{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T12:13:46Z","timestamp":1783426426267,"version":"3.54.6"},"reference-count":69,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T00:00:00Z","timestamp":1782950400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"UNICEF Regional Office for the Middle East and North Africa"},{"name":"Triangulate Health Ltd."},{"DOI":"10.13039\/100001125","name":"Gavi, The Vaccine Alliance","doi-asserted-by":"publisher","award":["SC220896"],"award-info":[{"award-number":["SC220896"]}],"id":[{"id":"10.13039\/100001125","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Background\/Objectives: Middle-income countries (MICs) in the Middle East and North Africa (MENA) face financial and health system barriers when introducing new vaccines. The Gavi MICs approach has supported the introduction of pneumococcal conjugate (PCV), human papillomavirus (HPV), and rotavirus (RV) vaccines; however, economic evidence from the region remains limited. This systematic review assessed the quantity, characteristics, and quality of economic evaluations of these vaccines in MENA MICs published between 2015 and 2025 and synthesised economic evidence to inform policy decisions in Algeria, Egypt, Iran, Jordan, Lebanon, Morocco, Palestine, and Tunisia. Methods: Relevant databases and registries were searched for cost\u2013effectiveness, cost\u2013utility, cost\u2013benefit, and budget impact analyses of PCV, HPV, and RV vaccination strategies. Two reviewers independently screened studies, extracted data, and assessed methodological quality. Results: Twenty-six studies met the inclusion criteria, including 12 on HPV, nine on RV, and five on PCV. Vaccine introduction was the most commonly evaluated intervention (n = 23), and most studies were cost\u2013effectiveness or cost\u2013utility analyses adopting payer, health system, societal, or mixed perspectives. PCV and RV introduction were consistently found to be cost-effective or cost-saving. HPV introduction showed mixed results, particularly in Iran, but was generally cost-effective in Tunisia and Morocco. Reporting of vaccine coverage, delivery costs, and programmatic constraints was limited, and overall methodological quality varied. Conclusions: Available evidence supports the economic value of PCV and RV introduction in MENA MICs, while HPV\u2019s cost-effectiveness is context dependent. Future evaluations should incorporate dynamic modelling, implementation costs, and affordability considerations to better inform sustainable vaccine introduction.<\/jats:p>","DOI":"10.3390\/vaccines14070591","type":"journal-article","created":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T11:48:32Z","timestamp":1782992912000},"page":"591","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Economic Evaluations of New Vaccine Introduction in Middle-Income Countries in the Middle East and North Africa Region: A Systematic Review"],"prefix":"10.3390","volume":"14","author":[{"given":"Chrissy","family":"Bishop","sequence":"first","affiliation":[{"name":"Triangulate Health Ltd., Doncaster DN11 9QU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Konstantina","family":"Politopoulou","sequence":"additional","affiliation":[{"name":"Triangulate Health Ltd., Doncaster DN11 9QU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Bermudez","sequence":"additional","affiliation":[{"name":"Triangulate Health Ltd., Doncaster DN11 9QU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Federico","family":"Rodriguez-Cairoli","sequence":"additional","affiliation":[{"name":"Triangulate Health Ltd., Doncaster DN11 9QU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Motuma","family":"Abeshu","sequence":"additional","affiliation":[{"name":"UNICEF MENA Regional Office, Abdulqader Al-Abed Street, Building No. 15 Tla\u2019a Al-Ali, Amman 11821, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sowmya","family":"Kadandale","sequence":"additional","affiliation":[{"name":"UNICEF MENA Regional Office, Abdulqader Al-Abed Street, Building No. 15 Tla\u2019a Al-Ali, Amman 11821, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ibironke","family":"Oyatoye","sequence":"additional","affiliation":[{"name":"UNICEF Headquarters, 3 UN Plaza, Room 816, New York, NY 10017, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8152-0662","authenticated-orcid":false,"given":"Saadia","family":"Farrukh","sequence":"additional","affiliation":[{"name":"UNICEF MENA Regional Office, Abdulqader Al-Abed Street, Building No. 15 Tla\u2019a Al-Ali, Amman 11821, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,2]]},"reference":[{"key":"ref_1","unstructured":"World Bank Group (2026, February 06). Middle Income Countries. Available online: https:\/\/www.worldbank.org\/ext\/en\/region\/mic#:~:text=The%20world\u2019s%20Middle%20Income%20Countries,exchange%20and%20South%2DSouth%20cooperation."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"S98","DOI":"10.1016\/j.vaccine.2023.06.079","article-title":"Opportunities to accelerate immunization progress in middle-income countries","volume":"42","author":"Zhu","year":"2024","journal-title":"Vaccine"},{"key":"ref_3","unstructured":"DeJong, J., and Bashour, H. (2016). UNFPA Regional Report Sexual and Reproductive Health Laws and Policies in Selected Arab Countries, UNFPA Regional Office for Arab States."},{"key":"ref_4","unstructured":"GAVI the Vaccine Alliance (2025). Gavi\u2019s Approach to Engaging with Middle-Income Countries, GAVI the Vaccine Alliance."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1016\/S0140-6736(20)30068-4","article-title":"Impact of HPV vaccination and cervical screening on cervical cancer elimination: A comparative modelling analysis in 78 low-income and lower-middle-income countries","volume":"395","author":"Brisson","year":"2020","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1016\/j.jped.2025.03.008","article-title":"Effectiveness of pneumococcal conjugate 13-valent vaccine against severe pneumonia in Panama: A matched case-control study","volume":"101","author":"Levy","year":"2025","journal-title":"J. Pediatr."},{"key":"ref_7","first-page":"CD008521","article-title":"Vaccines for preventing rotavirus diarrhoea: Vaccines in use","volume":"11","author":"Bergman","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e082592","DOI":"10.1136\/bmjopen-2023-082592","article-title":"Factors associated with HPV vaccine acceptance and hesitancy in Africa: A systematic review protocol","volume":"14","author":"Mavundza","year":"2024","journal-title":"BMJ Open"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1017\/ice.2017.237","article-title":"The Need for Rotavirus Vaccine Introduction in the National Immunization Program of More Than 100 Countries around the World","volume":"39","author":"Karami","year":"2018","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_10","unstructured":"World Health Organization (2026, February 05). Introduction of PCV (Pneumococcal Conjugate Vaccine). Available online: https:\/\/immunizationdata.who.int\/global\/wiise-detail-page\/introduction-of-pcv-(pneumococcal-conjugate-vaccine)?ISO_3_CODE=&CODE=Middle%20East%20and%20North%20Africa&YEAR=."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Bishop, C., Parashar, D., Kizza, D., Abeshu, M., Kaddar, M., Bchir, A., El Maghraby, A., Schirrmacher, H., Wang, Z., and Griffiths, U. (2025). New Vaccine Introduction in Middle-Income Countries Across the Middle East and North Africa\u2014Progress and Challenges. Vaccines, 13.","DOI":"10.20944\/preprints202508.0110.v1"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1159","DOI":"10.1080\/14737167.2021.1954508","article-title":"A systematic review of economic evaluations of vaccines in Middle East and North Africa countries: Is existing evidence good enough to support policy decision-making?","volume":"21","author":"Nagi","year":"2021","journal-title":"Expert Rev. Pharmacoecon. Outcomes Res."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Laraj, O., Benzina, B., Gzara, A., Kebir, A., Abbas, K., and Miled, S.B. (2024). Human papillomavirus vaccination at the national level in Tunisia: A cost-effectiveness analysis using a comparative modeling study. medRxiv, 24313756.","DOI":"10.1101\/2024.09.17.24313756"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e085462","DOI":"10.1136\/bmjopen-2024-085462","article-title":"Cost-effectiveness of human papillomavirus (HPV) vaccination in Tunisia: A modelling study","volume":"14","author":"Khiari","year":"2024","journal-title":"BMJ Open"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2353480","DOI":"10.1080\/21645515.2024.2353480","article-title":"Health economic evaluation of 2-dose and 3-dose rotavirus vaccines in children below 5 years of age in Morocco","volume":"20","author":"Mohy","year":"2024","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Hagens, A., Sloof, A.C., and Janghorban, R. (2024). Using a Dynamic Model to Estimate the Cost-Effectiveness of HPV Vaccination in Iran. Vaccines, 12.","DOI":"10.3390\/vaccines12040438"},{"key":"ref_17","unstructured":"PRISMA (2026, June 23). PRISMA 2020 Checklist [Internet]. Available online: https:\/\/www.prisma-statement.org\/prisma-2020-checklist."},{"key":"ref_18","unstructured":"The World Bank Group (2025). The World Bank Atlas Method-Detailed Methodology, The World Bank Group. Available online: https:\/\/datahelpdesk.worldbank.org\/knowledgebase\/articles\/378832-what-is-the-world-bank-atlas-method."},{"key":"ref_19","unstructured":"World Bank Group (2026, February 13). GDP per Capita (Current US$). Available online: https:\/\/data.worldbank.org\/indicator\/NY.GDP.PCAP.CD."},{"key":"ref_20","unstructured":"World Bank Group (2026, February 13). Official Exchange Rate (LCU Per US$, Period Average). Available online: https:\/\/data.worldbank.org\/indicator\/PA.NUS.FCRF."},{"key":"ref_21","unstructured":"World Bank Group (2026, February 13). Current Health Expenditure Per Capita (Current US$). Available online: https:\/\/data.worldbank.org\/indicator\/SH.XPD.CHEX.PC.CD."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e067975","DOI":"10.1136\/bmj-2021-067975","article-title":"Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: Updated reporting guidance for health economic evaluations","volume":"376","author":"Husereau","year":"2022","journal-title":"BMJ"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1016\/j.jval.2022.10.006","article-title":"Pneumococcal Vaccination in Children: A Systematic Review and Meta-Analysis of Cost-Effectiveness Studies","volume":"26","author":"Syeed","year":"2023","journal-title":"Value Health"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"100256","DOI":"10.1016\/j.jvacx.2022.100256","article-title":"Achieving immunization agenda 2030 coverage targets for 14 pathogens: Projected product and immunization delivery costs for 194 Countries, 2021\u20132030","volume":"13","author":"Sriudomporn","year":"2023","journal-title":"Vaccine X"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"27916","DOI":"10.1038\/s41598-025-13423-3","article-title":"HPV DNA screening and vaccination strategies in Tunisia","volume":"15","author":"Lahdhiri","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.jval.2020.07.012","article-title":"Informing Global Cost-Effectiveness Thresholds Using Country Investment Decisions: Human Papillomavirus Vaccine Introductions in 2006\u20132018","volume":"24","author":"Jit","year":"2021","journal-title":"Value Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e58","DOI":"10.1016\/S2214-109X(18)30422-4","article-title":"Effect and cost-effectiveness of pneumococcal conjugate vaccination: A global modelling analysis","volume":"7","author":"Chen","year":"2019","journal-title":"Lancet Glob. Health"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e1485","DOI":"10.1016\/S2214-109X(24)00232-8","article-title":"Re-evaluating the impact and cost-effectiveness of pneumococcal conjugate vaccine introduction in 112 low-income and middle-income countries in children younger than 5 years: A modelling study","volume":"12","author":"Chen","year":"2024","journal-title":"Lancet Glob. Health"},{"key":"ref_29","first-page":"1036","article-title":"The indirect costs of vaccine-preventable cancer mortality in the Middle East and North Africa (MENA)","volume":"27","author":"Bencina","year":"2024","journal-title":"J. Med. Econ."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"3903","DOI":"10.1016\/j.vaccine.2022.05.042","article-title":"Cost-effectiveness of rotavirus vaccination in children under five years of age in 195 countries: A meta-regression analysis","volume":"40","author":"Janko","year":"2022","journal-title":"Vaccine"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"715","DOI":"10.26719\/2019.25.10.715","article-title":"Cost\u2013benefit analysis of a projected national human papilloma virus vaccination programme in Lebanon","volume":"25","author":"Bahr","year":"2019","journal-title":"East. Mediterr. Health J."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Bashari, N., Davari, M., Akbarisari, A., Khorasani, E., and Daroudi, R. (2025). Cost-effectiveness analysis of different types of human papillomavirus vaccination to prevent cervical cancer in Iran. BMC Public Health, 25.","DOI":"10.1186\/s12889-025-24916-1"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"5091","DOI":"10.1016\/j.vaccine.2018.06.070","article-title":"National cervical cancer prevention program in the Arab States: Strategies and cost-minimization study of the Tunisian case","volume":"36","author":"Gamaoun","year":"2018","journal-title":"Vaccine"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e406","DOI":"10.1016\/S2214-109X(14)70237-2","article-title":"Cost-effectiveness of female human papillomavirus vaccination in 179 countries: A PRIME modelling study","volume":"2","author":"Jit","year":"2014","journal-title":"Lancet Glob. Health"},{"key":"ref_35","first-page":"225","article-title":"Cost-Effectiveness Evaluation of Quadrivalent Human Papilloma Virus Vaccine for HPV-Related Disease in Iran","volume":"13","author":"Khatibi","year":"2014","journal-title":"Iran. J. Pharm. Res. IJPR"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"100712","DOI":"10.1016\/j.jvacx.2025.100712","article-title":"Potential health impact and cost-effectiveness of human papillomavirus vaccination in Tunisia: A comparative modeling study","volume":"27","author":"Laraj","year":"2025","journal-title":"Vaccine X"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1153","DOI":"10.1080\/13696998.2019.1624556","article-title":"Cervical cancer prevention in Morocco: A model-based cost-effectiveness analysis","volume":"22","author":"Messoudi","year":"2019","journal-title":"J. Med. Econ."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Rosettie, K.L., Joffe, J.N., Sparks, G.W., Aravkin, A., Chen, S., Compton, K., Ewald, S.B., Mathew, E.B., Michael, D., and Velandia, P.P. (2021). Cost-effectiveness of HPV vaccination in 195 countries: A meta-regression analysis. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0260808"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1007\/s10935-022-00697-w","article-title":"Cost\u2013Benefit Analysis of Human Papillomavirus Vaccine in Iran","volume":"43","author":"Sargazi","year":"2022","journal-title":"J. Prev."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1016\/j.vhri.2018.03.001","article-title":"Cost-Effectiveness Analysis of the Introduction of HPV Vaccination of 9-Year-Old-Girls in Iran","volume":"15","author":"Yaghoubi","year":"2018","journal-title":"Value Health Reg. Issues"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"686","DOI":"10.26719\/emhj.19.039","article-title":"Cost-effectiveness of introducing the pneumococcal conjugate vaccine for children under 5 years in the Islamic Republic of Iran","volume":"25","author":"Ezoji","year":"2019","journal-title":"East. Mediterr. Health J."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2079305","DOI":"10.1080\/21645515.2022.2079305","article-title":"A cost-effectiveness analysis of PHiD-CV compared to PCV13 in a national immunization program setting in Tunisia","volume":"18","author":"Lagoubi","year":"2022","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1007\/s40121-018-0226-x","article-title":"Cost-Effectiveness of the Pneumococcal Conjugate Vaccine (10- or 13-Valent) Versus No Vaccination for a National Immunization Program in Tunisia or Algeria","volume":"8","author":"Pugh","year":"2019","journal-title":"Infect. Dis. Ther."},{"key":"ref_44","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":"Sevilla","year":"2022","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"A182","DOI":"10.1016\/j.vaccine.2014.12.044","article-title":"Cost-effectiveness analysis of the introduction of the pneumococcal conjugate vaccine (PCV-13) in the Egyptian national immunization program, 2013","volume":"33","author":"Sibak","year":"2015","journal-title":"Vaccine"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.vhri.2018.12.001","article-title":"Budget Impact Analysis of Rotavirus Vaccine Adoption in the Childhood Immunization Schedule of Iran","volume":"18","author":"Azad","year":"2019","journal-title":"Value Health Reg. Issues"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Debellut, F., Jaber, S., Bouzya, Y., Sabbah, J., Barham, M., Abu-Awwad, F., Hjaija, D., Ramlawi, A., Pecenka, C., and Clark, A. (2020). Introduction of rotavirus vaccination in Palestine: An evaluation of the costs, impact, and cost-effectiveness of ROTARIX and ROTAVAC. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0228506"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e942","DOI":"10.1016\/S2214-109X(21)00167-4","article-title":"Evaluating the potential economic and health impact of rotavirus vaccination in 63 middle-income countries not eligible for Gavi funding: A modelling study","volume":"9","author":"Debellut","year":"2021","journal-title":"Lancet Glob. Health"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"2040329","DOI":"10.1080\/21645515.2022.2040329","article-title":"Potential impact and cost-effectiveness of injectable next-generation rotavirus vaccines in 137 LMICs: A modelling study","volume":"18","author":"Debellut","year":"2022","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"A192","DOI":"10.1016\/j.vaccine.2014.12.035","article-title":"Cost-effectiveness analysis of the introduction of rotavirus vaccine in Iran","volume":"33","author":"Javanbakht","year":"2015","journal-title":"Vaccine"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"794","DOI":"10.1080\/21645515.2015.1087626","article-title":"The cost effectiveness of rotavirus vaccination in Iran","volume":"12","author":"Jarrahi","year":"2016","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e176","DOI":"10.1097\/INF.0000000000000727","article-title":"Epidemiological and Economic Impact of Monovalent and Pentavalent Rotavirus Vaccines in Low and Middle Income Countries","volume":"34","year":"2015","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"e2766","DOI":"10.5812\/ijp.2766","article-title":"Cost-Effectiveness of Rotavirus Vaccination for Under-Five Children in Iran","volume":"25","author":"Shakerian","year":"2015","journal-title":"Iran. J. Pediatr."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Shen, K., Wasserman, M., Liu, D., Yang, Y.-H., Yang, J., Guzauskas, G.F., Wang, B.C.M., Hilton, B., and Farkouh, R. (2018). Estimating the cost-effectiveness of an infant 13-valent pneumococcal conjugate vaccine national immunization program in China. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0201245"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"6700","DOI":"10.1016\/j.vaccine.2021.04.024","article-title":"Value of pneumococcal vaccination in controlling the development of antimicrobial resistance (AMR): Case study using DREAMR in Ethiopia","volume":"39","author":"Ozawa","year":"2021","journal-title":"Vaccine"},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Luo, Q., and Ni, Q. (2026). Gender-neutral human papillomavirus vaccination: An equitable and cost-effective public health investment. Front. Public Health, 13.","DOI":"10.3389\/fpubh.2025.1725127"},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Al-Eitan, L.N., Almahdawi, D.L., Abu Khiarah, R.A., and Alghamdi, M.A. (2025). Bridging Gaps in Vaccine Access and Equity: A Middle Eastern Perspective. Vaccines, 13.","DOI":"10.3390\/vaccines13080806"},{"key":"ref_58","unstructured":"Vande Maele, N., and Bourgoin, B. (2024). Unequal Access to Immunization in Middle-Income Countries Immunization Agenda 2030: In-Depth Review, Immunization Agenda 2030 Working Group on Middle-Income Countries\/World Health Organization."},{"key":"ref_59","unstructured":"World Health Organization (2025). MI4A Vaccine Purchase Data, World Health Organization. Available online: https:\/\/www.who.int\/teams\/immunization-vaccines-and-biologicals\/vaccine-access\/mi4a\/mi4a-vaccine-purchase-data."},{"key":"ref_60","unstructured":"Gavi the Vaccine Alliance (2025). Gavi MICs Approach-Considerations on Access to Sustainable Supply and Affordable Pricing, Gavi the Vaccine Alliance. Available online: https:\/\/www.gavi.org\/programmes-impact\/programmatic-policies\/eligibility-co-financing-policies\/considerations-access-sustainable-supply-affordable-pricing."},{"key":"ref_61","unstructured":"World Health Organization (2015). Sustainable Access to Vaccines in Middle-Income Countries (MICs): A Shared Partner Strategy Report of the WHO-Convened MIC Task Force, World Health Organization."},{"key":"ref_62","unstructured":"UNICEF Supply Division (2026, February 18). Middle-Income Countries\u2019 Financing Facility Closing the Gap on Global Health Inequity to Ensure the Survival and Development of Every Child. Available online: https:\/\/www.unicef.org\/supply\/middle-income-countries-financing-facility."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1016\/j.jval.2017.12.016","article-title":"Use and Misuse of Cost-Effectiveness Analysis Thresholds in Low- and Middle-Income Countries: Trends in Cost-per-DALY Studies","volume":"21","author":"Leech","year":"2018","journal-title":"Value Health"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"e833","DOI":"10.1016\/S2214-109X(23)00162-6","article-title":"Determining the efficiency path to universal health coverage: Cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures","volume":"11","author":"Drummond","year":"2023","journal-title":"Lancet Glob. Health"},{"key":"ref_65","unstructured":"Watkins, D.A., Twea, P.D., Gaudin, S., and Stenberg, K. (2025). Analytical Methods and Tools Used for Priority Setting and Costing for Health Benefits Packages in Low-and Lower-Middle-Income Countries. Country-Led Priority Setting for Health, The World Bank Group."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1016\/j.vaccine.2023.12.049","article-title":"National immunization technical advisory groups (NITAGs) in the WHO Eastern Mediterranean Region (EMR): A decade of shaping immunization policies, 2010\u20132021","volume":"42","author":"Sume","year":"2024","journal-title":"Vaccine"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"2239","DOI":"10.1016\/j.vaccine.2024.02.058","article-title":"Region-wide assessment of National Immunization Technical Advisory Groups (NITAGs) using the NITAG Maturity Assessment Tool (NMAT)\u2013Experience from the Eastern Mediterranean Region of the World Health Organization, 2023","volume":"42","author":"Sume","year":"2024","journal-title":"Vaccine"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1007\/s40258-021-00711-y","article-title":"Herd Immunity Effects in Cost-Effectiveness Analyses among Low- and Middle-Income Countries","volume":"20","author":"Ma","year":"2022","journal-title":"Appl. Health Econ. Health Policy"},{"key":"ref_69","unstructured":"World Health Organization (2026, June 23). Immunization, Vaccines and Biologicals [Internet]. Available online: https:\/\/www.who.int\/teams\/immunization-vaccines-and-biologicals\/policies\/who-recommendations-for-routine-immunization---summary-tables."}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/7\/591\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T11:16:44Z","timestamp":1783423004000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/14\/7\/591"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,2]]},"references-count":69,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["vaccines14070591"],"URL":"https:\/\/doi.org\/10.3390\/vaccines14070591","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,2]]}}}