title: New pneumococcal conjugate vaccine introductions in four sub-Saharan African countries: a cross-country analysis of health systems' impacts.
abstract: BACKGROUND
  Pneumonia is a main cause of under-five mortality in low-income settings. The pneumococcal conjugate vaccine (PCV) has been introduced in many countries as a tool in the disease's prevention. Although PCV's effectiveness has been established, less is known about the effects of introducing additional injectable vaccines into routine immunisation programmes, particularly in the context of resource-constrained settings.
  
  
  OBJECTIVE
  To explore the effects of PCV introduction on the immunisation programmes and health systems in four low-income countries.
  
  
  METHODS
  This study was carried out in Cameroon, Ethiopia, Kenya and Mali. Three to four regions and nine to 10 districts were selected within each country. Semi-structured interviews were carried out at national, regional and district levels (n=173). Researcher-administered questionnaires were completed with facility staff (n=124). Routine data on monthly vaccination activities were collected at district and facility levels.
  
  
  RESULTS
  PCV was generally well integrated into existing routine immunisation. Little or no impact was found in most areas of the health systems. Some minor effects were found on immunisation programmes, particularly in areas with either planning activities or investments e.g. staff skills were strengthened and there were limited improvements in surveillance. Although health sector workers perceived increases in the coverage of other vaccines following the introduction of PCV, routine service data did not confirm this claim. No substantial impacts were seen in health system management, service delivery or performance.
  
  
  CONCLUSIONS
  The introduction of PCV had marginal impacts on the Expanded Programme for Immunisation and little to none on broader health systems.
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sergio
authors.initials: S
authors.lastname: Torres-Rueda
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Helen Ed
authors.initials: HE
authors.lastname: Burchett
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Ulla K
authors.initials: UK
authors.lastname: Griffiths
authors.affiliation: Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon.
authors.forename: Pierre
authors.initials: P
authors.lastname: Ongolo-Zogo
authors.affiliation: Ministry of Health, Yaoundé, Cameroon.
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Edengue
authors.affiliation: Independent consultant, Addis Ababa, Ethiopia.
authors.forename: Yayehyirad
authors.initials: Y
authors.lastname: Kitaw
authors.affiliation: Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Mitike
authors.initials: M
authors.lastname: Molla
authors.affiliation: University of Nairobi, Nairobi, Kenya; University of Manitoba, Manitoba, Canada.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Gelmon
authors.affiliation: University of Nairobi, Nairobi, Kenya.
authors.forename: Washington
authors.initials: W
authors.lastname: Onyango-Ouma
authors.affiliation: Independent consultant, Bamako, Mali.
authors.forename: Mamadou
authors.initials: M
authors.lastname: Konate
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sandra
authors.initials: S
authors.lastname: Mounier-Jack
mesh_terms: D002163:Cameroon; D003695:Delivery of Health Care / Q000458:organization & administration*; D005002:Ethiopia; D006801:Humans; D007114:Immunization; D017589:Immunization Programs / Q000458:organization & administration*; D007630:Kenya; D022242:Pneumococcal Vaccines / Q000008:administration & dosage*; D015397:Program Evaluation; D014611:Vaccination / Q000706:statistics & numerical data*; D018074:Vaccines, Conjugate / Q000008:administration & dosage*
chemical_list: D022242:Pneumococcal Vaccines; D018074:Vaccines, Conjugate
keywords: health systems' impacts; pneumococcal conjugate vaccine; sub-Saharan