Elsevier

Vaccine

Volume 33, Supplement 1, 7 May 2015, Pages A13-A20
Vaccine

Costs and financing of routine immunization: Approach and selected findings of a multi-country study (EPIC)

https://doi.org/10.1016/j.vaccine.2014.12.066Get rights and content

Highlights

  • The EPIC studies are unique and provide high-quality detailed costs of routine immunization in Benin, Ghana, Honduras, Moldova, Uganda and Zambia.

  • The method (Common Approach) uses an ingredients-based approach to costing.

  • Unit costs of routine immunization are higher than previously estimated and governments are financing greater shares.

  • Facility-based costing studies provide useful detail for evaluating productivity and performance of RI.

Abstract

Background

Few detailed facility-based costing studies of routine immunization (RI) programs have been conducted in recent years, with planners, managers and donors relying on older information or data from planning tools. To fill gaps and improve quality of information, a multi-country study on costing and financing of routine immunization and new vaccines (EPIC) was conducted in Benin, Ghana, Honduras, Moldova, Uganda and Zambia.

Methods

This paper provides the rationale for the launch of the EPIC study, as well as outlines methods used in a Common Approach on facility sampling, data collection, cost and financial flow estimation for both the routine program and new vaccine introduction. Costing relied on an ingredients-based approach from a government perspective. Estimating incremental economic costs of new vaccine introduction in contexts with excess capacity are highlighted. The use of more disaggregated System of Health Accounts (SHA) coding to evaluate financial flows is presented.

Results

The EPIC studies resulted in a sample of 319 primary health care facilities, with 65% of facilities in rural areas. The EPIC studies found wide variation in total and unit costs within each country, as well as between countries. Costs increased with level of scale and socio-economic status of the country. Governments are financing an increasing share of total RI financing.

Conclusions

This study provides a wealth of high quality information on total and unit costs and financing for RI, and demonstrates the value of in-depth facility approaches. The paper discusses the lessons learned from using a standardized approach, as well as proposes further areas of methodology development. The paper discusses how results can be used for resource mobilization and allocation, improved efficiency of services at the country level, and to inform policies at the global level. Efforts at routinizing cost analysis to support sustainability efforts would be beneficial.

Introduction

Vaccines are one of the best buys in public health [1], [2] and a good candidate for government financing [3]. Historically, the cost per fully immunized child (FIC) with measles, polio, DTP, and BCG vaccines ranges from less than $3 to $22, with variation between countries by facility type and ownership, volume of vaccines administered, wastage rates, type of delivery strategy, and input prices [4], [5], [6], [7], [8], [9], [10], [11]1. Unit costs generally decline as output increases, but there is scant evidence on whether unit costs will rise as coverage increases beyond 80% [1], [12], [13].

Currently, all GAVI-eligible countries have introduced pentavalent vaccine into their routine immunization (RI) programs2. Rotavirus, pneumococcal, and HPV vaccine introductions also are on the rise worldwide [14]. Total and unit costs of RI have increased with the introduction of new vaccines [15], [16], [17] but many of these studies have relied on secondary estimates of costs and financing. Secondary sources have been shown to underestimate the cost of national immunization programs [11] and reliability of secondary sources has been questioned [18].

Facility-based costing surveys have the potential to more fully capture the costs and financing of immunization through more detailed analysis of input use. Given the pace and breadth of new vaccine introduction and universal coverage goals highlighted in the Global Vaccine Action Plan [19], as well as the emphasis by the global community on Universal Health Coverage (UHC), there is a critical need for updated cost and financing estimates for RI and new vaccine introduction. Understanding the costs of existing coverage levels is a first step toward adequate planning and budgeting for GVAP and UHC goals. Potential cost variation at the facility level merits further exploration, as such analyses can identify areas of program efficiency and value for money.

Section snippets

Objective and scope of the EPIC studies

This paper describes the methods, selected findings and policy focus the EPI Costing and Financing (EPIC) studies conducted between 2012 and 2013 in Benin, Ghana, Honduras, Moldova, Uganda and Zambia, supported by the Bill & Melinda Gates Foundation (BMGF). The purpose of the EPIC studies was to provide countries and the global community with updated and detailed cost estimates of RI programs with pentavalent vaccine in the schedule, as well as the incremental costs of other new vaccines.

The

Methods and common approach

Because EPIC studies were carried out by different organizations, a Common Approach was developed to harmonize and standardize methods for cost and financing estimation [23].

Selected findings of the EPIC studies

We report some of the findings from the EPIC studies across countries to illustrate trends. Additional detail and analysis can be found in other manuscripts in this Supplement. First, there is a wide range of total facility immunization economic costs within the country samples, with nearly 200-fold differences in Moldova and 60-fold differences in Uganda. Benin had the smallest range between high and low cost facilities. Second, differences in total facility cost between countries are related

Policy conclusions and lessons learned

The EPIC studies provide a unique set of high quality data on RI program costs, updating the evidence-base to include pentavalent vaccines in the immunization schedule. The studies reveal that governments are financing a larger total amount and share of RI than previously estimated [17]. The major cost drivers continue to be labor, followed by vaccines.

The EPIC studies also showed a wide range in facility-level total costs within countries, as well as variation in unit costs between countries.

Conflict of interest statement

The authors declare no conflict of interest. The EPIC studies and preparation of this manuscript were supported by the Bill & Melinda Gates Foundation. However, the views expressed represent those of the authors only.

Acknowledgements

We would like to thank all of the members of the study teams who provided inputs into the development of the methods and approaches used for the EPIC studies. The contributions of Steering Committee members, most notably Carol Levin and Ulla Griffiths, were critical to the successful outcome of the EPIC studies. Finally, we appreciate the comments of two independent reviewers.

References (37)

  • R.L. Robertson et al.

    Service volume and other factors affecting the costs of immunizations in the Gambia

    Bull World Health Organ

    (1984)
  • D.S. Shepard et al.

    Cost-effectiveness of routine and campaign vaccination strategies in Ecuador

    Bull World Health Org:

    (1989)
  • D. Mosquiera et al.

    Variation in the costs of delivery routine immunization services in Peru

    Bull World Health Organ

    (2004)
  • A.L. Creese et al.

    Cost-effectiveness of immunization programs in Colombia

    Bull Pan Am Health Organ

    (1987)
  • D. Bishai et al.

    The cost of scaling up vaccination services in the world's poorest countries

    Health Aff

    (2006)
  • Gavi, The Vaccine Alliance. Geneva, Switzerland. 〈www.gavi.org〉 (last accessed August...
  • L.J. Wolfson et al.

    Estimating the costs of achieving the WHO-UNICEF Global Immunization Vision and Strategy, 2006–2015

    Bull World Health Organ

    (2008)
  • L. Brenzel, C. Politi. Historical Analysis of the Comprehensive Multi-Year Plans in GAVI-Eligible countries...
  • Cited by (56)

    View all citing articles on Scopus
    View full text