Vaccine decision-making in Afghanistan: stakeholder analysis and evidence synthesis of policies and processes during 2010-2021

Introduction Vaccine policy decisions have substantial health, equity, and cost implications for resource-constrained countries. This study aimed to examine how vaccine decisions were made in Afghanistan between 2010 and the regime change in 2021, focusing on the processes, evidence, and actors that shaped national immunisation policy during this period. Methods We reviewed Afghanistan’s vaccine-policy architecture, vaccine adoption decision-making processes, and stakeholder dynamics between 1 January 2010 and 31 July 2021. We reviewed national guidelines, frameworks, meeting minutes, and other grey literature, and conducted semi-structured interviews with 18 immunisation experts representing government, non-governmental organizations, donors, and advisory bodies. The information from the semi-structured interviews was analysed thematically. A stakeholder network map was developed to illustrate the level of influence, interest and interaction among actors. Results Document review and stakeholder interviews identified major immunisation policy developments in Afghanistan, including the introduction of PCV13 (2013), hepatitis B birth dose (2014), IPV (2015), and rotavirus vaccine (2018), alongside schedule revisions. Three formal platforms, the EPI Taskforce, Interagency Coordination Committee (ICC), and the National Immunization Technical Advisory Group (NITAG), served as core decision-making bodies with distinct but interlinked mandates. Network analysis positioned the Ministry of Public Health (MoPH) at the centre of governance, though WHO, UNICEF, and Gavi exerted comparable influence. Four cross-cutting themes emerged: (1) declining NITAG functionality due to limited technical capacity, governance weaknesses, and communication barriers; (2) strong external influence, with policy timing often aligned to Gavi funding windows; (3) absence of structured evidence appraisal processes, resulting in reliance on WHO recommendations and operational feasibility; and (4) hierarchical culture, gender imbalance, and occasional partner-driven agenda setting that shape deliberations and outcomes. Conclusion Strengthening Afghanistan’s vaccine policy process will require programmatic, incremental reforms within current political and financial constraints. Feasible steps include targeted capacity-building for NITAG members, adoption of simplified evidence appraisal tools adopted to local context, and improved documentation to enhance transparency and consistency.