title: The use of cost-effectiveness analysis for pediatric immunization in developing countries.
abstract: BACKGROUND
  Developing countries face critical choices for introducing needed, effective, but expensive new vaccines, especially given the accelerated need to decrease the mortality of children under age five and the increased immunization resources available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision makers can use for efficiently allocating expanding resources. Its use in developing countries, however, lags behind that in industrialized countries.
  
  
  METHODS
  We explored how CEA could be made more relevant to immunization policymaking in developing countries by identifying the limitations for using CEA in developing countries and the impact of donor funding on the CEA estimation. We conducted a comprehensive literature search using formal search protocols and hand searching indexed and gray literature sources. We then systematically summarized the application of CEA in industrialized and developing countries through thematic analysis, focusing on pediatric immunization and methodological and contextual issues relevant to developing countries.
  
  
  RESULTS
  Industrialized and developing countries use CEA differently. The use of the Disability-Adjusted Life Year (DALY) outcome measure and an alternative generalized cost-effectiveness analysis approach is restricted to developing countries. In pediatric CEAs, the paucity of evaluations and the lack of attention to overcoming the methodological limitations pertinent to children's cognitive and development distinctiveness, such as discounting and preference characterization, means that pediatric interventions may be systematically understudied and undervalued. The ability to generate high-quality CEA evidence in child health is further threatened by an inadequate consideration of the impact of donor funding (such as GAVI immunization funding) on measurement uncertainty and the determination of opportunity cost.
  
  
  CONCLUSIONS
  Greater attention to pediatric interventions and donor funding in the conduct of CEA could lead to better policies and thus more worthwhile and good-value programs to benefit children's health in developing countries.
authors.affiliation: St. Michael's Hospital, Toronto, Canada.
authors.forename: Cindy Low
authors.initials: CL
authors.lastname: Gauvreau
authors.forename: Wendy J
authors.initials: WJ
authors.lastname: Ungar
authors.forename: Jillian Clare
authors.initials: JC
authors.lastname: Köhler
authors.forename: Stanley
authors.initials: S
authors.lastname: Zlotkin
mesh_terms: D001424:Bacterial Infections / Q000191:economics / Q000517:prevention & control; D002662:Child Health Services / Q000191:economics; D002669:Child Welfare / Q000191:economics*; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003906:Developing Countries / Q000191:economics*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000191:economics*; D006801:Humans; D017589:Immunization Programs / Q000191:economics*; D007223:Infant; D007231:Infant, Newborn; D007391:International Cooperation; D032541:Mass Vaccination / Q000191:economics*; D019057:Quality-Adjusted Life Years; D014777:Virus Diseases / Q000191:economics / Q000517:prevention & control