Political Economy of National HPV Vaccination in Fragile Settings: A Case of Policy Inertia, Financial Constraints, and Equity Gaps in Lebanon
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Background: Despite global health efforts to promote HPV vaccination for cervical cancer prevention, Lebanon has yet to include the vaccine in its National Immunization Program (NIP). This study examines the political, economic, and institutional barriers to national HPV vaccination adoption, using Lebanon as a critical case to examine how governance fragility, fiscal austerity, and contested policy spaces affect the uptake and implementation of global immunization strategies in middle-income countries facing compounding crises. Methods: This qualitative study applies a Problem-Driven Political Economy Analysis (PEA) framework, drawing on 22 key informant interviews with stakeholders involved in national vaccination policy. A thematic analysis was conducted to identify structural and institutional barriers to national HPV vaccination adoption, while stakeholder mapping using Policymaker software assessed actor influence and positioning, providing insights into policy challenges. Findings were then contrasted with theories such as Kingdon’s Multiple Streams examining the convergence – or lack thereof – of problem, policy, and political streams, offering a dynamic analysis of policy inertia in fragile governance settings. Results: HPV vaccination integration into Lebanon’s NIP has been delayed due to financial barriers, governance weaknesses, and political discretion. The economic crisis has deprioritized preventive interventions, while the absence of a comprehensive immunization framework has contributed to policy inertia. Misinformation and cultural resistance pose additional challenges. Limited disease awareness and vaccine access raise equity concerns, disproportionately affecting lower-literate and lower-income groups. These findings illuminate national challenges in translating global immunization norms into practice amid volatility. Nevertheless, the study identifies a time-sensitive policy window driven by WHO’s endorsement of a single-dose HPV vaccine schedule, Lebanon’s temporary GAVI eligibility – offering a rare opportunity to alleviate the burden of inequitable vaccine pricing imposed by global pharmaceutical companies on the Global South –, the inclusion of HPV vaccination in the National Cancer Plan, and growing regional momentum. Conclusion: The study offers novel insights into the interplay between crisis governance and immunization policy, with implications for other fragile and middle-income settings. Advancing HPV vaccination integration will require strengthening institutional governance, securing sustainable funding, and implementing socio-culturally sensitive communication strategies to mitigate vaccination uptake hesitancy. This analysis contributes to the global discourse on cervical cancer elimination and the politics of promoting equitable access to HPV vaccination and prevention care in challenging policy environments.