OBJECTIVES: To develop an understanding of the adoption decision process for vaccines, and the role of value demonstration (cost-effectiveness) in that process. METHODS:  The literature was searched for a) general information on decision criteria applicable to vaccines; b) information specific to vaccine value demonstration; and c) cost-effectiveness analyses for HPV, pneumococcal disease, and dTpa as examples of vaccines recently adopted.  Information was extracted by two reviewers to outline a) the general factors affecting vaccine adoption, and b) the role of value demonstration, and (c) what influences vaccine value demonstration. RESULTS:  Four published guidelines were identified which outline factors to consider in the vaccine adoption process.  These were combined to produce the following framework: 1)  The disease:  is it a high priority, and an important public health issue? 2) The vaccine:  is it safe and effective in reducing disease incidence?  3) The value:  is it cost-effective? 4)  The socio-political climate:  what are the concerns of the major stakeholders and how can they be addressed? and 5) The feasibility:  are there sufficient resources to adopt the vaccine? Factors identified as important in determining vaccine cost-effectiveness were: Vaccine efficacy - the more effective, including herd immunity effects, the higher the perceived value; Disease incidence – the higher the incidence, the greater the potential benefit and therefore value; Disease sequalae – the more severe and frequent the sequalae, the higher the potential value in avoiding the condition; and Duration of immunity - the longer the duration, the higher the value as fewer boosters are required. CONCLUSIONS:  While we were able to synthesise a framework to describe the vaccine adoption process, no information was found in the literature on how the elements of that framework might be combined, ranked or weighted to reach a decision.  Further research into the relative weighting of these factors is warranted.