Policy development process for introducing new malaria interventions in Tanzania : the case of Malaria vaccine RTS,S

This thesis describes research into anticipated policy processes and develops a comprehensive framework for informing policy decisions about the RTS,S malaria vaccine in Tanzania. RTS,S is the most advanced of malaria vaccines in development and has shown to protect children 5-17 months when used in conjunction with other malaria control strategies such as insecticides treated nets (ITNs) and anti-malaria drugs.
The goal of this study was to analyse the decision making and policy development process for introducing new malaria interventions in Tanzania, without any precedent of malaria vaccine use that might help to understand the context in which a malaria vaccine could be implemented. The goal was pursued using the following methods: a cross-sectional study, a qualitative approach and a synthesis approach. A cross-sectional study of 23 regions of Tanzania conducted during the Tanzanian Integrated Measles Campaign (IMC) survey in 2011 assessed awareness of and willingness to use a malaria vaccine among women aged 18 years or older with children under 11 months old. The main outcome measure was willingness to use a malaria vaccine. Document review and in-depth interviews with 20 key informants were conducted to assess malaria treatment policy changes in Tanzania and in other African RTS,S study countries. A comparative table and framework analysis was used as a practical guide to the steps of the decision making and policy process validated in Tanzania and other African RTS,S study countries. Synthesis and analysis of the results obtained from those studies were used to propose practical recommendations for malaria vaccine implementation. The main findings were as follows:
• A high willingness to use the malaria vaccine, associated with a high level of knowledge of the benefits of vaccinating children under-five, high acceptance of the mode of administering the malaria vaccine (2-3 injected doses delivered in the same day according to the proposed schedule for receiving the malaria vaccine).
• The framework was developed and applied to RTS, S African countries with regard to its readiness for adoption of the forthcoming malaria vaccine. The rating implies that Tanzania ((12), very good), Burkina Faso ((10), Malawi (9), Kenya and Gabon (8), good) are prepared —with regard to policy promoting factors —to embark on adopting the forthcoming malaria vaccine, RTS, S. Ghana ((5), little) has few policy promoting factors in place and had not yet documented information on barriers to decision making. Mozambique ((1), weak) had hardly documented any promoting factors or barriers. The attempt to compare showed some “good” and “very good” rankings regarding policy promoting factors although these factors may be hindered by some mentioned and documented barriers.
According to the findings, implementing the RTS,S malaria vaccine in programme settings still requires guidance in the form of proposed recommendations:
In Tanzania, the malaria vaccine is expected to be delivered through Immunization and Vaccine Development (IVD), and implemented at facility level by health care providers in both private and public facilities. In order to support and propagate the policy, a number of activities are recommended. For example, awareness should be created through developing a package of information for the community, the consumers of the vaccine that is accessible and offered in user friendly settings. Different types of media could be used for vaccine adverts and advocacy. A partnership between IVD and Global Alliance on Vaccine Initiative (GAVI) would help to ensure that the vaccine is delivered on time. IVD should strengthen its storage capacity to accommodate the malaria vaccine. To prepare for financing the vaccine, co-financing levels should be incorporated into the national budget. Guidelines, documents and training materials for immunization services should be modified to include the malaria vaccine. Health care personnel involved in vaccination should receive necessary training and a special surveillance system should be established to monitor vaccine pharmacovigilance both at national and district levels.
Implementing RTS,S in programme settings still requires some research into: i) assessing the packaging of RTS,S and the storage capacity of IVD to accommodate the malaria vaccine; ii) assessing vaccine pharmacovigilance in low and high transmission settings; iii) identifying the required numbers and skills of human resources iv) determining the additional workload for health care workers involved in vaccination.
This is the first report evaluating the policy and decision making process for introducing a malaria vaccine in Tanzania, without any precedent of malaria vaccine use. The results contribute to the growing knowledge that understanding people’s perceptions of a new malaria vaccine and the availability of a comprehension framework to understanding the policy process could speed up the decision making process and shorten the time needed to make the vaccine available to those in need. However, RTS, S vaccine alone does not provide a definitive solution to preventing malaria. The vaccine should be integrated with other strategies to address the burden of malaria in malaria endemic countries in Africa. These findings would be useful for other African countries planning to embark on implementing the RTS,S malaria vaccine when global RTS, S policy recommends its use.