Background Childhood vaccination rates fluctuate over time and do not always meet the levels recommended by the WHO. Objective This study aims to provide an overview of measures countries have introduced to increase vaccination rates. Methods We developed a structured data collection template that was completed by country experts from Europe, Israel, the USA, and Canada. Experts were identified using the European Observatory on Health Systems and Policies' HSPM (Health Systems and Policy Monitor) network. We approached experts from 32 countries and received responses from 22 countries. In the template we asked for measures introduced between 2014 and 2019. The experts were asked to indicate the type of intervention, the target population, possible positive and negative effects, and evidence on effectiveness. The information was collected between September 2019 and January 2020. Results We identified four main types of interventions: restrictive measures for the unvaccinated, financial incentives, measures supporting the logistics of vaccination, and vaccination promotion campaigns. Restrictive measures often involved expanding existing mandatory vaccination policies or limiting access to pre-school activities for unvaccinated children. Financial incentives for healthcare providers showed some positive effects. Regarding logistical support, several countries used schools as alternative vaccination sites, though this presented organisational challenges. Many countries invested in improving knowledge among both healthcare professionals and parents to encourage vaccine uptake. Conclusions Most initiatives implemented in the countries covered focussed on communication and knowledge enhancement. However, there is limited evidence on the impact of these measures on vaccination coverage.

Andrija Stampar School of Public Health University of Zagreb School of Medicine 4 Rockefeller Street Zagreb 10 000 Republic of Croatia

Austrian National Public Health Institute Stubenring 6 1010 Vienna Austria

Center for Social and Economic Strategies Faculty of Social Sciences Charles University Smetanovo nábřeží 6 110 01 Prague 1 Czechia

Dalla Lana School of Public Health University of Toronto Canada

Departement Gesundheitswissenschaften und Medizin Universität Luzern

Department of Health Care Management WHO Collaborating Centre for Health Systems Research and Management Berlin University of Technology Straße des 17 Juni 135 H 80 10623 Berlin Germany

Department of Life Sciences and Public Health Università Cattolica del Sacro Cuore and Fondazione Policlinico Universitario A Gemelli IRCCS Largo Agostino Gemelli 8 00168 Roma Italy

Department of Public Health Health Sciences Institute Faculty of Medicine Vilnius university M K Čiurlionio 21 27 LT 03101 Vilnius Lithuania

Escola Nacional de Saúde Pública Lisboa Portugal

European Observatory on Health Systems and Policies London School of Hygiene and Tropical Medicine London WC1E 7HT UK

European University Nicosia Cyprus

Faculty of Public Health Medical University Varna 55 Marin Drinov Str Varna Bulgaria

Institute of Health Policy Management and Evaluation University of Toronto Canada

Jagiellonian University Medical College Faculty of Health Sciences Institute of Public Health Krakow Poland

Lund University School of Economics and Management P O Box 7080 220 07 Lund Sweden

McMaster University Hamilton Canada

Myers JDC Brookdale Institute Jerusalem Israel; and Department of Health Care Management Technische Universität Berlin Berlin Germany

Nivel Otterstraat 118 124 3513 CR Utrecht Netherlands

Nivel Utrecht Netherlands and Maastricht University

Norwegian Institute of Public Health PO Box 222 Skøyen N 0213 Oslo Norway

Open University of Cyprus Nicosia Cyprus

Panteion University of Social and Political Sciences Athens Greece

Semmelweis University 1125 Budapest Kútvölgyi út 2 Hungary

The Faculty of Health and Sports Sciences Riga Stradins Univesrity Latvia 16 Dzirciema str LV 1007 Latvia

World Health Organization Regional Office for Europe formerly from WHO Country Office in Estonia

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