Closing the Pneumococcal Conjugate Vaccine (PCV) Introduction Gap: An Archetype Analysis of ‘last-mile’ countries

Pneumonia remains the leading infectious cause of global childhood deaths, despite the availability of World Health Organization (WHO)-prequalified pneumococcal conjugate vaccine (PCV) products and the evidence of their safety and efficacy for over two decades, along with financial and technical support from Gavi The Vaccine Alliance (Gavi). There are 39 remaining “last-mile” countries (33 low- and middle-income countries [LMICs] and six high-income countries) that haven’t fully included PCV in their National Immunization Programs. To address this inequitable distribution of PCV, we conducted a rapid assessment and landscaping exercise of country indicators related to barriers and facilitators for PCV decision-making, aiming to categorize countries into archetypes that could benefit from shared advocacy approaches. The archetype analysis first created a country matrix focused on three domains - health characteristics, immunization factors, and policy framework - and identified ten related indicators. Countries were scored based on indicator performance and subsequently ranked and grouped into three overarching archetypes of low-, moderate-, and high-barrier to PCV introduction. 15 countries were classified as “low-barrier,” indicating that they have more factors favorable for PCV introduction, such as high immunization coverage of common childhood vaccines, recent “new” vaccine introductions, and supportive governments, as well as substantial disease burden and eligibility for Gavi support. Most of the countries classified in the “moderate-barrier” (12 countries) and “high-barrier” (6 countries) archetypes have strong immunization systems, but competing country priorities and cost barriers impede policy decision-making on PCV introduction. Other countries require strengthening of their health systems despite political will. The barrier-based categorization can provide an actionable framework to design tailored PCV advocacy that addresses obstacles to new vaccine introductions within these “last-mile” countries. Implementation approaches that emerge from this framework can lead to strengthened decision-making on vaccine introduction and mobilization of investments in vaccine access that can enhance child survival worldwide.