By Sachiko Ozawa, Samantha Clark, Allison Portnoy, Simrun Grewal, Logan Brenzel, and Damian G. Walker Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011–20 ABSTRACT An analysis of return on investment can help policy makers support, optimize, and advocate for the expansion of immunization programs in the world’s poorest countries. We assessed the return on investment associated with achieving projected coverage levels for vaccinations to prevent diseases related to ten antigens in ninety-four low- and middle-income countries during 2011–20, the Decade of Vaccines. We derived these estimates by using costs of vaccines, supply chains, and service delivery and their associated economic benefits. Based on the costs of illnesses averted, we estimated that projected immunizations will yield a net return about 16 times greater than costs over the decade (uncertainty range: 10–25). Using a full-income approach, which quantifies the value that people place on living longer and healthier lives, we found that net returns amounted to 44 times the costs (uncertainty range: 27–67). Across all antigens, net returns were greater than costs. But to realize the substantial positive return on investment from immunization programs, it is essential that governments and donors provide the requisite investments. A t the start of the decade 2011–20, declared the Decade of Vaccines, the global health community com- mitted itself to accelerating the in- troduction of new vaccines and in- creasing coverage of existing vaccines to save lives and avert illness in the world’s poorest countries. Endorsed by all 194 member states of the World Health Organization (WHO) in May 2012, the Global Vaccine Action Plan iden- tified vaccination as an essential public health tool for improving global health and advancing economic development. Despite increased glob- al attention to immunization, comprehensive evidence on its value remains limited. For key stakeholders, including funders and multilateral organizations, estimating the global return on investment (ROI) associated with immunization can play an integral role in advocating for ex- panded investment during the decade. The return on investment quantifies the net benefits gained from every dollar invested on an aggregate level. It can serve as a useful policy- making tool with advantages beyond estimates of costs or benefits alone because it provides an assessment of the returns in relation to their costs. Unlike cost-effectiveness analysis, which employs various health metrics such as disabili- ty-adjusted life-years or quality-adjusted life- years to measure benefits, return on investment measures benefits in monetary units, thus pro- viding more comparability and easier compre- hension. In addition, ROI analyses typically in- corporate productivity losses and societal costs that go beyond the economic benefits captured in cost-effectiveness analyses. This versatility is particularly important for policy makers who require evidence to make financial decisions across sectors. Unfortunately, ROI estimates for health care interventions are rare, which lim- doi: 10.1377/hlthaff.2015.1086 HEALTH AFFAIRS 35, NO. 2 (2016): 199–207 ©2016 Project HOPE— The People-to-People Health Foundation, Inc. Sachiko Ozawa (ozawa@ jhu.edu) is an assistant scientist in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland. Samantha Clark is a research associate in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. Allison Portnoy is an SD candidate in the Department of Global Health and Population, Harvard T.H. Chan School of Public Health, in Boston, Massachusetts. Simrun Grewal is a PhD candidate in the Pharmaceutical Outcomes Research and Policy Program, University of Washington, in Seattle. Logan Brenzel is a senior program officer for cost- effectiveness in vaccine delivery at the Bill & Melinda Gates Foundation in Washington, D.C. Damian G. Walker is a deputy director for data and analytics in global development at the Bill & Melinda Gates Foundation in Seattle. February 2016 35:2 Health Affairs 199 Value Of Vaccines Downloaded from HealthAffairs.org on July 03, 2020. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.