The World Health Organization (WHO) defines health innovation as the development or refinement of policies, systems, technologies, and delivery methods that enhance health and wellbeing [1]. Embedding innovations such as a new malaria vaccine into existing routine healthcare is inherently complex, context-specific and presents several potential operational pitfalls, such as inadequate integration with existing health infrastructure, supply chains and workflows, [2] inadequate capacity and poor training of healthcare workers. Supply chain weaknesses can compromise vaccine availability and efficacy. Additionally, poor community engagement may lead to mistrust, low acceptance, and vaccine hesitancy. Misalignment between innovation timelines and national health planning cycles can hinder institutional adoption and sustainability. Finally, limited coordination between stakeholders - including government agencies, donors, and implementing partners - can result in fragmented efforts and resource inefficiencies.

Addressing these pitfalls requires realistic planning, inclusive stakeholder engagement and adaptive implementation strategies. Typically, the introduction of health innovations follows a phased approach, which not only supports the creation of solutions but also addresses critical factors necessary for sustainable implementation and scale-up. The example of malaria vaccine illustrates the substantial delays and pitfalls in the process of translating evidence into policy and practices [3]. The Ghana malaria vaccine introduction plan was developed in 2018 and the pilot started in May 2019 [4].

The planning processes around a malaria vaccine embedment in routine health services must actively engage a diverse range of stakeholders - those who influence, are affected by, or have a vested interest in the innovation. Incorporating their insights and experiences ensures that innovations are contextually relevant, ethically grounded, and more likely to be adopted in practice. Stakeholder analysis is thus a critical tool [5, 6].

Firstly, stakeholder analysis helps map the landscape of interests and power dynamics, identifying key actors, such as government agencies, healthcare providers, community leaders, civil society organizations, the private sector, donors and the public. Understanding their roles, motivations, interconnections, power dynamics and concerns enables tailored engagement strategies that foster support and mitigate resistance to the introduction of health innovations. For instance, engaging frontline health workers early in the process can enhance ownership and trust in the vaccine rollout, while involving community leaders and local influencers can improve public acceptance and uptake [7].

Secondly, stakeholder analysis facilitates inclusive planning by integrating diverse perspectives into the design and implementation of innovations. This enhances contextual relevance, ethical acceptability, and alignment with existing workflows and health priorities. In Ghana, such an approach can ensure that the vaccine introduction aligns with national health goals, respects cultural norms, and addresses logistical realities at different levels of the health system.

Finally, stakeholder analysis contributes to sustainability by identifying potential champions and barriers for long-term integration. It supports the development of adaptive strategies that can respond to emerging concerns and evolving stakeholder dynamics.

The SAVING (Sustainable Access and Delivery of New Vaccines in Ghana) consortium [8], funded by the European and Developing Countries Clinical Trials Partnership (EDCTP) and led by the University of Health and Allied Sciences (UHAS), Ghana [9], was formed at the end of 2020 with the aim “to identify and address implementation challenges for the efficient and effective delivery and uptake of new medical interventions”. The focus of the intervention is on implementation research capacity strengthening, enhancing the use of evidence to inform decision-making on the adoption of new health technologies.

The SAVING setup is inspired by the Access and Delivery Partnership (ADP), a collaborative initiative of the United Nations Development Programme (UNDP) launched in 2013. Its goal is to bridge the gap between innovation and public health outcomes [10]. The ADP framework value chain components include 7 aspects: (i) new medicines, vaccines, diagnostics, (ii) regulatory authorisation, (iii) selection, prioritisation and resource allocation, (iv) public procurement, (v) storage and distribution, (vi) health service delivery and (vii) patients (Figure 1). The ADP supports countries in integrating innovations into national health systems efficiently and equitably and points at a wide range of stakeholders that can support each of the seven components.

In this context, the objective of our research was to map stakeholders against the ADP components and to describe their positioning in relation to the introduction of the RTS,S malaria vaccine in Ghana. By identifying the key stakeholders involved in the vaccine’s introduction and understanding their interrelationships, our study sought to illuminate the dynamics that can either facilitate or impede the adoption of such health innovations. This insight was essential for informing policy recommendations and optimizing the design of implementation strategies in similar contexts.

We compiled a list of stakeholders using inputs from SAVING’s consortium members, as well as from their institutional networks and personal contacts of the research team. This included contacts in the Ministry of Health of Ghana, the Ghana Health Service, the Ghana Food and Drugs Authority and the University of Health and Allied Sciences in Ho. Consortium institutions had already carried out a stakeholder mapping and produced their own stakeholder lists, which we used and widened further with our own contacts. We discussed the completeness of the list with consortium leaders and distributed the online questionnaire link by email, following which two reminders were sent to all recipients.

Our questionnaire covered the following domains: informed consent, respondents’ characteristics, self-positioning in relation to the ADP framework components, knowledge on the SAVING Consortium research programme, decision-making processes and positioning in relation to the introduction of the RTS,S malaria vaccine (i.e., influence, interest, implementation capacity, knowledge and funding). The respondents were asked to self-report their perceptions about their own positioning within the seven ADP components. Each component was unfolded into the roles that stakeholders could play in each of them: funding, giving advice, ideation, planning, implementing, analysing or reporting. Multiple answers were allowed.

Additionally, regardless of the positioning of stakeholders in the ADP framework, we asked them in the online questionnaire about their perceptions on which stakeholders or institutions had higher interest, influence (or power), knowledge, implementation involvement, or were able to pay for innovations or new interventions implemented in the Ghanaian health system. This approach was based on the process described in Varvasovszky and Brugha 2000 [6].

Six months after the launch of the online questionnaire, in June 2023, we organised a workshop in Ghana among the SAVING Consortium partner institutions, gathering between 25 and 30 people, to refine and reflect on the stakeholders’ positioning in relation to the ADP framework and the underlying processes in decision-making for the malaria vaccine introduction. We brought the online questionnaire findings to the workshop for their review and validation. The workshop consisted of discussions and group work (i) matching each participant, assuming the role of the stakeholder group he or she belonged to, with the most suitable ADP framework component and (ii) identifying the key stakeholders’ involved in the evidence generation and decision-making for introduction of new interventions in Ghana. The decision-making framework was inspired in a model proposed to describe how innovations find their ways through existing organisations [11, 12].

We calculated absolute frequencies by counting the number of responses and then calculated proportions. Variables included: respondents’ demographics and affiliations, ADP components and the stakeholders assigned to the positioning criteria, mentioned above.

All calculations and graphs were carried out in R [13].

We carried out a stakeholder analysis to describe the positioning of several stakeholders in relation to the recent RTS,S malaria vaccine introduction in Ghana, using the ADP framework. This is particularly relevant in the case of the RTS,S malaria vaccine introduction, given the delays in its adoption in policy and practice [3] and the challenges in the availability of malaria vaccines themselves [14].

In Ghana, stakeholders mapped along the ADP framework for the introduction of new vaccines or interventions seem to be concentrated in the regulatory and implementation aspects of it. Interestingly, much lesser presence was assigned to the ‘New Medicines’ component of the ADP framework, even though Ghana was one of the few countries that carried out Randomised Controlled Trials to assess the efficacy of RTS,S [15], contributing to the evidence for its eventual adoption. This reflects, however, the relative imbalance between Africa’s demand for vaccines and its Research and Development (R&D) and production capacity [16] despite the good level of maturity in the regulatory systems of many countries in the African region [17]. Much less presence was found in the components related to the initial phases of innovations, partially attributable to a potential bias in the selection of stakeholders (see ‘limitations’ below). In this context, it is highly relevant that Ghana, in collaboration with Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), is taking steps to become a vaccine producer [18].

The positioning of stakeholders, in terms of influence and interest is mainly focused on the MOH, the WHO, and to a lesser extent the GHS, despite that GHS has no normative role. This partially reflects the ‘raison d’être’ of both institutions but may also suggest that there is a concentration of functions in those institutions, when it comes to the introduction of new health interventions or technologies. We could not observe in our analysis the richness of institutions that are portrayed in the institutionalisation of Health Technology Assessment in Ghana, where many stakeholders were identified representing government, academia, multilateral organisations, NGO and beneficiaries [19]. We believe that the workshop in 2023 allowed us to identify a richer scope of stakeholders, since it focused not so much on perceptions about what was going on, but rather on an open discussion about what different stakeholders could contribute to the processes underlying the acquisition of innovations in health. Comparing this with the perceptions in the questionnaire, in real life situations, with limited time and resources, the decision-making cycle is rather concentrated within a few actors over a short period of time, with the potential of missing contributions from other stakeholders. Interestingly, the private sector was largely absent from the workshop’s final conclusions related to decision-making actors.

Finally, while RTS,S introduction has been an excellent platform for Ghana to engage in complex policy and implementation processes [4], it would seem that the COVID-19 pandemic brought more efforts into play: this was reflected in the responses to our questionnaire, as the most frequent mentioned intervention. Indeed, the imbalance in the importance given to COVID-19 vaccine over malaria vaccines is patent at global level [20]: annual deaths attributed to malaria in Ghana is around 20,000 [21] and the total COVID-19 deaths reported from Ghana were 1,463 [22]. All in all, we expect that the COVID-19 events may have brought experience and lessons for malaria vaccine scale-up or the introduction of new malaria vaccines in the near future.

In conclusion, Ghana seems to have the institutional network of stakeholders to support each step in the pathway from new interventions to service delivery. Decision-makers may want to consider (i) how to build capacity at the start of the ADP value chain to ideate, research and produce new interventions and (ii) whether to optimise stakeholders’ involvement in the pathway between evidence to policy (and how, if so).