Costs of routine immunization and the introduction of new and underutilized vaccines in Ghana

Timeliness of Childhood Vaccinations Following Strengthening of the Second Year of Life (2YL) Immunization Platform and Introduction of Catch-Up Vaccination Policy in Ghana

Strengthening routine immunization systems to successfully deliver childhood vaccines during the second year of life (2YL) is critical for vaccine-preventable disease control. In Ghana, the 18-month visit provides opportunities to deliver the second dose of the measles-rubella vaccine (MR2) and for healthcare workers to assess for and provide children with any missed vaccine doses. In 2016, the Ghana Health Service (GHS) revised its national immunization policies to include guidelines for catch-up vaccinations. This study assessed the change in the timely receipt of vaccinations per Ghana's Expanded Program on Immunizations (EPI) schedule, an important indicator of service quality, following the introduction of the catch-up policy and implementation of a multifaceted intervention package. Vaccination coverage was assessed from household surveys conducted in the Greater Accra, Northern, and Volta regions for 392 and 931 children aged 24-35 months with documented immunization history in 2016 and 2020, respectively. Age at receipt of childhood vaccines was compared to the recommended age, as per the EPI schedule. Cumulative days under-vaccinated during the first 24 months of life for each recommended dose were assessed. Multivariable Cox regression was used to assess the associations between child and caregiver characteristics and time to MR2 vaccination. From 2016 to 2020, the proportion of children receiving all recommended doses on schedule generally improved, the duration of under-vaccination was shortened for most doses, and higher coverage rates were achieved at earlier ages for the MR series. More timely infant doses and caregiver awareness of the 2YL visit were positively associated with MR2 vaccination. Fostering a well-supported cadre of vaccinators, building community demand for 2YL vaccination, sustaining service utilization through strengthened defaulter tracking and caregiver-reminder systems, and creating a favorable policy environment that promotes vaccination over the life course are critical to improving the timeliness of childhood vaccinations.

Rotavirus vaccine product switch in Ghana: An assessment of service delivery costs, switching costs, and cost-effectiveness

Ghana introduced rotavirus vaccine (ROTARIX 1-dose presentation) into the routine national immunization program in 2012 and switched to a different product (ROTAVAC 5-dose presentation) in 2020. ROTAVAC has a lower price per dose (US$0.85 versus US$2.15 for ROTARIX) and smaller cold chain footprint but requires more doses per regimen (three versus two). This study estimates the supply chain and service delivery costs associated with each product, the costs involved in switching products, and compares the cost-effectiveness of both products over the next ten years. We estimated the supply chain and service delivery costs associated with ROTARIX and ROTAVAC (evaluating both the 5-dose and 10-dose presentations) using primary data collected from health facilities in six of the 14 regions in the country. We estimated the costs of switching from ROTARIX to ROTAVAC using information collected from key informant interviews and financial records provided by the government. All costs were reported in 2020 US$. We used the UNIVAC decision-support model to evaluate the cost-effectiveness (US$ per disability-adjusted life-year (DALY) averted from government and societal perspectives) of ROTARIX and ROTAVAC (5-dose or 10-dose presentations) compared to no vaccination, and to each other, over a ten-year period (2020 to 2029). We ran probabilistic sensitivity analyses and other threshold analyses. The supply chain and service delivery economic cost per dose was $2.40 for ROTARIX, $1.81 for ROTAVAC 5-dose, and $1.76 for ROTAVAC 10-dose. The financial and economic cost of switching from ROTARIX to ROTAVAC 5-dose was $453,070 and $883,626, respectively. Compared to no vaccination, the cost per DALY averted was $360 for ROTARIX, $298 for ROTAVAC 5-dose, and $273 for ROTAVAC 10-dose. ROTAVAC 10-dose was the most cost-effective option and would be cost-effective at willingness-to-pay thresholds exceeding 0.12 times the national GDP per capita ($2,206 in the year 2020). The switch from ROTARIX to ROTAVAC 5-dose in 2020 was cost-saving. Rotavirus vaccination is highly cost-effective in Ghana. A switch from ROTAVAC 5-dose to ROTAVAC 10-dose would be cost-saving and should be considered.

Cost of introducing and delivering RTS,S/AS01 malaria vaccine within the malaria vaccine implementation program

BACKGROUND

The World Health Organization (WHO) recommended widespread use of the RTS,S/AS01 (RTS,S) malaria vaccine among children residing in regions of moderate to high malaria transmission. This recommendation is informed by RTS,S evidence, including findings from the pilot rollout of the vaccine in Ghana, Kenya, and Malawi. This study estimates the incremental costs of introducing and delivering the malaria vaccine within routine immunization programs in the context of malaria vaccine pilot introduction, to help inform decision-making.

METHODS

An activity-based, retrospective costing was conducted from the governments' perspective. Vaccine introduction and delivery costs supported by the donors during the pilot introduction were attributed as costs to the governments under routine implementation. Detailed resource use data were extracted from the pilot program expenditure and activity reports for 2019-2021. Primary data from representative health facilities were collected to inform recurrent operational and service delivery costs.Costs were categorized as introduction or recurrent costs. Both financial and economic costs were estimated and reported in 2020 USD. The cost of donated vaccine doses was evaluated at $2, $5 and $10 per dose and included in the economic cost estimates. Financial costs include the procurement add on costs for the donated vaccines and immunization supplies, along with other direct expenses.

FINDINGS

At a vaccine price of $5 per dose, the incremental cost per dose administered across countries ranges from $2.30 to $3.01 (financial), and $8.28 to $10.29 (economic). The non-vaccine cost of delivery ranges between $1.04 and $2.46 (financial) and $1.52 and $4.62 (economic), by country. Considering only recurrent costs, the non-vaccine cost of delivery per dose ranges between $0.29 and $0.89 (financial) and $0.59 and $2.29 (economic), by country. Introduction costs constitute between 33% and 71% of total financial costs. Commodity and procurement add-on costs are the main cost drivers of total cost across countries. Incremental resource needs for implementation are dependent on country's baseline immunization program capacity constraints.

INTERPRETATION

The financial costs of introducing RTS,S are comparable with costs of introducing other new vaccines. Country resource requirements for malaria vaccine introduction are most influenced by vaccine price and potential donor funding for vaccine purchases and introduction support.

The costs of introducing a vaccine in sub-Saharan Africa: a systematic review of the literature

Purpose

This study provides a systematic literature review and categorization of the costs reported in the literature for the introduction of new vaccines, focusing on sub-Saharan Africa within LMICs, where vaccines are highly needed, financial resources are scarce and data are lacking and scattered.

Design/methodology/approach

A systematic literature search of PubMed and Web of Science databases was conducted according to the PRISMA requirements. Searches also included the relevant grey literature. In total, 39 studies were selected and nine cost categories were investigated to build a comprehensive framework.

Findings

The paper considers nine cost categories that cover the whole life of the vaccine, from its initial study to its full implementation, including for each of them the relevant subcategories. The systematic review, besides providing specific quantitative data and allowing to assess their variability within each category, points out that delivery, program preparation, administration and procurement costs are the most frequently estimated categories, while the cost of the good sold, costs borne by households and costs associated to AEFI are usually overlooked. Data reported on R&D costs and investment in the production plant differ significantly among the selected contributions.

Originality/value

The literature contributions on cost estimation tend to focus on a precise vaccine, a specific geographic area, or to adopt a narrow approach that captures only a subset of the costs. This article presents a rich and inclusive set of the economic quantitative data on immunization costs in limited-resource countries.

The economic impact of the switch from single- to multi-dose PCV13 vial in Benin

Background

Little is known on the economic implications of multi-dose 13 valent pneumococcal conjugate vaccine (PCV13) introduction in expanded program on immunization (EPI). Based on evidence of PCV13’s reduced pressure on vaccine cold chain, Benin, a third world country in West Africa, introduced the multi-dose PCV13 starting in April 2018 in its EPI program in replacement of the single-dose presentation. The objective of this study was to conduct a rapid assessment of the costs and economic impact of switching from single- to multi-dose PCV13 vial in Benin.

Methods

The data collected retrospectively between January 1 and February 16, 2019 using a quantitative questionnaire was analyzed using Excel 2010 and Stata 13. Resources consumed from April 1st to September 30th, 2017 for the single-dose PCV13 and from April 1st to September 30th, 2018 for multi-dose were analyzed. For both presentations, costs analyzed included vaccines, injections supplies, waste management, cold chain, personnel (salaries and per diems), supervision and monitoring, training, social mobilization and overheads. Moreover, additional costs incurred for the introduction of multi-dose PCV13 were also collected. Costs were estimated for each presentation of PCV13 vaccine by calculating the half-year value of recurrent and capital costs, discounted at a rate of 3% for capital items. To enable comparisons, costs pertaining to 2017 were converted to 2018 equivalent values taking inflation in US$ into account.

Results

The economic costs of the single-dose PCV13 exceeded that of the multi-dose: US$ 3,708,795 versus US$ 3,698,795, respectively. Three cost items, including costs of vaccines, injection supplies, and cold chain appeared to be the main drivers of the observed reduction in costs of multi-dose PCV13. Moreover, the cost per infant vaccinated was lower with the single-dose PCV13 than the multi-dose, respectively US$ 6.28 versus US$ 10.92, and costs of vaccines wasted higher for the multi-dose PCV13.

Conclusions

This evaluation seemed to show that the switch from single- to multi-dose PCV13 resulted in reduced economic costs of PCV13. Vaccinating more infants together with a rigorous application of vaccine open vial policy could lead to the change being more cost-effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12108-6.

Assessment of vaccine wastage in South Sudan

Introduction

vaccine utilization monitoring provides valuable information for practical forecasting and formulation of strategies to reduce avoidable wastage. This monitoring is weak at county and health facility levels in South Sudan. Lack of national wastage rates could result in inaccurate forecasting, leading to vaccine shortages or overstocking and expiration of vaccines at the subnational and service delivery points. As the country gears to introduce relatively expensive vaccines such as rotavirus and pneumococcal vaccines, a robust vaccine utilization monitoring system must be rolled out. This study provides the best possible estimates of vaccine wastage rates and the possible causes of the wastage.

Methods

we conducted the study in 45 conveniently sampled health facilities across 9 of the ten states in South Sudan. Vaccine consumption data was prospectively collected to estimate vaccine wastage and the reason for the wastage of each vaccine type.

Results

wastage of lyophilized vaccines, measles, and Bacillus Calmette–Guérin (BCG) ranged between 39.0-66.7% and 52.1-74.3%, respectively, mainly due to doses that were discarded 6 hours after the opening of the vial or at the end of the immunization session. Wastage of liquid vaccines Oral poliovirus vaccines (OPV), Penta, Inactivated polio vaccine (IPV), and Tetanus- diphtheria (Td) ranged between 24.4-49%, 15.5-43.4%, 25.3-57.9%, and 3.8-57.2%, respectively, mainly due to unusable VVM, expiry, unused doses at the end of outreach sessions, and vials without labels.

Conclusion

wasted rates for all vaccines were higher than the indicative WHO wastage rates used in South Sudan to forecast national vaccine needs. Unopened vial wastage was high and needs immediate attention.

Evaluation of the Impact of Immunization Second Year of Life Training Interventions on Health Care Workers in Ghana

Applying performance-based training interventions that follow adult learning principles and include follow-up activities after training may help to solve specific performance problems and improve health care workers’ performance in immunization service delivery. These strategies facilitate learning, minimize the forgetting curve for health care workers, and should be considered as a standard practice for future training interventions.

Introduction:

As part of a suite of training interventions to improve the knowledge and practice of immunization in the second year of life (2YL), training of trainers workshops were conducted with regional and district health management teams (DHMTs) in 15 districts in 3 regions of Ghana. Using adult learning principles, DHMTs implemented several capacity-building activities at the subdistrict and health facility levels, including health facility visits, on-the-job training, and review meetings. The current evaluation investigated whether frontline health care workers (HCWs) reported or demonstrated improvements in knowledge, attitudes, and practices after training interventions.

Methods:

Quantitative and qualitative methods with a utilization-focused approach guided the framework for this evaluation. A systematic random sample of 115 HCWs in 3 regions of Ghana was selected to complete a competency survey before and after training, which focused on 3 core competency areas—Expanded Programme on Immunization (EPI) policy; communication with caregivers; and immunization data management, recording, and use. Interviews and direct observations by data collectors were done to assess HCWs’ knowledge, self-reported attitude, and behavior changes in practices.

Results:

Of 115 HCWs, 102 were surveyed before and 4 months after receiving capacity-building interventions. Modest but not statistically significant improvements were found in knowledge on EPI policy, immunization data management, and communication skills with caregivers. HCWs reported that they had improved several attitudes and practices after the 2YL training. The most improved practice reported by HCWs and observed in all 3 regions was the creation of a defaulter list.

Discussion:

Findings of this evaluation provide encouraging evidence in taking the first step toward improving HCW knowledge, attitudes, and practices for 3 core immunization competency areas. The use of learner-focused teaching methods combined with adult learning principles is helpful in solving specific performance problems (such as lack of knowledge of EPI policy).

Systematic review of the costs for vaccinators to reach vaccination sites: Incremental costs of reaching hard-to-reach populations

INTRODUCTION

Economic evidence on how much it may cost for vaccinators to reach populations is important to plan vaccination programs. Moreover, knowing the incremental costs to reach populations that have traditionally been undervaccinated, especially those hard-to-reach who are facing supply-side barriers to vaccination, is essential to expanding immunization coverage to these populations.

METHODS

We conducted a systematic review to identify estimates of costs associated with getting vaccinators to all vaccination sites. We searched PubMed and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the following costs to vaccinators: (1) training costs; (2) labor costs, per diems, and incentives; (3) identification of vaccine beneficiary location; and (4) travel costs. We assessed if any of these costs were specific to populations that are hard-to-reach for vaccination, based on a framework for examining supply-side barriers to vaccination.

RESULTS

We found 19 studies describing average vaccinator training costs at $0.67/person vaccinated or targeted (SD $0.94) and $0.10/dose delivered (SD $0.07). The average cost for vaccinator labor and incentive costs across 29 studies was $2.15/dose (SD $2.08). We identified 13 studies describing intervention costs for a vaccinator to know the location of a beneficiary, with an average cost of $19.69/person (SD $26.65), and six studies describing vaccinator travel costs, with an average cost of $0.07/dose (SD $0.03). Only eight of these studies described hard-to-reach populations for vaccination; two studies examined incremental costs per dose to reach hard-to-reach populations, which were 1.3-2 times higher than the regular costs. The incremental cost to train vaccinators was $0.02/dose, and incremental labor costs for targeting hard-to-reach populations were $0.16-$1.17/dose.

CONCLUSION

Additional comparative costing studies are needed to understand the potential differential costs for vaccinators reaching the vaccination sites that serve hard-to-reach populations. This will help immunization program planners and decision-makers better allocate resources to extend vaccination programs.

Nasopharyngeal Carriage and Antimicrobial Susceptibility Profile of Staphylococcus aureus among Children under Five Years in Accra

This cross-sectional study investigated the Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA) nasopharyngeal carriage epidemiology in Accra approximately five years post-pneumococcal conjugate vaccines introduction in the country. Archived nasopharyngeal swabs collected from 410 children aged under five years old were bacteriologically cultured. The resultant S. aureus isolates were subjected to antimicrobial susceptibility testing and screening for carriage of the mecA and LukF-PV (pvl) genes, following standard procedures. The data obtained were analyzed with Statistical Products and Services Solutions (SPSS) using descriptive statistics and Chi square tests of associations. The isolated bacteria decreased across coagulase-negative Staphylococci (47.3%, n = 194), S. aureus (23.2%, n = 95), Diphtheroids (5.4%, n = 22), Micrococcus species (3.7%, n = 15), Klebsiella pneumoniae (3.2%, n = 13), Moraxella species and Citrobacter species (1.5% each, n = 6), Escherichia coli, Enterobacter species, and Pseudomonas species (0.9% each, n = 2). The MRSA carriage prevalence was 0.49% (n = 2). Individuals aged 37-48 months recorded the highest proportion of S. aureus carriage (32.6%, 31/95). Resistance of S. aureus to the antibiotics tested were penicillin G (97.9%, n = 93), amoxiclav (20%, n = 19), tetracycline (18.9%, n = 18), erythromycin (5.3%, n = 5), ciprofloxacin (2.1%, n = 2), gentamicin (1.1%, n = 1), cotrimoxazole, clindamycin, linezolid, and teicoplanin (0% each). No inducible clindamycin resistance was observed for the erythromycin-resistant isolates. Three (3.2%) of the isolates were multidrug resistant, of which 66.7% (2/3) were MRSA. The pvl gene was associated with 59.14% (55/93) of the methicillin-sensitive S. aureus (MSSA) isolates, but was not detected among any of the MRSA isolates.

Costs of continuing RTS,S/ASO1E malaria vaccination in the three malaria vaccine pilot implementation countries

BACKGROUND

The RTS,S/ASO1E malaria vaccine is being piloted in three countries-Ghana, Kenya, and Malawi-as part of a coordinated evaluation led by the World Health Organization, with support from global partners. This study estimates the costs of continuing malaria vaccination upon completion of the pilot evaluation to inform decision-making and planning around potential further use of the vaccine in pilot areas.

METHODS

We used an activity-based costing approach to estimate the incremental costs of continuing to deliver four doses of RTS,S/ASO1E through the existing Expanded Program on Immunization platform, from each government's perspective. The RTS,S/ASO1E pilot introduction plans were reviewed and adapted to identify activities for costing. Key informant interviews with representatives from Ministries of Health (MOH) were conducted to inform the activities, resource requirements, and assumptions that, in turn, inform the analysis. Both financial and economic costs per dose, cost of delivery per dose, and cost per fully vaccinated child (FVC) are estimated and reported in 2017 USD units.

RESULTS

At a vaccine price of $5 per dose and assuming the vaccine is donor-funded, our estimated incremental financial costs range from $1.70 (Kenya) to $2.44 (Malawi) per dose, $0.23 (Malawi) to $0.71 (Kenya) per dose delivered (excluding procurement add-on costs), and $11.50 (Ghana) to $13.69 (Malawi) per FVC. Estimates of economic costs per dose are between three and five times higher than financial costs. Variations in activities used for costing, procurement add-on costs, unit costs of per diems, and allowances contributed to differences in cost estimates across countries.

CONCLUSION

Cost estimates in this analysis are meant to inform country decision-makers as they face the question of whether to continue malaria vaccination, should the intervention receive a positive recommendation for broader use. Additionally, important cost drivers for vaccine delivery are highlighted, some of which might be influenced by global and country-specific financing and existing procurement mechanisms. This analysis also adds to the evidence available on vaccine delivery costs for products delivered outside the standard immunization schedule.

Immunization costs, from evidence to policy: Findings from a nationally representative costing study and policy translation effort in Tanzania

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Delivery costs represent 33% of total immunization program costs in Tanzania.

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Costs are higher for outreach than for facility-based delivery.

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We used calibration methods to estimate unit and total costs.

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This work will inform domestic resource advocacy and planning.

Introduction

Information on the costs of routine immunization programs is needed for budgeting, planning, and domestic resource mobilization. This information is particularly important for countries such as Tanzania that are preparing to transition out of support from Gavi, the Vaccine Alliance. This study aimed to estimate the total and unit costs for of child immunization in Tanzania from July 2016 to June 2017 and make this evidence available to key stakeholders.

Methods

We used an ingredients-based approach to collect routine immunization cost data from the facility, district, regional, and national levels. We collected data on the cost of vaccines as well as non-vaccine delivery costs. We estimated total and unit costs from a provider perspective for each level and overall, and examined how costs varied by delivery strategy, geographic area, and facility-level service delivery volume. An evidence-to-policy plan identified key opportunities and stakeholders to target to facilitate the use of results.

Results

The total annual economic cost of the immunization program, inclusive of vaccines, was estimated to be US$138 million (95% CI: 133, 144), or $4.32 ($3.72, $4.98) per dose. The delivery costs made up $45 million (38, 52), or $1.38 (1.06, 1.70) per dose. The costs of facility-based delivery were similar in urban and rural areas, but the costs of outreach delivery were higher in rural areas than in urban areas. The facility-level delivery cost per dose decreased with the facility service delivery volume.

Discussion

We estimated the costs of the routine immunization program in Tanzania, where no immunization costing study had been conducted for five years. These estimates can inform the program’s budgeting and planning as Tanzania prepares to transition out of Gavi support. Next steps for evidence-to-policy translation have been identified, including technical support requirements for policy advocacy and planning.

Producing Standardized Country-Level Immunization Delivery Unit Cost Estimates

BACKGROUND

To plan for the financial sustainability of immunization programs and make informed decisions to improve immunization coverage and equity, decision-makers need to know how much these programs cost beyond the cost of the vaccine. Non-vaccine delivery cost estimates can significantly influence the cost-effectiveness estimates used to allocate resources at the country level. However, many low- and middle-income countries (LMICs) do not have immunization delivery unit cost estimates available, or have estimates that are uncertain, unreliable, or old. We undertook a Bayesian evidence synthesis to generate country-level estimates of immunization delivery unit costs for LMICs.

METHODS

From a database of empirical immunization costing studies, we extracted estimates of the delivery cost per dose for routine childhood immunization services, excluding vaccine costs. A Bayesian meta-regression model was used to regress delivery cost per dose estimates, stratified by cost category, against a set of predictor variables including country-level [gross domestic product per capita, reported diphtheria-tetanus-pertussis third dose coverage (DTP3), population, and number of doses in the routine vaccination schedule] and study-level (study year, single antigen or programmatic cost per dose, and financial or economic cost) predictors. The fitted prediction model was used to generate standardized estimates of the routine immunization delivery cost per dose for each LMIC for 2009-2018. Alternative regression models were specified in sensitivity analyses.

RESULTS

We estimated the prediction model using the results from 29 individual studies, covering 24 countries. The predicted economic cost per dose for routine delivery of childhood vaccines (2018 US dollars), not including the price of the vaccine, was $1.87 (95% uncertainty interval $0.64-4.38) across all LMICs. By individual cost category, the programmatic economic cost per dose for routine delivery of childhood vaccines was $0.74 ($0.26-1.70) for labor, $0.26 ($0.08-0.67) for supply chain, $0.22 ($0.06-0.57) for capital, and $0.65 ($0.20-1.66) for other service delivery costs.

CONCLUSIONS

Accurate immunization delivery costs are necessary for assessing the cost-effectiveness and strategic planning needs of immunization programs. The cost estimates from this analysis provide a broad indication of immunization delivery costs that may be useful when accurate local data are unavailable.

Estimating the cost of vaccination in southeastern Iran

Background: Specification of vaccination cost of children would help policymakers in determining the nation-wide budget needed for the maintenance of the vaccination program. The budget came these days under scrutiny due to the imposed sanctions tightening the public funds. This study aims at estimating the cost of vaccination in southeastern Iran for obtaining more accurate budget projections. Methods: Fifty-two healthcare centers from 10 cities in south-east Iran participated in using a quota sampling method for their selection. A bottom-up method determined the human resource use, the consumption, and the overhead costs to estimate the cost of vaccination. Data collection used a standard tool that was adjusted to local conditions. Sensitivity analyses were performed. Results: The overall vaccination cost for the region was estimated at around 5,984,000 USD for the year 2015. Salaries took the largest part of the cost estimate (64%), while vaccine cost and its equipment were much lower (22%). The average cost per vaccine dose administrated was 40.94 USD. Sensitivity analysis of the population and inflation rate indicates that the vaccination cost may fluctuate between 37% and 53% over 6 years (2021) from the data of 2015. Conclusion: Maintaining vaccination has a substantial cost. The results of the study will support the budget planning and decision making and will define more precisely the resource allocation needed for maintaining the vaccination at a high level across the country. It may also help to facilitate the assessment of cost-benefit and cost-effectiveness analysis when new vaccines should be introduced.

The efficiency of routine infant immunization services in six countries: a comparison of methods

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.

Systematic review of the costs and effectiveness of interventions to increase infant vaccination coverage in low- and middle-income countries

Background

In recent years, several large studies have assessed the costs of national infant immunization programs, and the results of these studies are used to support planning and budgeting in low- and middle-income countries. However, few studies have addressed the costs and cost-effectiveness of interventions to improve immunization coverage, despite this being a major focus of policy attention. Without this information, countries and international stakeholders have little objective evidence on the efficiency of competing interventions for improving coverage.

Methods

We conducted a systematic literature review on the costs and cost-effectiveness of interventions to improve immunization coverage in low- and middle-income countries, including both published and unpublished reports. We evaluated the quality of included studies and extracted data on costs and incremental coverage. Where possible, we calculated incremental cost-effectiveness ratios (ICERs) to describe the efficiency of each intervention in increasing coverage.

Results

A total of 14 out of 41 full text articles reviewed met criteria for inclusion in the final review. Interventions for increasing immunization coverage included demand generation, modified delivery approaches, cash transfer programs, health systems strengthening, and novel technology usage. We observed substantial heterogeneity in costing methods and incompleteness of cost and coverage reporting. Most studies reported increases in coverage following the interventions, with coverage increasing by an average of 23 percentage points post-intervention across studies. ICERs ranged from $0.66 to $161.95 per child vaccinated in 2017 USD. We did not conduct a meta-analysis given the small number of estimates and variety of interventions included.

Conclusions

There is little quantitative evidence on the costs and cost-effectiveness of interventions for improving immunization coverage, despite this being a major objective for national immunization programs. Efforts to improve the level of costing evidence—such as by integrating cost analysis within implementation studies and trials of immunization scale up—could allow programs to better allocate resources for coverage improvement. Greater adoption of standardized cost reporting methods would also enable the synthesis and use of cost data.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4468-4) contains supplementary material, which is available to authorized users.

Prioritizing the vaccine supply chain issues of developing countries using an integrated ISM-fuzzy ANP framework

Purpose

Delivering vaccines to the children who need them requires a supply chain that is efficient and effective. In most of the developing countries, however, the unknown and unresolved supply chain issues are causing inefficiencies in distributing vaccines. There is, therefore, a great need in such countries to recognize the issues that cause delays in vaccine delivery. With this purpose, the present study aims to identify and analyze the key issues in the supply chain of basic vaccines required to immunize children in developing countries.

Design/methodology/approach

Based on a field survey of three states of India, in-depth review of relevant literature and experts’ opinions, 25 key issues were recognized as factors of the vaccine supply chain (VSC) and categorized into five main domains. Using integrated interpretive structural modeling and fuzzy analytic network process approaches, the issues have been prioritized to determine their relative importance in the VSC. In addition, a sensitivity analysis has been performed to investigate the priority stability of the issues.

Findings

The results of the analysis show that among the five domains of VSC issues, the economic domain with a weight of 0.4262 is the most important domain, followed by the management (0.2672), operational (0.2222), environmental (0.0532) and social (0.0312).

Research limitations/implications

This study focuses on the prioritization of VSC issues; therefore, the results of the present study can provide direction to the decision-makers of immunization programs of developing countries in driving their efforts and resources on eliminating the most important obstacles to design successful vaccination programs.

Originality/value

To the authors’ knowledge, this paper is first to provide a direction to the decision-makers in identifying and managing important issues through the use of an analytical approach.

Estimators Used in Multisite Healthcare Costing Studies in Low- and Middle-Income Countries: A Systematic Review and Simulation Study

BACKGROUND

In low- and middle-income countries, multisite costing studies are increasingly used to estimate healthcare program costs. These studies have employed a variety of estimators to summarize sample data and make inferences about overall program costs.

OBJECTIVE

We conducted a systematic review and simulation study to describe these estimation methods and quantify their performance in terms of expected bias and variance.

METHODS

We reviewed the published literature through January 2017 to identify multisite costing studies conducted in low- and middle-income countries and extracted data on analytic approaches. To assess estimator performance under realistic conditions, we conducted a simulation study based on 20 empirical cost data sets.

RESULTS

The most commonly used estimators were the volume-weighted mean and the simple mean, despite theoretical reasons to expect bias in the simple mean. When we tested various estimators in realistic study scenarios, the simple mean exhibited an upward bias ranging from 12% to 113% of the true cost across a range of study sample sizes and data sets. The volume-weighted mean exhibited minimal bias and substantially lower root mean squared error. Further gains were possible using estimators that incorporated auxiliary information on delivery volumes.

CONCLUSIONS

The choice of summary estimator in multisite costing studies can significantly influence study findings and, therefore, the economic analyses they inform. Use of the simple mean to summarize the results of multisite costing studies should be considered inappropriate. Our study demonstrates that several alternative better-performing methods are available.

A Systematic Review of the Incremental Costs of Implementing a New Vaccine in the Expanded Program of Immunization in Sub-Saharan Africa

Background. The World Health Organization is planning a pilot introduction of a new malaria vaccine in three sub-Saharan African countries. To inform considerations about including a new vaccine in the vaccination program of those and other countries, estimates from the scientific literature of the incremental costs of doing so are important. Methods. A systematic review of scientific studies reporting the costs of recent vaccine programs in sub-Saharan countries was performed. The focus was to obtain from each study an estimate of the cost per dose of vaccine administered excluding the acquisition cost of the vaccine and wastage. Studies published between 2000 and 2018 and indexed on PubMed could be included and results were standardized to 2015 US dollars (US$). Results. After successive screening of 2119 titles, and 941 abstracts, 58 studies with 80 data points (combinations of country, vaccine type, and vaccination approach-routine v. campaign) were retained. Most studies used the so-called ingredients approach as costing method combining field data collection with documented unit prices per cost item. The categorization of cost items and the extent of detailed reporting varied widely. Across the studies, the mean and median cost per dose administered was US$1.68 and US$0.88 with an interquartile range of US$0.54 to US$2.31. Routine vaccination was more costly than campaigns, with mean cost per dose of US$1.99 and US$0.88, respectively. Conclusion. Across the studies, there was huge variation in the cost per dose delivered, between and within countries, even in studies using consistent data collection tools and analysis methods, and including many health facilities. For planning purposes, the interquartile range of US$0.54 to US$2.31 may be a sufficiently precise estimate.

Incorporating costing study results into district and service planning to enhance immunization programme performance: a Zambian case study

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.

A systematic review of vaccine preventable disease surveillance cost studies

BACKGROUND

Planning and monitoring vaccine introduction and effectiveness relies on strong vaccine-preventable disease (VPD) surveillance. In low and middle-income countries (LMICs) especially, cost is a commonly reported barrier to VPD surveillance system maintenance and performance; however, it is rarely calculated or assessed. This review describes and compares studies on the availability of cost information for VPD surveillance systems in LMICs to facilitate the design of future cost studies of VPD surveillance.

METHODS

PubMed, Web of Science, and EconLit were used to identify peer-reviewed articles and Google was searched for relevant grey literature. Studies selected described characteristics and results of VPD surveillance systems cost studies performed in LMICs. Studies were categorized according to the type of VPD surveillance system, study aim, the annual cost of the system, and per capita costs.

RESULTS

Eleven studies were identified that assessed the cost of VPD surveillance systems. The studies assessed systems from six low-income countries, two low-middle-income countries, and three middle-income countries. The majority of the studies (n = 7) were conducted in sub-Saharan Africa and fifteen distinct VPD surveillance systems were assessed across the studies. Most studies aimed to estimate incremental costs of additional surveillance components and presented VPD surveillance system costs as mean annual costs per resource category, health structure level, and by VPD surveillance activity. Staff time/personnel cost represents the largest cost driver, ranging from 21% to 61% of total VPD surveillance system costs across nine studies identifying a cost driver.

CONCLUSIONS

This review provides a starting point to guide LMICs to invest and advocate for more robust VPD surveillance systems. Critical gaps were identified including limited information on the cost of laboratory surveillance, challenges with costing shared resources, and missing data on capital costs. Appropriate guidance is needed to guide LMICs conducting studies on VPD surveillance system costs.

Improved calibration estimators for the total cost of health programs and application to immunization in Brazil

Multi-stage/level sampling designs have been widely used by survey statisticians as a means of obtaining reliable and efficient estimates at a reasonable implementation cost. This method has been particularly useful in National country-wide surveys to assess the costs of delivering public health programs, which are generally originated in different levels of service management and delivery. Unbiased and efficient estimates of costs are essential to adequately allocate resources and inform policy and planning. In recent years, the global health community has become increasingly interested in estimating the costs of immunization programs. In such programs, part of the cost correspond to vaccines and it is in most countries procured at the central level, while the rest of the costs are incurred in states, municipalities and health facilities, respectively. As such, total program cost is a result of adding these costs, and its variance should account for the relation between the totals at the different levels. An additional challenge is the missing information at the various levels. A variety of methods have been developed to compensate for this missing data. Weighting adjustments are often used to make the estimates consistent with readily-available information. For estimation of total program costs this implies adjusting the estimates at each level to comply with the characteristics of the country. In 2014, A National study to estimate the costs of the Brazilian National Immunization Program was initiated, requested by the Ministry of Health and with the support of international partners. We formulate a quick and useful way to compute the variance and deal with missing values at the various levels. Our approach involves calibrating the weights at each level using additional readily-available information such as the total number of doses administered. Taking the Brazilian immunization costing study as an example, this approach results in substantial gains in both efficiency and precision of the cost estimate.

Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage?

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.

Re-evaluating the cost and cost-effectiveness of rotavirus vaccination in Bangladesh, Ghana, and Malawi: A comparison of three rotavirus vaccines

Introduction

Diarrhea is a leading cause of mortality worldwide and rotavirus accounts for many of these deaths. As of August 2018, 96 countries have introduced rotavirus vaccines into their immunization programs. Two rotavirus vaccines, Rotarix® and RotaTeq®, have been WHO-prequalified since 2009, with Rotarix® being the preferred product of most Gavi-supported countries. ROTAVAC® and ROTASIIL® have both been prequalified recently.

Materials and methods

We reevaluated the costs and cost-effectiveness of rotavirus vaccination in Bangladesh, Ghana, and Malawi and compared Rotarix®, ROTAVAC®, and ROTASIIL® in each country. For consistency with previously published analyses in these countries, we used the same Excel-based cohort model and much of the same data as the original analyses. We varied the expected price (with and without Gavi subsidy), wastage, and incremental health system costs associated with each vaccine. We assumed the same efficacy and waning assumptions following administration of two or three doses for the respective product.

Results

The discounted cost per DALY averted compared to no vaccination ranged from 0.3 to 1.3 times GNI per capita for each vaccine. With the Gavi subsidy, the average cost-effectiveness ratios were below 0.3 times GNI per capita in all three countries. Though critical empirical cost data are not yet available, Rotarix® is the least costly and most cost-effective product in the countries examined in this modelling study. However, small decreases in the incremental health system cost for other products could result in cost and cost-effectiveness outcomes that match or surpass those of Rotarix®.

Conclusion

Countries may wish to consider new rotavirus vaccines entering the market. Countries should carefully examine multiple product attributes including price and the incremental health system costs associated with each vaccine. These costs will vary by country and may be a defining factor in determining the least costly and most cost-effective product for the population.

Determinants of cost of routine immunization programme in India

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.

Vaccine wastage in The Gambia: a prospective observational study

Background

Vaccination is a cost-effective and life-saving intervention. Recently several new, but more expensive vaccines have become part of immunization programmes in low and middle income countries (LMIC). Monitoring vaccine wastage helps to improve vaccine forecasting and minimise wastage. As the costs of vaccination increases better vaccine management is essential. Many LMIC however do not consistently monitor vaccine wastage.

Methods

We conducted two surveys in health facilities in rural and urban Gambia; 1) a prospective six months survey in two regions to estimate vaccine wastage rates and type of wastage for each of the vaccines administered by the Expanded programme on Immunization (EPI) and 2) a nationwide cross sectional survey of health workers from randomly selected facilities to assess knowledge, attitude and practice on vaccine waste management. We used WHO recommended forms and standard questionnaires. Wastage rates were compared to EPI targets.

Results

Wastage rates for the lyophilised vaccines BCG, Measles and Yellow Fever ranged from 18.5–79.0%, 0–30.9% and 0–55.0% respectively, mainly through unused doses at the end of an immunization session.

Wastage from the liquid vaccines multi-dose/ single dose vials were minimal, with peaks due to expiry or breakage of the vaccine diluent.

We interviewed 80 health workers and observed good knowledge. Batching children for BCG was uncommon (19%) whereas most health workers (73.4%) will open a vial as needed.

Conclusion

National projected wastage targets were met for the multi-dose/single dose vials, but for lyophilised vaccines, the target was only met in the largest major health facility.

Variation in cost and performance of routine immunisation service delivery in India

A comprehensive understanding of the costs of routine vaccine delivery is essential for planning, budgeting and sustaining India’s Universal Immunisation Programme. India currently allocates approximately US$25 per child for vaccines and operational costs. This budget is prepared based on historical expenditure data as information on cost is not available. This study estimated the cost of routine immunisation services based on a stratified, random sample of 255 public health facilities from 24 districts across seven states—Bihar, Gujarat, Kerala, Meghalaya, Punjab, Uttar Pradesh and West Bengal. The economic cost for the fiscal year 2013–2014 was measured by adapting an internationally accepted approach for the Indian context. Programme costs included the value of personnel, vaccines, transport, maintenance, training, cold chain equipment, building and other recurrent costs. The weighted average national level cost per dose delivered was US$2.29 including vaccine costs, and the cost per child vaccinated with the third dose of diphtheria–pertussis–tetanus (DPT) vaccine (a proxy for full immunisation) was US$31.67 (at 2017 prices). There was wide variation in the weighted average state-level cost per dose delivered inclusive of vaccine costs (US$1.38 to US$2.93) and, for the cost per DTP3 vaccinated child (US$20.08 to US$34.81). Lower costs were incurred by facilities and districts that provided the largest number of doses of vaccine. Out of the total cost, the highest amount (57%) was spent on personnel. This costing study, the most comprehensive conducted to date in India, provides evidence, which should help improve planning and budgeting for the national programme. The budget generally considers financial costs, while this study focused on economic costs. For using this study’s results for planning and budgeting, the collected data can be used to extract the relevant financial costs. Variation in cost per dose and doses administered across facilities, districts and states need to be further investigated to understand the drivers of cost and measure the efficiency of service delivery.

Systematic review of the incremental costs of interventions that increase immunization coverage

Achieving and maintaining high vaccination coverage requires investments, but the costs and effectiveness of interventions to increase coverage remain poorly characterized. We conducted a systematic review of the literature to identify peer-reviewed studies published in English that reported interventions aimed at increasing immunization coverage and the associated costs and effectiveness of the interventions. We found limited information in the literature, with many studies reporting effectiveness estimates, but not providing cost information. Using the available data, we developed a cost function to support future programmatic decisions about investments in interventions to increase immunization coverage for relatively low and high-income countries. The cost function estimates the non-vaccine cost per dose of interventions to increase absolute immunization coverage by one percent, through either campaigns or routine immunization. The cost per dose per percent increase in absolute coverage increased with higher baseline coverage, demonstrating increasing incremental costs required to reach higher coverage levels. Future studies should evaluate the performance of the cost function and add to the database of available evidence to better characterize heterogeneity in costs and generalizability of the cost function.

The cost structure of routine infant immunization services: a systematic analysis of six countries

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.

Maternal influenza immunization in Malawi: Piloting a maternal influenza immunization program costing tool by examining a prospective program

BACKGROUND

This costing study in Malawi is a first evaluation of a Maternal Influenza Immunization Program Costing Tool (Costing Tool) for maternal immunization. The tool was designed to help low- and middle-income countries plan for maternal influenza immunization programs that differ from infant vaccination programs because of differences in the target population and potential differences in delivery strategy or venue.

METHODS

This analysis examines the incremental costs of a prospective seasonal maternal influenza immunization program that is added to a successful routine childhood immunization and antenatal care program. The Costing Tool estimates financial and economic costs for different vaccine delivery scenarios for each of the major components of the expanded immunization program.

RESULTS

In our base scenario, which specifies a donated single dose pre-filled vaccine formulation, the total financial cost of a program that would reach 2.3 million women is approximately $1.2 million over five years. The economic cost of the program, including the donated vaccine, is $10.4 million over the same period. The financial and economic costs per immunized pregnancy are $0.52 and $4.58, respectively. Other scenarios examine lower vaccine uptake, reaching 1.2 million women, and a vaccine purchased at $2.80 per dose with an alternative presentation.

CONCLUSION

This study estimates the financial and economic costs associated with a prospective maternal influenza immunization program in a low-income country. In some scenarios, the incremental delivery cost of a maternal influenza immunization program may be as low as some estimates of childhood vaccination programs, assuming the routine childhood immunization and antenatal care systems are capable of serving as the platform for an additional vaccination program. However, purchasing influenza vaccines at the prices assumed in this analysis, instead of having them donated, is likely to be challenging for lower-income countries. This result should be considered as a starting point to understanding the costs of maternal immunization programs in low- and middle-income countries.

Cost-effectiveness of rotavirus vaccination in Ghana: Examining impacts from 2012 to 2031

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Ghana is currently transitioning away from Gavi support.

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Thus, cost-effectiveness is crucial for improving health system efficiency.

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Rotavirus vaccination brings health and economic benefits to Ghana.

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Rotavirus vaccination is highly cost-effective in Ghana, even Gavi transition.

Background

Diarrhea causes about 10% of all deaths in children under five years globally, with rotavirus causing about 40% of all diarrhea deaths. Ghana introduced rotavirus vaccination as part of routine immunization in 2012 and it has been shown to be effective in reducing disease burden in children under five years. Ghana’s transition from low to lower-middle income status in 2010 implies fewer resources from Gavi as well as other major global financing mechanisms. Ghana will soon bear the full cost of vaccines. The aim of this study was to estimate the health impact, costs and cost-effectiveness of rotavirus vaccination in Ghana from introduction and beyond the Gavi transition.

Methods

The TRIVAC model is used to estimate costs and effects of rotavirus vaccination from 2012 through 2031. Model inputs include demographics, disease burden, health system structure, health care utilization and costs as well as vaccine cost, coverage, and efficacy. Model inputs came from local data, the international literature and expert consultation. Costs were examined from the health system and societal perspectives.

Results

The results show that continued rotavirus vaccination could avert more than 2.2 million cases and 8900 deaths while saving US$6 to US$9 million in costs over a 20-year period. The net cost of vaccination program is approximately US$60 million over the same period. The societal cost per DALY averted is US$238 to US$332 with cost per case averted ranging from US$27 to US$38. The cost per death averted is approximately US$7000.

Conclusion

The analysis shows that continued rotavirus vaccination will be highly cost-effective, even for the period during which Ghana will assume responsibility for purchasing vaccines after transition from Gavi support.

Experiences of operational costs of HPV vaccine delivery strategies in Gavi-supported demonstration projects

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.

The cost determinants of routine infant immunization services: a meta-regression analysis of six country studies

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.

Costing of immunization service provision in Kalutara district, Sri Lanka: a cross-sectional study

BACKGROUND

Immunization is regarded as the single most cost-effective way to prevent vaccine-preventable diseases. With the rising cost of the National Immunization Programme (NIP) in Sri Lanka, immunization costing studies could help programme managers to ensure sustainable immunization financing in the country.

METHODS

Four medical officer of health (MOH) divisions in Kalutara district were included, to estimate the cost incurred for the NIP programme. Fifteen immunization clinics from urban and rural settings were selected from the selected MOH divisions, by a simple random sampling method. Data were collected for a period of 3 months, using pretested check-lists. In addition, related data at national and district levels were also collected. Cost estimates were made for direct capital and recurrent costs.

RESULTS

The cost of vaccines under the national immunization schedule for infants was 1361.84 SL Rs (US$ 10.32). For children under 5 years of age, it was 1535.64 SL Rs (US$ 11.63). The majority of these costs were direct recurrent costs (93.4%). Vaccines (84.3%) and staff salaries (6.4%) were the main components of direct recurrent costs, while cold-chain equipment (5.3%) was the main contributor to direct capital cost.

CONCLUSION

The cost of vaccine is the highest proportion among all other cost components in the NIP in Sri Lanka, and this is largely attributable to new costly vaccines. Staff payments are not significant, as they are a shared cost of public health service providers. Studies exploring the costing of the NIP in the country would be beneficial, to ensure sustainable immunization financing.

Costs of introducing pneumococcal, rotavirus and a second dose of measles vaccine into the Zambian immunisation programme: Are expansions sustainable?

Background

Introduction of new vaccines in low- and lower middle-income countries has accelerated since Gavi, the Vaccine Alliance was established in 2000. This study sought to (i) estimate the costs of introducing pneumococcal conjugate vaccine, rotavirus vaccine and a second dose of measles vaccine in Zambia; and (ii) assess affordability of the new vaccines in relation to Gavi’s co-financing and eligibility policies.

Methods

Data on ‘one-time’ costs of cold storage expansions, training and social mobilisation were collected from the government and development partners. A detailed economic cost study of routine immunisation based on a representative sample of 51 health facilities provided information on labour and vaccine transport costs. Gavi co-financing payments and immunisation programme costs were projected until 2022 when Zambia is expected to transition from Gavi support. The ability of Zambia to self-finance both new and traditional vaccines was assessed by comparing these with projected government health expenditures.

Results

‘One-time’ costs of introducing the three vaccines amounted to US$ 0.28 per capita. The new vaccines increased annual immunisation programme costs by 38%, resulting in economic cost per fully immunised child of US$ 102. Co-financing payments on average increased by 10% during 2008–2017, but must increase 49% annually between 2017 and 2022. In 2014, the government spent approximately 6% of its health expenditures on immunisation. Assuming no real budget increases, immunisation would account for around 10% in 2022. Vaccines represented 1% of government, non-personnel expenditures for health in 2014, and would be 6% in 2022, assuming no real budget increases.

Conclusion

While the introduction of new vaccines is justified by expected positive health impacts, long-term affordability will be challenging in light of the current economic climate in Zambia. The government needs to both allocate more resources to the health sector and seek efficiency gains within service provision.

EPIC Studies: Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010-11

Governments in resource-poor settings have traditionally relied on external donor support for immunization. Under the Global Vaccine Action Plan, adopted in 2014, countries have committed to mobilizing additional domestic resources for immunization. Data gaps make it difficult to map how well countries have done in spending government resources on immunization to demonstrate greater ownership of programs. This article presents findings of an innovative approach for financial mapping of routine immunization applied in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This approach uses modified System of Health Accounts coding to evaluate data collected from national and subnational levels and from donor agencies. We found that government sources accounted for 27-95 percent of routine immunization financing in 2011, with countries that have higher gross national product per capita better able to finance requirements. Most financing is channeled through government agencies and used at the primary care level. Sustainable immunization programs will depend upon whether governments have the fiscal space to allocate additional resources. Ongoing robust analysis of routine immunization should be instituted within the context of total health expenditure tracking.