Confidence (1-5): 4
Quality Scale Rating
“On a ‘scale of journals’, what ‘quality of journal’ should this be published in?: Note: 0= lowest/none, 5= highest/best”
Confidence (1-5): 5
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In “Advance Market Commitments: Insights from Theory and Experience.” Kremer, Levin and Snyder describe the Advanced Market Commitment (AMC) mechanism that was used to increase coverage of Pneumococcal Conjugate Vaccines (PCV) in low-income countries. This mechanism represents one of the most important public health achievements of the recent past leading to PCV coverage rates of around 50% in eligible countries compared to an almost 0% coverage rate before the onset of the AMC. The authors estimate the AMC saved 700,000 lives. This paper provides a convincing argument for AMCs and a reasonable method for evaluating its effects. I will highlight two areas where further research could be beneficial.
In evaluating the impact of the AMC, the authors assume that, absent the AMC, PCV adoption would have followed the same path as Rotavirus vaccine adoption in the same countries. While this is a reasonable baseline, there are many reasons why that may not be the case. These vaccines are produced by different manufacturers who may have different willingness to supply vaccines to low-income countries. They also impact different diseases and take-up may reflect the relative importance of treating these diseases in low-income countries. Future research would be useful in this area. Perhaps constructing a counterfactual using each country's coverage of additional GAVI supported vaccines and using data on PCV coverage in countries that are not eligible for the AMC could be useful.
The theoretical portion of the paper provides a clear model of how the AMC provides value. Additionally, it makes important points about the cost of setting the subsidy too low and the potential costs of including co-payments for eligible countries. In future work it would be valuable to consider if the AMC is a permanent mechanism or one used to promote the adoption of a vaccine. Since adoption of a vaccine usually necessitates large annual expenditures indefinitely (as vaccines are rarely removed from a national immunization program), it would be helpful to know how to fund an AMC in perpetuity or how to transition off the AMC. This point also relates to considering country co-financing commitments as the hope with these is that countries will eventually be able to finance these vaccines on their own. Therefore, the cost of removing county co-financing requirements may be larger than the model assumes. Relatedly, the model is a one-shot model, but, in reality, there can be multiple bargaining periods and manufacturers may initially reject offers but then accept higher offers in later periods. In this case, risk of setting the price too low initially is less important. Finally, in many of these cases, the manufactures are not strictly profit maximizing but are constrained by social pressures to provide vaccines at an affordable price. It would be useful to understand how these pressures impact the ability of the manufacturer to bargain over the vaccine price.
How long have you been in this field?
About 15 years.
How many proposals and papers have you evaluated?
I have evaluated roughly 50 papers and proposals in this time.