Background: Recent surveys, studies and reviews in urban areas of Pakistan have highlighted the impacts of social inequities on access of women and children to health services for women and children in Pakistan. Objectives: The Urban Slum Profiles and coverage surveys were conducted between 2017 and 2019. The objective of the profiles was to obtain an updated listing of slums and other underserved areas, and to better understand current vaccination and health service coverage in these areas. Utilising findings from these studies, this paper aims to better understand the gender and social determinants of health that are giving rise to health inequalities in the slums. Methods: The Urban Slum Profiles adopted a mixed methods approach combining both qualitative and quantitative methods. The study was comprised of two main survey approaches of Urban Slum Profiles and Immunisation Coverage Survey in 4431 urban poor areas of the 10 most highly populated cities of Pakistan. Results: Findings are classified into six analytic categories of (1) access to health services, (2) female workforce participation, (3) gender-friendly health services, (4) access to schools and literacy, (5) social connections, and (6) autonomy of decision making. Out of a national sample of 14,531 children in urban poor areas of 10 cities, the studies found that just over half of the children are fully immunised (54%) and 14% of children had received zero doses of vaccine. There are large shortages of health facilities and female health workforce in the slums, with significant gaps in the quality of health infrastructure, which all serve to limit both demand for, and supply of, health services for women and children. Results demonstrate low availability of schools, low levels of female literacy and autonomy over decision making, limited knowledge of the benefits of vaccination, and few social connections outside the home. All these factors interact and reinforce existing gender norms and low levels of health literacy and service access. Conclusion: The Urban Slum profiles and coverage studies provide an opportunity to introduce gender transformative strategies that include expansion of a female health workforce, development of costed urban health action plans, and an enabling policy environment to support community organisation and more equitable health service delivery access.

Background/Objectives: The middle-income countries (MICs) in the Middle East and North Africa (MENA) region face multifaceted challenges—including fiscal constraints, conflict, and vaccine hesitancy—that impede the timely introduction of critical vaccines. This study examines the status, barriers, and facilitators to introducing three critical vaccines—human papillomavirus vaccine (HPV), pneumococcal conjugate vaccine (PCV), and rotavirus vaccine (RV)—across seven MENA MICs, to identify actionable solutions to enhance vaccine uptake and immunisation coverage. Methods: Using the READ methodology (ready materials, extract, analyse, and distil data), this review systematically analysed policy documents, reports, and the literature on the introduction of HPV, PCV, and RV vaccines in seven MENA MICs. A data extraction framework was designed to capture the status of vaccine introduction and barriers and facilitators to introduction. Findings and data gaps were validated with stakeholder consultations. Results: Of the seven study countries, progress in introducing PCV and RV has been uneven across the region (five countries have introduced PCV, four have introduced RV, and only a single country has introduced HPV at time of writing), hindered by vaccine hesitancy, fiscal challenges, and insufficient epidemiological data. Morocco is the only country to introduce all three vaccines, while Egypt has yet to introduce any. Other common barriers include the impact of conflict and displacement on healthcare infrastructure, delayed introduction due to the 2020 COVID-19 pandemic, and limited local production facilities and regional cooperation. In addition, not all countries eligible for Gavi MICs support have applied. These findings provide a roadmap for policymakers to accelerate equitable vaccine introduction in the MENA region. Conclusions: Targeted efforts, such as addressing fiscal constraints, improving local manufacturing, tackling gender barriers, and fostering public trust, paired with regional collaboration, can help bridge gaps and ensure no community is left behind in preventing vaccine-preventable diseases.

Background/Objectives: The middle-income countries (MICs) in the Middle East and North Africa (MENA) region face multifaceted challenges—including fiscal constraints, conflict, and vaccine hesitancy—that impede the timely introduction of critical vaccines. This study examines the status, barriers, and facilitators to introducing three critical vaccines— human papillomavirus vaccine (HPV), pneumococcal conjugate vaccine (PCV), and rotavirus vaccine (RV) vaccine—across seven MENA MICs, to identify actionable solutions to enhance vaccine uptake and immunisation coverage. Methods: Using the READ methodology (ready materials, extract, analyse, and distil data), this review systematically analysed policy documents, reports, and literature on the introduction of HPV, PCV, and RV vaccines in seven MENA MICs. A data extraction framework was designed to capture the status of vaccine introduction and barriers and facilitators to introduction. Findings and data gaps were validated with stakeholder consultations. Results: Of the seven study countries, progress in introducing PCV and RV has been uneven across the region (five countries have introduced PCV while four have introduced the RV vaccine), while HPV vaccine rollout remains limited to one country, hindered by vaccine hesitancy, fiscal challenges, and insufficient epidemiological data. Morocco is the only country to introduce all three vaccines, while Egypt has yet to introduce any. Other common barriers include the impact of conflict and displacement on healthcare infrastructure, delayed introduction due to the 2020 Covid-19 pandemic, limited local production facilities and regional cooperation. In addition, not all countries eligible for Gavi MICs support have applied. These findings provide a roadmap for policymakers to accelerate equitable vaccine introduction in the MENA region. Conclusions: Targeted efforts, such as addressing fiscal constraints, improving local manufacturing, tackling gender barriers, and fostering public trust, paired with regional collaboration, can help bridge gaps and ensure no community is left behind in preventing vaccine-preventable diseases.

Background/Objectives: Streptococcus pneumoniae remains a major cause of morbid-ity and mortality in Egypt, yet pneumococcal conjugate vaccines (PCVs) are not in-cluded in the national immunization program. Recent commitments to domestic vac-cine manufacturing and temporary Gavi support create a timely decision context for policymakers to assess whether PCV introduction is cost-effective, affordable, and sustainable within Egypt’s health financing constraints. This study evaluates the cost-effectiveness, budget impact, and return on investment (ROI) of PCV introduction in Egypt. Methods: An age-structured dynamic transmission model was used to estimate health and economic outcomes of PCV introduction over a 20-year horizon from a healthcare payer perspective, in line with CHEERS 2022 guidelines. The model captures direct and indirect effects across all age groups and includes pneumonia, meningitis, non-pneumonia non-meningitis invasive disease, and acute otitis media. Scenarios as-sessed immediate versus delayed introduction, alternative PCV10-to-PCV13 pathways, and domestic manufacturing price assumptions. Outcomes included deaths averted, incremental cost-effectiveness ratios (ICERs) relative to GDP per capita, budget im-pact, and ROI using value of statistical life. Results: Immediate PCV13 introduction was projected to avert 139,451 deaths across all age groups over 20 years, with an ICER of 523.31 USD per DALY averted equal to 0.16× GDP per capita. Total budget impact was USD 124.9 million per year without Gavi support and USD 120.9 million with support, yielding an ROI of 23.1. Delaying introduction substantially reduced health gains and economic returns. Pathways involving initial PCV10 introduction followed by transition to PCV13 achieved similar health outcomes with lower budget impact and higher ROI. Conclusions: PCV introduction in Egypt represents a high-value investment. Immediate introduction maximizes health and economic benefits, while delayed introduction entails substantial opportunity costs. Alternative PCV10-to-PCV13 pathways offer a more affordable route with similar long-term impact.

Background/Objectives: Streptococcus pneumoniae remains a major cause of morbidity and mortality in Egypt, yet pneumococcal conjugate vaccines (PCVs) are not included in the national immunization program. Recent commitments to domestic vaccine manufacturing and temporary Gavi support create a timely decision context for policymakers to assess whether PCV introduction is cost-effective, affordable, and sustainable within Egypt’s health financing constraints. This study evaluates the cost-effectiveness, budget impact, and return on investment (ROI) of PCV introduction in Egypt. Methods: A deterministic, age-structured dynamic transmission model was developed to estimate the health and economic outcomes of PCV introduction over a 20-year horizon from a healthcare payer perspective. The analysis was conducted in line with the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) guidelines. The model captures direct and indirect effects across all age groups and includes pneumonia, meningitis, non-pneumonia non-meningitis invasive disease, and acute otitis media. Scenarios assessed immediate versus delayed introduction, alternative PCV10-to-PCV13 pathways, and domestic manufacturing price assumptions. Outcomes included deaths averted, incremental cost-effectiveness ratios (ICERs) relative to GDP per capita, budget impact, and ROI using the value of statistical life. Results: Immediate PCV13 introduction was projected to avert 139,451 deaths across all age groups over 20 years, with an ICER of 523.31 USD per DALY averted equal to 0.16 × GDP per capita. The total budget impact was USD 124.9 million per year without Gavi support and USD 120.9 million with support, yielding an ROI of 23.1. Delaying the introduction substantially reduced health gains and economic returns. Pathways involving initial PCV10 introduction followed by transition to PCV13 achieved similar health outcomes with a lower budget impact and higher ROI. Conclusions: PCV introduction in Egypt represents a high-value investment. Immediate introduction maximizes health and economic benefits, while delayed introduction entails substantial opportunity costs. Alternative PCV10-to-PCV13 pathways offer a more affordable route with a similar long-term impact.