Accounting for the Full Benefits of Childhood Vaccination in South Africa (Medicine and Economics‪)‬

While remarkable gains in health have been achieved since the mid-20th century, they have been unequally distributed, and mortality and morbidity burdens in some regions remain enormous. Of the almost 10 million children under 5 years of age who died in 2006, only 100 000 died in industrialised countries, while 4.8 million died in sub-Saharan Africa. (1) In deciding whether to finance an intervention to improve population health, policy makers commonly weigh the expected population health gains against the costs of the intervention. Most vaccinations included in national immunisation schedules, such as measles vaccination, are both effective in preventing ill health and relatively inexpensive. (2) Newer vaccinations, such as those with pneumococcal conjugate vaccine (PCV) or rotavirus vaccine, can effectively prevent child mortality and morbidity but are expensive relative to the vaccinations currently included in national immunisation schedules. Policy makers may therefore decide that--at current prices--the comparison of health gains with costs does not justify the free public provision of these vaccinations. We argue that in addition to the health benefits of vaccinations, their effects on education and income (3) and their benefits for unvaccinated community members can be considerable and should therefore be included in calculations to establish the value of vaccinations. Most economic evaluations of vaccinations focus heavily on the benefits of avoided health care costs (Table I). While it is theoretically possible to take productivity gains into account in economic evaluation (Table II), traditionally, evaluations of vaccinations have either not considered such gains or have only included one particular type of gain: the value of the time that parents would have spent caring for a sick child had a disease episode not been averted by vaccination (care-related productivity gains, Table I). (4) Such a narrow perspective may lead to substantial underestimates of the value of some vaccinations. It neglects lifetime productivity gains because a vaccination prevents diseases that can cause cognitive impairment, lead to physical handicap, or reduce school attendance (outcome-related productivity gains, Table I). Cost-benefit analyses (CBAs) in developing countries find return on investment in vaccinations (due to improved cognitive development and worker productivity) (5) of similar magnitude to the return on investment in education. (6)