Cost-Effective but Still Out of Reach: MENA’s Vaccine Financing Crisis

Middle-income countries in the Middle East and North Africa (MENA) are facing a difficult vaccine choice: the economic case for introducing key vaccines is increasingly strong, but the financing and delivery systems needed to act on that evidence remain uneven. A systematic review published in Vaccines assesses economic evaluations of pneumococcal conjugate vaccines, human papillomavirus vaccines and rotavirus vaccines across Algeria, Egypt, Iran, Jordan, Lebanon, Morocco, Palestine and Tunisia, covering studies published between 2015 and 2025.

Pneumococcal conjugate vaccines and rotavirus vaccines generally offer strong value for money in MENA middle-income countries, while HPV vaccination shows more mixed results depending on vaccine price, country context, screening systems and assumptions about coverage. However, the study also exposes a deeper policy problem: too many vaccine decisions are still being shaped by incomplete evidence on affordability, implementation costs and real-world delivery constraints.

The Cost Trap Facing Middle-Income Immunization

For MENA's middle-income countries, vaccine introduction is not simply a technical decision about health benefits; it's a fiscal, political and governance challenge. The review notes that these countries face high vaccine costs, fiscal pressure, and disruptions linked to conflict and displacement. It makes new vaccine introduction harder even when the long-term health and economic benefits appear compelling.

The vaccines examined in the review address major public health burdens. HPV vaccination is linked to cervical cancer prevention, pneumococcal vaccines target severe pneumonia and related disease in young children, and rotavirus vaccines reduce severe diarrhoeal illness. The review highlights that rollout remains uneven across the region: Morocco is identified as the only middle-income country in the group to have introduced all three vaccines, while Egypt had not added any of the three to its national programme at the time referenced by the study.

The uneven progress points to a wider problem in global health financing. Middle-income countries often fall between two systems. They may no longer qualify for the same level of concessional support available to poorer countries, but they still face constrained budgets, competing public spending needs and fragile health infrastructure. That leaves governments with a hard question: how do they finance vaccines that are likely to save lives and reduce future costs, without destabilizing current health budgets?

The review shows that a vaccine can look like good value in a model but still be difficult to introduce if the budget impact is high, delivery systems are weak, or procurement prices are unfavourable.

PCV and Rotavirus Make the Strongest Case

Five studies assessed PCV in Egypt, Iran, Tunisia, and Algeria/Tunisia, mostly among young children. The review reports that PCV13 was cost-effective compared with no vaccination in Egypt and Iran, while both PCV13 and PCV10 were cost-effective in Algeria and Tunisia. The practical significance is substantial.

Pneumonia and related infections continue to place pressure on health systems, households and public budgets. If PCV introduction is consistently cost-effective across multiple country settings, delays may carry a real opportunity cost. The review itself notes that delayed introduction of PCV and rotavirus vaccines can allow preventable disease burdens to continue accumulating.

Rotavirus evidence is similarly supportive. Nine studies assessed rotavirus vaccines, including Iran-specific studies, a Palestine study, a Morocco study and multi-country analyses. In Iran, rotavirus vaccination was found to be highly cost-effective in several studies, and cost-saving from a societal perspective in one. In Palestine, rotavirus vaccination was cost-effective from the health-system perspective and cost-saving from the societal perspective when household-related costs were considered.

For countries seeking universal health coverage, the societal case is relevant because it captures financial protection, not only clinical outcomes.

Still, the review shows that value for money does not automatically resolve affordability. One Iran budget-impact analysis concluded that adding rotavirus vaccine to the national schedule would significantly affect health budgets, with an incremental cost of USD 131.45 million over five years of immunization.

HPV's Promise Depends on Price, Coverage and Strategy

HPV vaccination presents a more complicated picture. The review identified 12 HPV studies, with evidence concentrated in Iran and Tunisia, alongside studies in Morocco and Lebanon and multi-country analyses.

Three Iranian studies concluded that HPV vaccination was not cost-effective, while another found girls-only vaccination cost-effective but boys-only vaccination not cost-effective. A cost-benefit analysis in Iran reached a more favourable conclusion for bivalent and quadrivalent vaccination. In Tunisia, HPV vaccination was found to be cost-effective compared with no vaccination, and vaccination combined with screening was cost-effective compared with screening alone. In Morocco, vaccination was cost-effective relative to no intervention and more efficient than scaling up screening in some scenarios.

HPV economics are highly sensitive to context. Vaccine price, dose schedule, cervical cancer burden, existing screening coverage, target age group and negotiated procurement terms can all shift the result. A programme that looks borderline under one price or coverage assumption may become attractive under another.

HPV vaccination should not be assessed in isolation from screening policy, adolescent health platforms, gender equity goals and long-term cancer control planning. In settings where screening coverage is weak, vaccination may offer a strategic prevention route. In settings where screening systems already exist, the optimal policy may involve combining vaccination and screening in a way that maximizes health gains while controlling costs.

The review also highlights why procurement policy is crucial. Vaccine price repeatedly emerged as a major driver of cost-effectiveness, and the authors note that procurement decisions, product selection, tender design and volume commitments can shape economic conclusions. For MENA middle-income countries, this means health ministries cannot separate economic evaluation from purchasing strategy. Price negotiation, pooled procurement and financing mechanisms may determine whether HPV vaccination becomes feasible at scale.

Evidence Is Strong Enough to Act

The review supports the economic value of key vaccines, but it also warns that many studies are not yet detailed enough to guide real-world implementation. The authors found that many evaluations offered limited insight into affordability, budget impact and delivery feasibility.

Several gaps stand out. Country-specific evaluations were concentrated in Iran, Tunisia, Morocco and Egypt, while Palestine and Lebanon had far less evidence. That makes regional generalization risky. Smaller countries, conflict-affected settings and fragmented health systems may face different delivery costs, coverage barriers and procurement constraints.

The review also reports that many studies omitted delivery and injection supply costs, wastage, baseline coverage assumptions and the marginal cost of reaching underserved populations. These are not minor technical omissions. They are the costs that often determine whether a vaccine programme succeeds outside a model. Cold-chain capacity, outreach logistics, workforce availability, public trust and access for displaced or underserved communities can all affect both costs and coverage.

The authors acknowledge limitations in their own review as well. Embase, Scopus and Web of Science were not searched because of lack of institutional access, and grey and unpublished evidence was not systematically sought through dedicated grey-literature databases or ministry and agency websites. This means some relevant policy evidence may not have been captured, particularly government analyses that never reach academic publication.

The review recommends using pooled procurement and middle-income-country financing mechanisms, generating country-specific delivery and cold-chain cost data, and pairing cost-effectiveness analysis with budget-impact evidence rather than relying on cost-effectiveness ratios alone.

The next phase will depend on whether ministries of health, ministries of finance, procurement agencies, international partners and national immunization advisory bodies can use that evidence to make timely, affordable and equitable decisions. In a region where fiscal space is tight and health needs are urgent, delayed vaccine introduction is not a neutral choice. It can mean preventable illness, avoidable household costs and missed opportunities to strengthen public health resilience.