: https:\/\/datatopics.worldbank.org\/sdgatlas\/targets\/"},{"key":"pmed.1004764.ref003","unstructured":"World Health Organization. Sustainable development goals [cited 2023 June 5]. Available from: https:\/\/www.who.int\/europe\/about-us\/our-work\/sustainable-development-goals"},{"issue":"2","key":"pmed.1004764.ref004","article-title":"Progress on catastrophic health spending in 133 countries: a retrospective observational study","volume":"6","author":"A Wagstaff","year":"2018","journal-title":"Lancet Glob Health"},{"issue":"2","key":"pmed.1004764.ref005","article-title":"Progress on impoverishing health spending in 122 countries: a retrospective observational study","volume":"6","author":"A Wagstaff","year":"2018","journal-title":"Lancet Glob Health"},{"key":"pmed.1004764.ref006","author":"World Health Organization","year":"2021"},{"key":"pmed.1004764.ref007","unstructured":"World Health Organization, World Bank Group. Tracking universal health coverage: 2023 global monitoring report. 2023. Available from: https:\/\/cdn.who.int\/media\/docs\/default-source\/hgf\/9789240080379.pdf?sfvrsn=780a6606_3&download=true"},{"key":"pmed.1004764.ref008","unstructured":"World Health Organization. SDG 3.8.2 Catastrophic health spending (and related indicators) [cited 2023 Sep 29]. Available from: https:\/\/www.who.int\/data\/gho\/data\/themes\/topics\/financial-protection"},{"issue":"2","key":"pmed.1004764.ref009","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1093\/heapol\/czac107","article-title":"Catastrophic health care expenditure and impoverishment in Bhutan","volume":"38","author":"J Sharma","year":"2023","journal-title":"Health Policy Plan"},{"issue":"10","key":"pmed.1004764.ref010","doi-asserted-by":"crossref","first-page":"1397","DOI":"10.1093\/heapol\/czx120","article-title":"The effect of costs on Kenyan households\u2019 demand for medical care: why time and distance matter","volume":"32","author":"M Kukla","year":"2017","journal-title":"Health Policy Plan"},{"key":"pmed.1004764.ref011","doi-asserted-by":"crossref","first-page":"115583","DOI":"10.1016\/j.socscimed.2022.115583","article-title":"The importance of wage loss in the financial burden of illness: longitudinal evidence from India","volume":"317","author":"A Shrinivas","year":"2023","journal-title":"Soc Sci Med"},{"key":"pmed.1004764.ref012","article-title":"Global action on the social determinants of health","volume":"3","author":"A Donkin","year":"2017","journal-title":"BMJ Glob Health"},{"issue":"1","key":"pmed.1004764.ref013","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1186\/s12916-018-1074-y","article-title":"Estimating the distribution of morbidity and mortality of childhood diarrhea, measles, and pneumonia by wealth group in low- and middle-income countries","volume":"16","author":"AY Chang","year":"2018","journal-title":"BMC Med"},{"issue":"8","key":"pmed.1004764.ref014","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0000819","article-title":"Modeling the relative risk of incidence and mortality of select vaccine-preventable diseases by wealth group and geographic region in Ethiopia","volume":"2","author":"S Bolongaita","year":"2022","journal-title":"PLOS Glob Public Health"},{"issue":"9","key":"pmed.1004764.ref015","doi-asserted-by":"crossref","first-page":"522","DOI":"10.2471\/BLT.24.292198","article-title":"Inequalities in diarrhoea, pneumonia and measles deaths: estimates for 21 sub-Saharan African countries","volume":"103","author":"S Verguet","year":"2025","journal-title":"Bull World Health Organ"},{"issue":"9","key":"pmed.1004764.ref016","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001701","article-title":"Financial risk protection and universal health coverage: evidence and measurement challenges","volume":"11","author":"P Saksena","year":"2014","journal-title":"PLoS Med"},{"issue":"9849","key":"pmed.1004764.ref017","doi-asserted-by":"crossref","first-page":"1259","DOI":"10.1016\/S0140-6736(12)61068-X","article-title":"The quest for universal health coverage: achieving social protection for all in Mexico","volume":"380","author":"FM Knaul","year":"2012","journal-title":"Lancet"},{"issue":"9974","key":"pmed.1004764.ref018","doi-asserted-by":"crossref","first-page":"1230","DOI":"10.1016\/S0140-6736(14)61646-9","article-title":"Health-system reform and universal health coverage in Latin America","volume":"385","author":"R Atun","year":"2015","journal-title":"Lancet"},{"issue":"10195","key":"pmed.1004764.ref019","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1016\/S0140-6736(19)31243-7","article-title":"Brazil\u2019s unified health system: the first 30 years and prospects for the future","volume":"394","author":"MC Castro","year":"2019","journal-title":"Lancet"},{"issue":"10204","key":"pmed.1004764.ref020","doi-asserted-by":"crossref","first-page":"1192","DOI":"10.1016\/S0140-6736(19)32136-1","article-title":"10 years of health-care reform in China: progress and gaps in Universal Health Coverage","volume":"394","author":"W Yip","year":"2019","journal-title":"Lancet"},{"key":"pmed.1004764.ref021","doi-asserted-by":"crossref","DOI":"10.7554\/eLife.67635","article-title":"Lives saved with vaccination for 10 pathogens across 112 countries in a pre-COVID-19 world","volume":"10","author":"J Toor","year":"2021","journal-title":"Elife"},{"issue":"10272","key":"pmed.1004764.ref022","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1016\/S0140-6736(20)32657-X","article-title":"Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: a modelling study","volume":"397","author":"X Li","year":"2021","journal-title":"Lancet"},{"key":"pmed.1004764.ref023","author":"World Bank","year":"2022"},{"key":"pmed.1004764.ref024","unstructured":"World Health Organization. COVID-19 pandemic fuels largest continued backslide in vaccinations in three decades; 2022 [cited 2023 June 6]. Available from: https:\/\/www.who.int\/news\/item\/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades"},{"issue":"5","key":"pmed.1004764.ref025","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1016\/S1473-3099(20)30304-2","article-title":"COVID-19 disrupts vaccine delivery","volume":"20","author":"R Nelson","year":"2020","journal-title":"Lancet Infect Dis"},{"issue":"5","key":"pmed.1004764.ref026","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1038\/s41562-021-01096-7","article-title":"Socioeconomic impacts of COVID-19 in low-income countries","volume":"5","author":"A Josephson","year":"2021","journal-title":"Nat Hum Behav"},{"issue":"2","key":"pmed.1004764.ref027","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1377\/hlthaff.2017.0861","article-title":"The equity impact vaccines may have on averting deaths and medical impoverishment in developing countries","volume":"37","author":"AY Chang","year":"2018","journal-title":"Health Aff (Millwood)"},{"key":"pmed.1004764.ref028","author":"Gavi, The Vaccine Alliance","year":"2022"},{"key":"pmed.1004764.ref029","unstructured":"World Bank Group. June 2025 update to global poverty lines. 5 June 2025 [cited 9 June 2025]. Available from: https:\/\/www.worldbank.org\/en\/news\/factsheet\/2025\/06\/05\/june-2025-update-to-global-poverty-lines"},{"key":"pmed.1004764.ref030","unstructured":"World Health Organization. Global health expenditure database [cited 2023 April 14]. Available from https:\/\/apps.who.int\/nha\/database"},{"key":"pmed.1004764.ref031","unstructured":"World Bank Group. World development indicators [cited 2023 June 5]. Available from: https:\/\/databank.worldbank.org\/source\/world-development-indicators"},{"key":"pmed.1004764.ref032","unstructured":"The World Bank. Gini index [cited 2023 April 14]. Available from: https:\/\/data.worldbank.org"},{"key":"pmed.1004764.ref033","unstructured":"Johns Hopkins Bloomberg School of Public Health. Decade of vaccine economics [cited 2023 April 14]. Available from: https:\/\/immunizationeconomics.org\/dove-home"},{"issue":"1","key":"pmed.1004764.ref034","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1186\/s12916-023-02957-w","article-title":"Financial hardship associated with catastrophic out-of-pocket spending tied to primary care services in low- and lower-middle-income countries: findings from a modeling study","volume":"21","author":"S Bolongaita","year":"2023","journal-title":"BMC Med"},{"key":"pmed.1004764.ref035","unstructured":"United States Agency for International Development. The DHS program\u2014data [cited 2023 April 14]. Available from: https:\/\/dhsprogram.com\/data\/"},{"key":"pmed.1004764.ref036","unstructured":"World Health Organization. STEPwise approach to NCD risk factor surveillance (STEPS) [cited 2023 June 5]. Available from: https:\/\/www.who.int\/teams\/noncommunicable-diseases\/surveillance\/systems-tools\/steps"},{"key":"pmed.1004764.ref037","unstructured":"World Bank Group. Health Equity and Financial Protection Indicators (HEFPI) [cited 2023 June 5]. Available from: https:\/\/datatopics.worldbank.org\/health-equity-and-financial-protection\/"},{"key":"pmed.1004764.ref038","author":"World Bank Group"},{"key":"pmed.1004764.ref039","doi-asserted-by":"crossref","first-page":"1115","DOI":"10.2307\/1914221","article-title":"A convenient descriptive model of income distribution: the gamma density","author":"AB Salem","year":"1974","journal-title":"Econometrica"},{"key":"pmed.1004764.ref040","unstructured":"World Bank Group. Number of people spending more than 10% of household consumption or income on out-of-pocket health care expenditure [cited 2023 June 7]. Available from: https:\/\/data.worldbank.org"},{"key":"pmed.1004764.ref041","volume-title":"Using\u00a0cost-effectiveness analysis to address health equity concerns. Value in Health 2017;20(2):206-12","author":"R Cookson"},{"issue":"9","key":"pmed.1004764.ref042","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1007\/s40273-016-0414-z","article-title":"Extended cost-effectiveness analysis for health policy assessment: a tutorial","volume":"34","author":"S Verguet","year":"2016","journal-title":"Pharmacoeconomics"},{"issue":"1","key":"pmed.1004764.ref043","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1177\/0272989X15583266","article-title":"Distributional cost-effectiveness analysis: a tutorial","volume":"36","author":"M Asaria","year":"2016","journal-title":"Med Decis Making"},{"issue":"12","key":"pmed.1004764.ref044","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2021-007479","article-title":"Using geospatial models to map zero-dose children: factors associated with zero-dose vaccination status before and after a mass measles and rubella vaccination campaign in Southern province, Zambia","volume":"6","author":"R Arambepola","year":"2021","journal-title":"BMJ Glob Health"},{"key":"pmed.1004764.ref045","doi-asserted-by":"crossref","DOI":"10.1596\/978-1-4648-0348-2_ch10","article-title":"Vaccines for children in low- and middle-income countries.","volume-title":"Reproductive, maternal, newborn, and child health: disease control priorities, third edition (Volume 2)","author":"DR Feikin","year":"2016"}],"container-title":["PLOS Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004764","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T18:32:01Z","timestamp":1762281121000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pmed.1004764"}},"subtitle":[],"editor":[{"given":"Mirjam E. 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