| BackgroudImmunization is among the most effective and economical health investments. The National Expanded Program on Immunization (EPI) of China was originally initiated in1978. The targeted children were vaccinated with the BCG, DPT, OPV and measles vaccine. In2002hepatitis B vaccine was integrated into the national EPI. In2007vaccines against meningococcal, Japanese encephalitis, hepatitis A, rubella, mumps were integrated into the national EPI. In light with the "Vaccine distribution and vaccination regulations," vaccines integrated into the national EPI are category Ⅰ vaccines which are provided free of charge by the government. Targeted children are obligated to be fully vaccinated of category Ⅰ vaccines. Vaccines that are not integrated in EPI programs are category Ⅱ vaccines, which can be received voluntarily while households need to pay the full cost. Some of the Category Ⅱ vaccines, like vaccines against H. influenzae type b, S. pneumoniae and varicella, are recommended by the WHO for target population. And illness and death caused by these vaccine-preventable diseases remains a concern. However these vaccines coverage rates remain low. At the same time, in recent year some kinds of Category Ⅱ vaccines that can substitute category Ⅰ vaccines are being comparatively wide used. Many parents choose to give up the free category Ⅰ, and choose to vaccinate their children with alternative types of category Ⅱ vaccines at their own expense. Studies on category II vaccination are still limited. Relative studies on this issue including childhood category Ⅱ vaccination rates report, childhood category Ⅱ vaccination influencing factors analysis and economic evaluation. In the background that childhood category Ⅱ vaccination is quite prevailing nationwide in China, there is still a lack of in-depth analysis of category Ⅱ vaccination, especifically for parents’ willingness to pay and demand for category Ⅱ vaccines. In addition, although alternative category Ⅱ vaccines inoculation rates have already reach a certain level in China, but up to now, no empirical research was found to carry out in-depth analysis of alternative category Ⅱ vaccines inoculation either from the view of demand or supply. Finally, immunization service providers play a key role in the voluntary vaccinations. Their recommendation and vaccine-related information delivery was reported to have an important impact on parental decisions. However, no research yet has well studied the providing behavior of immunization service providers in China. Based on the background and current relative studies, this study is conducted to answer the following questions. First, the study analyzed the status quo and determinants of parental willingness to pay for non-alternative category Ⅱ vaccines? Second, a demand assessment for non-alternative category Ⅱ vaccines was carried out based on the willingness to pay data. Third, the study analyzed parental decision of alternative category Ⅱ vaccines types of vaccine and its influencing factors? Forth, the study analyzed immunization service providers’willingness to recommend category Ⅱ vaccines and its relative factors.ObjectivesThe overall objective of this study was systematically analyze to study parents’ willingness to pay and immunization service providers’ willingness to provide category Ⅱ vaccines and their influencing factors, offering policy recommendations on promoting non-alternative category Ⅱ vaccination and improving management of category Ⅱ vaccination. Specific study objectives include:1) to study parets and immunization providers’ perception and experience related to category Ⅱ vaccines;2) to measure parents’ willingness to pay for non-alternative category Ⅱ vaccines and choice of alternative category Ⅱ vaccines, revealing their influencing factors;3) to estimate the relationship between price, price-elasticity and demand of non-alternative category Ⅱvaccine;4) to analyze immunization service providers’ willingness to provide category Ⅱ vaccines and to reveal its influencing factors;5) to offer relative recommendations on policy making.MethodBased on cross-sectional study design, the data used in this study are derived from the project "Study on vaccine distribution, delivery and financing policy in China" which was funded by the Ministry of Health of China. The survey was carried out in early2013. Stratified cluster random sampling was used for sampling and2179parents of under-3-year-old children and448immunization service providers were finally sampled from three provinces.The major contents of the qustionaire survey include:parents’ willingness to pay for non-alternative category Ⅱ vaccine; parental choice for alternative category Ⅱ vaccine; immunization service providers’ willingness to provide category Ⅱ vaccines and parents and immunization service providers’ perception and experiments related to categoryⅡ vaccines. Contingent valuation method was applied and bidding games was performed for willingness to pay eliciting.Data analysis method of this study include:Interval regression was used to analyze the determinants of parents’ willingness to pay for non-alternative category Ⅱ vaccine, while further analysis of demand assessment of non-alternative category Ⅱ vaccine was based on survival analysis and Weibull regression; Logit regression was used to analyze influencing factors of parental choice on alternative category Ⅱ vaccines. In analysis of immunization service providers’ intentions, the first step is to discover the potential common factors among the explanatory variables by using exploratory factor analysis, the first step is to analyze relative factors of immunization service providers’ willingness to provide by using ordered Logit regression. In addition, the ability to pay assessment in the study was based on household spending data and the extended linear expenditure system (ELES), ELES parameters was obtained by the least squares estimation. Stata12.0was used to carry out most of these analyses.Results(1) Willingness to pay for non-alternative category Ⅱ vaccine:the mean willingness to pay for pneumococcal vaccine is325.95(±299.79) Yuan, with a median of200Yuan.8.17%parents’ willingness to pay were more than800Yuan.171parents’willingness to pay were at zero, accounting for8.85%. Among them,157parents agreed to receive the vaccine if the price is at zero, accounting for7.21%; only14parents refused to let their child be vaccinated even if the vaccine price is at zero, accounting for0.64%. Multivariate analysis shows that ability to pay has a positive effect on willingness to pay (P<0.05), after control the effects of other independent variables, willingness to pay of parents from families with the ability to pay are65.83Yuan higher than those parents from families without the ability to pay. Perceived severity of the disease has a positive effect on willingness to pay; while perceived price barriers have negative effects on willingness to pay (P<0.05). Parents with comply-motive of immunization service providers’ recommendation and immunization service providers played a role in child’s prevail immunization decision were willing to more (P<0.05). Parents of child with a history of infectious diseases were willing to pay more (P<0.05).(2) Demand assessment of non-alternative category Ⅱ vaccine:the results suggest the demand for pneumococcal vaccine is inelastic when the price is below420Yuan, and demand becomes more and more elastic as price continue to rise. When the price is above420Yuan, the demand for pneumococcal vaccine is elastic. The prevailing price of one dose7-valent pneumococcal conjugate vaccine in China is860Yuan. At this price, in light with our estimations, only10.87%parents would choose to buy. And in the price range between860Yuan and420Yuan, according to our results, with the decrease of the price, the demand and total revenue will both continue to increase. Taking the prevailing price as reference, assuming the price dropped to420Yuan, the demand will increase162.74%, and meanwhile the revenue will increase28.31%.(3) Parental choices of alternative category Ⅱ vaccines:18.10%,56.92%,65.85% parents will choose category Ⅱ vaccines costing500Yuan respectively in hypothetical scenarios of foreign brand, better safety and longer duration. Multivariate analysis shows that parents from families with ability to pay were more inclined to choose self-paid vaccines (P<0.1). Parents’ immunization related knowledge has a negative effect on inclination of choosing self-paid vaccines (P<0.05). Perceived price barriers have negative impact effects on choosing all three hypothetical self-paid alternative vaccines; perceived safety barrier has a negative effect on choosing foreign brand alternative vaccines (P<0.05), and has a positive effect on choosing better safety alternative vaccines(P<0.05). Parents with comply-motive with immunization service providers’ recommendation are more inclined to choose all three hypothetical alternative vaccines (P<0.05). Social norms have significant positive effect on choosing foreign brands alternative vaccines (P<0.05), while in other two scenarios, no such significant correlation was found.(4) Immunization service providers’ willingness to provide:there are significant correlation between the willingness to provide7-valent pneumococcal conjugate vaccine and the relative attitude, subjective norms and perceived behavioral control (P<0.05).Immunization service providers perceived that citizens would have positive attitudes toward their recommendation are more willing to provide (P<0.05). Immunization service providers perceived citizens’ negative attitude toward category Ⅱ vaccines has a negative effect on their willingness to provide alternative hepatitis A vaccine (P<0.05). In different scenarios, perceived behavioral control and attitude toward non-alternative vaccines positively correlated with willingness to provide (P<0.05); subjective norms positively correlated with willingness to recommend in appointment scenario and category Ⅰ vaccination scenario (P<0.05); Immunization service providers perceived that residents would have positive attitude toward their recommendation are more willing to recommend vaccines in appointment scenario and category Ⅰ vaccination scenario, and are more willing to introduce category Ⅱ vaccines related information in health education scenario (P<0.05). There is a negative correlation between perceived negative residents attitude toward category Ⅱ vaccines and willingness to introduce information in health education scenario (P<0.05), while positive correlations were found between perceived negative residents attitude toward category Ⅱ vaccines and willingness to provide in appointment scenario (P<0.05). Monetary incentives have significant positive effect on willingness to provide in health education scenario and appointment scenario (P<0.05).Coclusions and ImplicationsAlthough most parents are willing to pay for pneumococcal vaccine, but only a handful of parents’ willingness to pay are above the prevailing price of7-valent pneumococcal conjugate vaccine in China. Meanwhile, willingness to pay positive correlated with household ability to pay and negatively correlated with perceived price barriers. These results implied that although parents generally willing to immunize children against pneumococcal, but the price factor will hinder the majority of children receiving this vaccine. Parents’ willingness to pay is also affected by its own beliefs like perceived severity of the disease. In addition, the social effect including immunization service providers and peers has an impact on parents’ willingness to pay. Currently, the prevailing price of7-valent pneumococcal conjugate vaccine in China is high. Demand assessment shows that the demand is elastic at the prevailing price,, reducing the price could both increase the demand and collected revenue.When faced with choice of alternative category Ⅱ vaccines, if parents were told that self-paid vaccines are safer, or with longer duration, more than half of them would choose alternative category Ⅱ vaccines; but nearly one-fifth of parents would choose alternative category Ⅱ vaccines if they were told that self-paid vaccines are foreign brands. Family economic factors closely associated with parents’ choice of alternative category Ⅱ vaccines. Parents with better related knowledge are less inclined to give up category Ⅰ vaccines.Immunization service providers’ willingness to provide category Ⅱ vaccines is quite strong. Taking7-valent pneumococcal vaccine and alternative hepatitis A vaccine as example, the willingness to provide non-alternative category Ⅱ vaccines are stronger than the willingness to provide alternative category Ⅱ vaccines. Other people’s support and better organizational related conditions could promote immunization service providers’ willingness to provide. Economic incentives have positive impact on immunization service providers’ willingness to provide in some cases.Based on these conclusions, our recommendations are as follows:(1) To put more effort on vaccine-preventable disease burden information collecting which is the basis for related economic evaluation.(2)The economic barriers to vaccination should be removed to increase the demand. In the region with adequate financial ability, subsidy or health insurance are promising path in sharing out-of-pocket expense for non-alternative category Ⅱ vaccines.(3)Health education and other forms of interventions targeting psychosocial factors could be effective in promoting vaccination.(4) The level of economic incentive of alternative category Ⅱ vaccines providing for immunization service providers shouldn’t be higher than counterpart of category Ⅰ vaccines providing.Innovations and LimitationsThe innovations of this study:(1)In the context that childhood category Ⅱ vaccination becomes more and more popularized in China accompany with the development of EPI. Baesed on a demand and supply perspective, this study analyzed systematically the parents’ willingness to pay and immunization service providers’ willingness to provide category Ⅱ vaccination in China. No similar studies have been found.(2)In this study, the application of contingent valuation method and bidding game elicitation technique are advanced in this research field. No study was found that analyzed the willingness to pay of childhood category Ⅱ vaccines in China.(3)Demand assessment based on willingness-to-pay was performed using Weibull regression model which predicted the level of demand, price elasticitycorresponding to different price level, providing valuable informations for financing policies.The limitations of this study:(1) In this study, analysis was restricted to the individual intention level, rather than individual behavior level. There might be differences between the intentions expressed by the subjects and the corresponding actual behavior. Future studies need to further confirm our findings.(2)Sampling of parents may be some bias. In each smallest unit of sampling, random sampling process was preformed in the list of the children enrolled in the immunization program management list. In this case, children not enrolled in the immunization program were in fact excluded from the sampled population, which may lead to some sampling bias. |
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