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Estimating the value of global investment in immunization programs is critical to helping decision makers plan and mobilize immunization programs and allocate resources required to realize their full benefits. We estimated economic benefits using cost-of-illness and value-of-a-statistical-life approaches and combined this estimation with immunization program costs to derive the return on investment from immunization programs against ten pathogens for ninety-four low- and middle-income countries for the period 2011-30. Using the cost-of-illness approach, return on investment for one dollar invested in immunization against our ten pathogens was 26.1 for the ninety-four countries from 2011 to 2020 and 19.8 from 2021 to 2030. Using the value-of-a-statistical-life approach, return on investment was 51.0 from 2011 to 2020 and 52.2 from 2021 to 2030. The results demonstrate continued high return on investment from immunization programs. The return-on-investment estimates from this study will inform country policy makers and decision makers in funding agencies and will contribute to efforts to mobilize resources for immunization. Realization of the full benefits of immunization will depend on sustained investment in and commitment to immunization programs.

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of interventions to improve immunization coverage in low- and middle-income countries, including both published and unpublished reports.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.

Background To improve the efficient use of scarce resources, low- and middle-income countries and development partners are increasingly encouraged to deliver multiple vaccines and other interventions in a single integrated campaign. However, little is known regarding the cost of delivering vaccines through integrated campaigns, and the extent to which efficiencies are achieved. To fill this evidence gap, we estimated the cost of integrated immunization campaigns in Nigeria and Sierra Leone, and the potential savings from integration. Methods We conducted a retrospective ingredients-based costing study from a payer perspective of a campaign held in 2019 in Sierra Leone with measles-rubella vaccine and oral polio vaccine, during which nutrition supplements were also offered in part of the country, and yellow fever campaigns held in three states in Nigeria in 2019 and 2020, where in one state (Anambra) meningococcal A vaccines were co-delivered. We collected data from 108 health facilities, all relevant administrative levels, and implementing partners. We estimated the full financial and economic cost of each campaign, the average unit cost of delivery, as well as the cost by activity and resource type. We also estimated the cost savings from integration in Anambra state by modelling out the cost of the alternative of two standalone campaigns. Results The average financial delivery cost was $0.34 per dose in Sierra Leone, and the economic cost was $0.73 per dose. In Nigeria, the financial cost per dose was $0.29–$0.35 across the three states, and the economic cost per dose was $0.62–$0.85. Facilities and wards delivering more doses achieved a lower financial and economic unit cost of delivery, demonstrating evidence of economies of scale. We estimated that Anambra may have saved at least $1,204,133 in financial resources by integrating yellow fever and meningitis A vaccine delivery, amounting to $0.17 per dose delivered. When including opportunity costs, the economic cost saving was estimated at $0.34 per dose delivered. Conclusions The study offers evidence on what it costs to deliver integrated campaigns, and shows that integrated delivery is likely to result in significant cost savings. Where high delivery volumes can be achieved, integrated campaigns can benefit from economies of scale. The findings can be used to inform planning and budgeting for immunization campaigns in low- and middle-income countries.

Background Differences in definitions and methodological approaches have hindered comparison and synthesis of economic evaluation results across multiple health domains, including immunization. At the request of the World Health Organization’s (WHO) Immunization and Vaccines-related Implementation Research Advisory Committee (IVIR-AC), WHO convened an ad hoc Vaccine Delivery Costing Working Group, comprising experts from eight organizations working in immunization costing, to address a lack of standardization and gaps in definitions and methodological guidance. The aim of the Working Group was to develop a consensus statement harmonizing terminology and principles and to formulate recommendations for vaccine delivery costing for decision making. This paper discusses the process, findings of the review, and recommendations in the Consensus Statement. Methods The Working Group conducted several interviews, teleconferences, and one in-person meeting to identify groups working in vaccine delivery costing as well as existing guidance documents and costing tools, focusing on those for low- and middle-income country settings. They then reviewed the costing aims, perspectives, terms, methods, and principles in these documents. Consensus statement principles were drafted to align with the Global Health Cost Consortium costing guide as an agreed normative reference, and consensus definitions were drafted to reflect the predominant view across the documents reviewed. Results The Working Group identified four major workstreams on vaccine delivery costing as well as nine guidance documents and eleven costing tools for immunization costing. They found that some terms and principles were commonly defined while others were specific to individual workstreams. Based on these findings and extensive consultation, recommendations to harmonize differences in terminology and principles were made. Conclusions Use of standardized principles and definitions outlined in the Consensus Statement within the immunization delivery costing community of practice can facilitate interpretation of economic evidence by global, regional, and national decision makers. Improving methodological alignment and clarity in program costing of health services such as immunization is important to support evidence-based policies and optimal resource allocation. On the other hand, this review and Consensus Statement development process revealed the limitations of our ability to harmonize given that study designs will vary depending upon the policy question that is being addressed and the country context.

With social policies increasingly directed toward enhancing equity through health programs, it is important that methods for estimating the health and economic benefits of these programs by subpopulation be developed, to assess both equity concerns and the programs' total impact. We estimated the differential health impact (measured as the number of deaths averted) and household economic impact (measured as the number of cases of medical impoverishment averted) of ten antigens and their corresponding vaccines across income quintiles for forty-one low- and middle-income countries. Our analysis indicated that benefits across these vaccines would accrue predominantly in the lowest income quintiles. Policy makers should be informed about the large health and economic distributional impact that vaccines could have, and they should view vaccination policies as potentially important channels for improving health equity. Our results provide insight into the distribution of vaccine-preventable diseases and the health benefits associated with their prevention.

Background Dynamic modeling is commonly used to evaluate direct and indirect effects of interventions on infectious disease incidence. The risk of secondary outcomes (e.g., death) attributable to infection may depend on the underlying disease incidence targeted by the intervention. Consequently, the impact of interventions (e.g., the difference in vaccination and no-vaccination scenarios) on secondary outcomes may not be proportional to the reduction in disease incidence. Here, we illustrate the estimation of the impact of vaccination on measles mortality, where case fatality ratios (CFRs) are a function of dynamically changing measles incidence. Methods We used a previously published model of measles CFR that depends on incidence and vaccine coverage to illustrate the effects of (1) assuming higher CFR in “no-vaccination” scenarios, (2) time-varying CFRs over the past, and (3) time-varying CFRs in future projections on measles impact estimation. We used modeled CFRs in alternative scenarios to estimate measles deaths from 2000 to 2030 in 112 low- and middle-income countries using two models of measles transmission: Pennsylvania State University (PSU) and DynaMICE. We evaluated how different assumptions on future vaccine coverage, measles incidence, and CFR levels in “no-vaccination” scenarios affect the estimation of future deaths averted by measles vaccination. Results Across 2000–2030, when CFRs are separately estimated for the “no-vaccination” scenario, the measles deaths averted estimated by PSU increased from 85.8% with constant CFRs to 86.8% with CFRs varying 2000–2018 and then held constant or 85.9% with CFRs varying across the entire time period and by DynaMICE changed from 92.0 to 92.4% or 91.9% in the same scenarios, respectively. By aligning both the “vaccination” and “no-vaccination” scenarios with time-variant measles CFR estimates, as opposed to assuming constant CFRs, the number of deaths averted in the vaccination scenarios was larger in historical years and lower in future years. Conclusions To assess the consequences of health interventions, impact estimates should consider the effect of “no-intervention” scenario assumptions on model parameters, such as measles CFR, in order to project estimated impact for alternative scenarios according to intervention strategies and investment decisions.

Background Equitable access to vaccines has been suggested as a priority for low- and middle-income countries (LMICs). However, it is unclear whether providing equitable access is enough to ensure health equity. Furthermore, disaggregated data on health outcomes and benefits gained across population subgroups are often unavailable. This paper develops a model to estimate the distribution of childhood disease cases and deaths across socioeconomic groups, and the potential benefits of three vaccine programs in LMICs. Methods For each country and for three diseases (diarrhea, measles, pneumonia), we estimated the distributions of cases and deaths that would occur across wealth quintiles in the absence of any immunization or treatment programs, using both the prevalence and relative risk of a set of risk and prognostic factors. Building on these baseline estimates, we examined what might be the impact of three vaccines (first dose of measles, pneumococcal conjugate, and rotavirus vaccines), under five scenarios based on different sets of quintile-specific immunization coverage and disease treatment utilization rates. Results Due to higher prevalence of risk factors among the poor, disproportionately more disease cases and deaths would occur among the two lowest wealth quintiles for all three diseases when vaccines or treatment are unavailable. Country-specific context, including how the baseline risks, immunization coverage, and treatment utilization are currently distributed across quintiles, affects how different policies translate into changes in cases and deaths distribution. Conclusions Our study highlights several factors that would substantially contribute to the unequal distribution of childhood diseases, and finds that merely ensuring equal access to vaccines will not reduce the health outcomes gap across wealth quintiles. Such information can inform policies and planning of programs that aim to improve equitable delivery of healthcare services.

•This paper reports a statistical analysis of 40 comprehensive multi-year plans (cMYPs) for immunization.•The cost of routine immunization varies by region and has increased to $27 per fully immunized child.•Non-vaccine delivery costs account for nearly half of total RI costs.•Governments finance 67% of RI costs, though shares in African countries are less than 50%.•RI costs represent 5% of government health spending, potentially posing challenges for sustainability in poorer countries. Immunization is one of the most cost-effective health interventions, but as countries introduce new vaccines and scale-up immunization coverage, costs will likely increase. This paper updates estimates of immunization costs and financing based on information from comprehensive multi-year plans (cMYPs) from GAVI-eligible countries during a period when countries planned to introduce a range of new vaccines (2008–2016). The analysis database included information from baseline and 5-year projection years for each country cMYP, resulting in a total sample size of 243 observations. Two-thirds were from African countries. Cost data included personnel, vaccine, injection, transport, training, maintenance, cold chain and other capital investments. Financing from government and external sources was evaluated. All estimates were converted to 2010 US Dollars. Statistical analysis was performed using STATA, and results were population-weighted. Results pertain to country planning estimates. Average annual routine immunization cost was $62 million. Vaccines continued to be the major cost driver (51%) followed by immunization-specific personnel costs (22%). Non-vaccine delivery costs accounted for almost half of routine program costs (44%). Routine delivery cost per dose averaged $0.61 and the delivery cost per infant was $10. The cost per DTP3 vaccinated child was $27. Routine program costs increased with each new vaccine introduced. Costs accounted for 5% of government health expenditures. Governments accounted for 67% of financing. Total and average costs of routine immunization programs are rising as coverage rates increase and new vaccines are introduced. The cost of delivering vaccines is nearly equivalent to the cost of vaccines. Governments are financing greater proportions of the immunization program but there may be limits in resource scarce countries. Price reductions for new vaccines will help reduce costs and the burden of financing. Strategies to improve efficiency in service delivery should be pursued.

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.

BackgroundFew 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.MethodsUsing 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.ResultsUsing 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.ConclusionsResults 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.