1
|
Menzies NA, Suharlim C, Resch SC, Brenzel L. The efficiency of routine infant immunization services in six countries: a comparison of methods. HEALTH ECONOMICS REVIEW 2020; 10:1. [PMID: 31916025 PMCID: PMC6950861 DOI: 10.1186/s13561-019-0259-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 12/30/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Few studies have systematically examined the efficiency of routine infant immunization services. Using a representative sample of infant immunization sites in Benin, Ghana, Honduras, Moldova, Uganda and Zambia (316 total), we estimated average efficiency levels and variation in efficiency within each country, and investigated the properties of published efficiency estimation techniques. METHODS Using a dataset describing 316 immunization sites we estimated site-level efficiency using Data Envelopment Analysis (DEA), Stochastic Frontier Analysis (SFA), and a published ensemble method combining these two approaches. For these three methods we operationalized efficiency using the Sheppard input efficiency measure, which is bounded in (0, 1), with higher values indicating greater efficiency. We also compared these methods to a simple regression approach, which used residuals from a conventional production function as a simplified efficiency index. Inputs were site-level service delivery costs (excluding vaccines) and outputs were total clients receiving DTP3. We analyzed each country separately, and conducted sensitivity analysis for different input/output combinations. RESULTS Using DEA, average input efficiency ranged from 0.40 in Ghana and Moldova to 0.58 in Benin. Using SFA, average input efficiency ranged from 0.43 in Ghana to 0.69 in Moldova. Within each country scores varied widely, with standard deviation of 0.18-0.23 for DEA and 0.10-0.20 for SFA. Input efficiency estimates generated using SFA were systematically higher than for DEA, and the rank correlation between scores ranged between 0.56-0.79. Average input efficiency from the ensemble estimator ranged between 0.41-0.61 across countries, and was highly correlated with the simplified efficiency index (rank correlation 0.81-0.92) as well as the DEA and SFA estimates. CONCLUSIONS Results imply costs could be 30-60% lower for fully efficient sites. Such efficiency gains are unlikely to be achievable in practice - some of the apparent inefficiency may reflect measurement errors, or unmodifiable differences in the operating environment. However, adapted to work with routine reporting data and simplified methods, efficiency analysis could triage low performing sites for greater management attention, or identify more efficient sites as models for other facilities.
Collapse
Affiliation(s)
- Nicolas A. Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Ave, Boston, MA 02115 USA
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Christian Suharlim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Stephen C. Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, Washington USA
| |
Collapse
|
2
|
Feldhaus I, Schütte C, Mwansa FD, Undi M, Banda S, Suharlim C, Menzies NA, Brenzel L, Resch SC, Kinghorn A. Incorporating costing study results into district and service planning to enhance immunization programme performance: a Zambian case study. Health Policy Plan 2019; 34:327-336. [PMID: 31157376 PMCID: PMC6736183 DOI: 10.1093/heapol/czz039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 11/13/2022] Open
Abstract
Donors, researchers and international agencies have made significant investments in collection of high-quality data on immunization costs, aiming to improve the efficiency and sustainability of services. However, improved quality and routine dissemination of costing information to local managers may not lead to enhanced programme performance. This study explored how district- and service-level managers can use costing information to enhance planning and management to increase immunization outputs and coverage. Data on the use of costing information in the planning and management of Zambia's immunization programme was obtained through individual and group semi-structured interviews with planners and managers at national, provincial and district levels. Document review revealed the organizational context within which managers operated. Qualitative results described managers' ability to use costing information to generate cost and efficiency indicators not provided by existing systems. These, in turn, would allow them to understand the relative cost of vaccines and other resources, increase awareness of resource use and management, benchmark against other facilities and districts, and modify strategies to improve performance. Managers indicated that costing information highlighted priorities for more efficient use of human resources, vaccines and outreach for immunization programming. Despite decentralization, there were limitations on managers' decision-making to improve programme efficiency in practice: major resource allocation decisions were made centrally and planning tools did not focus on vaccine costs. Unreliable budgets and disbursements also undermined managers' ability to use systems and information. Routine generation and use of immunization cost information may have limited impact on managing efficiency in many Zambian districts, but opportunities were evident for using existing capacity and systems to improve efficiency. Simpler approaches, such as improving reliability and use of routine immunization and staffing indicators, drawing on general insights from periodic costing studies, and focusing on maximizing coverage with available resources, may be more feasible in the short-term.
Collapse
Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Carl Schütte
- Strategic Development Consultants, Pietermaritzburg, South Africa
| | - Francis D Mwansa
- Department of Public Health, Ministry of Health, Plot 12193, Woodlands Chalala, Lusaka, Zambia
| | - Masauso Undi
- Independent consultant, 35 Nalikwanda Road, Woodlands, Lusaka, Zambia
| | - Stanley Banda
- Independent consultant, Plot 34270, Shantumbu Road, Hillview Park, Lusaka, Zambia
| | - Chris Suharlim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, 500 Fifth Avenue N, Seattle, WA, USA
| | - Stephen C Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Anthony Kinghorn
- Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, South Africa
| |
Collapse
|
3
|
Aye HNN, Saw YM, Thar AMC, Oo N, Aung ZZ, Tin H, Than TM, Kariya T, Yamamoto E, Hamajima N. Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage? Vaccine 2018; 36:7542-7548. [PMID: 30377065 DOI: 10.1016/j.vaccine.2018.10.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Myanmar's national immunization program was launched in 1978. Routine immunization is mainly provided at sub-center level with midwives assigned as main vaccinators. The vaccinators at the sub-centers have to obtain vaccines from their designated township health department's cold room for immunization services. This study aimed to calculate the operational costs of routine immunization at sub-centers in Myanmar. METHODS A cross-sectional study was conducted among 160 sub-centers throughout the country. Face-to-face interviews were conducted with the main vaccinator at each sub-center using a pre-tested questionnaire. The study analyzed the operational costs per facility and the associations between sub-center characteristics and operational costs. RESULTS In Myanmar, the average operational costs of routine immunization per sub-center ranged from 434,700-990,125 MMK for rural areas and 235,875-674,250 MMK for urban areas. The operational costs increased by 8,749.50 MMK (95% CI: 6,805.79-10,693.21; p < 0.001) per mile and 5,752.50 MMK (95% CI: 914.22-10,590.79; p < 0.05) per working day. CONCLUSION This study indicated that the operational costs at sub-centers were high and varied significantly among the different geographical areas. The operational costs could be reduced by additional support for the resources, for example, installing cold chain facilities at sub-centers and opening new sub-centers throughout the country.
Collapse
Affiliation(s)
- Hnin Nwe Ni Aye
- Expanded Programme on Immunization/Communicable Diseases Unit, Mandalay Regional Public Health Department, Ministry of Health and Sports, Mandalay, Myanmar; Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yu Mon Saw
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan; Nagoya University Asian Satellite Campuses Institute, Nagoya, Japan.
| | - Aye Mya Chan Thar
- Central Expanded Programme on Immunization, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nwe Oo
- Department of Food and Drug Administration, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Zaw Zaw Aung
- Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Htun Tin
- Central Epidemiological Unit, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Thet Mon Than
- Department of Medical Services, Ministry of Health and Sports, Myanmar
| | - Tetsuyoshi Kariya
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Hamajima
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
4
|
Chatterjee S, Ghosh A, Das P, Menzies NA, Laxminarayan R. Determinants of cost of routine immunization programme in India. Vaccine 2018; 36:3836-3841. [PMID: 29776749 PMCID: PMC5999352 DOI: 10.1016/j.vaccine.2018.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 04/18/2018] [Accepted: 05/01/2018] [Indexed: 11/24/2022]
Abstract
The costs of delivering routine immunization services in India vary widely across facilities, districts and states. Understanding the factors influencing this cost variation could help predict future immunization costs and suggest approaches for improving the efficiency of service provision. We examined determinants of facility cost for immunization services based on a nationally representative sample of sub-centres and primary health centres (99 and 89 facilities, respectively) by regressing logged total facility costs, both including and excluding vaccine cost, against several explanatory variables. We used a multi-level regression model to account for the multi-stage sampling design, including state- and district-level random effects. We found that facility costs were significantly associated with total doses administered, type of facility, salary of the main vaccinator, number of immunization sessions, and the distance of the facility from the nearest cold chain point. Use of pentavalent vaccine by the state was an important determinant of total facility cost including vaccine cost. India is introducing several new vaccines including some supported by Gavi. Therefore, the government will have to ensure that additional resources will be made available after the support from Gavi ceases.
Collapse
Affiliation(s)
| | - Arpita Ghosh
- Public Health Foundation of India, Gurgaon, Haryana, India
| | - Palash Das
- Public Health Foundation of India, Gurgaon, Haryana, India
| | - Nicolas A Menzies
- Department of Global Health and Population and Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ramanan Laxminarayan
- Centre for Disease Dynamics, Economics & Policy, Washington, DC, USA; Princeton Environmental Institute, Princeton University, Princeton, NJ, USA
| |
Collapse
|
5
|
Geng F, Suharlim C, Brenzel L, Resch SC, Menzies NA. The cost structure of routine infant immunization services: a systematic analysis of six countries. Health Policy Plan 2018; 32:1174-1184. [PMID: 28575193 PMCID: PMC5886070 DOI: 10.1093/heapol/czx067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2017] [Indexed: 11/14/2022] Open
Abstract
Little information exists on the cost structure of routine infant immunization services in low- and middle-income settings. Using a unique dataset of routine infant immunization costs from six countries, we estimated how costs were distributed across budget categories and programmatic activities, and investigated how the cost structure of immunization sites varied by country and site characteristics. The EPIC study collected data on routine infant immunization costs from 319 sites in Benin, Ghana, Honduras, Moldova, Uganda, Zambia, using a standardized approach. For each country, we estimated the economic costs of infant immunization by administrative level, budget category, and programmatic activity from a programme perspective. We used regression models to describe how costs within each category were related to site operating characteristics and efficiency level. Site-level costs (incl. vaccines) represented 77-93% of national routine infant immunization costs. Labour and vaccine costs comprised 14-69% and 13-69% of site-level cost, respectively. The majority of site-level resources were devoted to service provision (facility-based or outreach), comprising 48-78% of site-level costs across the six countries. Based on the regression analyses, sites with the highest service volume had a greater proportion of costs devoted to vaccines, with vaccine costs per dose relatively unaffected by service volume but non-vaccine costs substantially lower with higher service volume. Across all countries, more efficient sites (compared with sites with similar characteristics) had a lower cost share devoted to labour. The cost structure of immunization services varied substantially between countries and across sites within each country, and was related to site characteristics. The substantial variation observed in this sample suggests differences in operating model for otherwise similar sites, and further understanding of these differences could reveal approaches to improve efficiency and performance of immunization sites.
Collapse
Affiliation(s)
- Fangli Geng
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Christian Suharlim
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, Seattle, Washington, DC, USA
| | - Stephen C Resch
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, Boston, MA, USA.,Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
6
|
Botwright S, Holroyd T, Nanda S, Bloem P, Griffiths UK, Sidibe A, Hutubessy RCW. Experiences of operational costs of HPV vaccine delivery strategies in Gavi-supported demonstration projects. PLoS One 2017; 12:e0182663. [PMID: 29016596 PMCID: PMC5634534 DOI: 10.1371/journal.pone.0182663] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/13/2017] [Indexed: 11/18/2022] Open
Abstract
From 2012 to 2016, Gavi, the Vaccine Alliance, provided support for countries to conduct small-scale demonstration projects for the introduction of the human papillomavirus vaccine, with the aim of determining which human papillomavirus vaccine delivery strategies might be effective and sustainable upon national scale-up. This study reports on the operational costs and cost determinants of different vaccination delivery strategies within these projects across twelve countries using a standardized micro-costing tool. The World Health Organization Cervical Cancer Prevention and Control Costing Tool was used to collect costing data, which were then aggregated and analyzed to assess the costs and cost determinants of vaccination. Across the one-year demonstration projects, the average economic and financial costs per dose amounted to US$19.98 (standard deviation ±12.5) and US$8.74 (standard deviation ±5.8), respectively. The greatest activities representing the greatest share of financial costs were social mobilization at approximately 30% (range, 6–67%) and service delivery at about 25% (range, 3–46%). Districts implemented varying combinations of school-based, facility-based, or outreach delivery strategies and experienced wide variation in vaccine coverage, drop-out rates, and service delivery costs, including transportation costs and per diems. Size of target population, number of students per school, and average length of time to reach an outreach post influenced cost per dose. Although the operational costs from demonstration projects are much higher than those of other routine vaccine immunization programs, findings from our analysis suggest that HPV vaccination operational costs will decrease substantially for national introduction. Vaccination costs may be decreased further by annual vaccination, high initial investment in social mobilization, or introducing/strengthening school health programs. Our analysis shows that drivers of cost are dependent on country and district characteristics. We therefore recommend that countries carry out detailed planning at the national and district levels to define a sustainable strategy for national HPV vaccine roll-out, in order to achieve the optimal balance between coverage and cost.
Collapse
Affiliation(s)
- Siobhan Botwright
- Vaccine Implementation, Gavi, the Vaccine Alliance, Geneva, Switzerland
| | - Taylor Holroyd
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - Shreya Nanda
- Initiative for Vaccine Research, World Health Organization, Geneva, Switzerland
| | - Paul Bloem
- Expanded Program on Immunization, World Health Organization, Geneva, Switzerland
| | - Ulla K. Griffiths
- Health Section, UNICEF, New York, New York, United States of America
| | - Anissa Sidibe
- Vaccine Implementation, Gavi, the Vaccine Alliance, Geneva, Switzerland
| | | |
Collapse
|
7
|
The cost determinants of routine infant immunization services: a meta-regression analysis of six country studies. BMC Med 2017; 15:178. [PMID: 28982358 PMCID: PMC5629762 DOI: 10.1186/s12916-017-0942-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 09/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence on immunization costs is a critical input for cost-effectiveness analysis and budgeting, and can describe variation in site-level efficiency. The Expanded Program on Immunization Costing and Financing (EPIC) Project represents the largest investigation of immunization delivery costs, collecting empirical data on routine infant immunization in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. METHODS We developed a pooled dataset from individual EPIC country studies (316 sites). We regressed log total costs against explanatory variables describing service volume, quality, access, other site characteristics, and income level. We used Bayesian hierarchical regression models to combine data from different countries and account for the multi-stage sample design. We calculated output elasticity as the percentage increase in outputs (service volume) for a 1% increase in inputs (total costs), averaged across the sample in each country, and reported first differences to describe the impact of other predictors. We estimated average and total cost curves for each country as a function of service volume. RESULTS Across countries, average costs per dose ranged from $2.75 to $13.63. Average costs per child receiving diphtheria, tetanus, and pertussis ranged from $27 to $139. Within countries costs per dose varied widely-on average, sites in the highest quintile were 440% more expensive than those in the lowest quintile. In each country, higher service volume was strongly associated with lower average costs. A doubling of service volume was associated with a 19% (95% interval, 4.0-32) reduction in costs per dose delivered, (range 13% to 32% across countries), and the largest 20% of sites in each country realized costs per dose that were on average 61% lower than those for the smallest 20% of sites, controlling for other factors. Other factors associated with higher costs included hospital status, provision of outreach services, share of effort to management, level of staff training/seniority, distance to vaccine collection, additional days open per week, greater vaccination schedule completion, and per capita gross domestic product. CONCLUSIONS We identified multiple features of sites and their operating environment that were associated with differences in average unit costs, with service volume being the most influential. These findings can inform efforts to improve the efficiency of service delivery and better understand resource needs.
Collapse
|
8
|
Andrus JK, Walker DG. Perspectives on expanding the evidence base to inform vaccine introduction: Program costing and cost-effectiveness analyses. Vaccine 2016; 33 Suppl 1:A2-3. [PMID: 25919161 DOI: 10.1016/j.vaccine.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jon Kim Andrus
- Sabin Vaccine Institute, 2000 Pennsylvania Avenue, NW Suite 7100, Washington, DC 20006, USA.
| | - Damian G Walker
- Bill and Melinda Gates Foundation, 500 Fifth Avenue, North Seattle, WA 98109, USA.
| |
Collapse
|