OBJECTIVES: In most European countries, there are usually four steps before population access to a vaccination programme: vaccine marketing authorization by the European Commission, transposition of this agreement by national drug agencies, then recommendation and policy-decision steps on funding and implementation. During the recommendation step, specific to vaccines, health technology assessment is often performed. Using rotavirus vaccination as an illustrative case, this study aims at better understanding the picture of population access, and identifying lessons learnt from current experience. METHODS: An extensive systematic review of national universal rotavirus vaccination policies was conducted in 20 industrialized countries (17 European & 3 major non-European). After key categories in vaccine evaluations were identified, comparative quantitative and qualitative analyses were conducted. RESULTS: At mid-March 2014, out of the 20 countries considered, 13 decided to include rotavirus vaccination in their childhood national vaccination programme, 2 decided not to include it, while rotavirus decision-making process has not started or is underway in the remaining five countries. Published evaluations and/or advices on rotavirus vaccination were available in 16 countries. Quantitative analyses revealed that most of the countries did not take all categories into consideration, and some countries even assessed only two or three. ‘Burden of disease’ and ‘assessment of vaccine efficacy/safety' were always taken into account, while ‘acceptability’ and ‘implementation’ were less addressed. Qualitative analyses pointed out many differences in content and outcomes. CONCLUSIONS: Rotavirus vaccination policies across industrialised countries were found to be disparate, leading to unequal population access. Comparative analyses suggest there are different interpretations of the available evidence. This raises the need of a common decision integrated framework, using structured and systematic approach. This approach is not intended to substitute to authorities, but it could contribute to provide reproducible and structured interpretation of evidence, pave the way of the legitimacy of rotavirus vaccination programme.