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This piece originally appeared on MOMENTUM, USAID here.

MOMENTUM Private Healthcare Delivery is supporting and strengthening private sector providers’ capacity to sustainably integrate and participate in public purchasing programs, including for family planning services. Led by ThinkWell, MOMENTUM has conducted a rapid landscape review that identifies the common barriers for private providers when engaging in public purchasing programs. The landscape draws on literature from across 23 countries and presents opportunities and recommendations to address private health provider challenges in engagement and collaboration within the public health sector.

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“To achieve and sustain access to quality primary health care services for all consumers, our health system needs to engage, optimize, and mobilize both the public
and private sectors to provide primary health care services.” 
—Kenneth Ronquillo, Assistant Secretary Department of Health

Our team in the Philippines held a forum that brought together public and private stakeholders to discuss the current state of Health Care Provider Networks (HCPNs) in the country and identify possible opportunity areas to engage private sector partners and increase their participation in HCPNs.  

During PSPH Series 2 Back on Track, Full Speed Ahead: Engaging Private Providers in HCPN, Kenneth Ronquillo, Assistant Secretary Department of Health, recalled that it had been two years since the UHC Bill became law—ensuring citizens have access to all the health care they need without financial hardship. Yet, there is still room to develop guidelines to improve the health system goals.

Though private and public stakeholders have been taking strides towards more co-equal participation of private healthcare providers in HCPNs. The three sessions in this forum further created an opportunity for stakeholders to identify ways to improve public-private partnerships, an information-sharing platform, fund pooling and purchasing mechanisms, and capacity development of private sector partners to be engaged in HCPNs. 

Watch the sessions here and learn more about our work in the Philippines here

Many thanks to all participants who took part in the conversation and helped explore concrete opportunities to move UHC forward.

AC Health
Antique Provincial Health Office
Antique Provincial DOH Office
Asian Development Bank Philippines
Commission on Population and Development
DOH Bureau of Local Health Systems Development
DKT International
Family Planning Organization of the Philippines
Guimaras Provincial Health Office
Guimaras Provincial DOH Office
Integrated Midwives Association Of The Philippines
Likhaan Center for Women’s Health
Mt. Grace Hospitals, Inc.
PhilHealth
Philippine Center for Population and Development
Philippine Primary Care Studies of the University of the Philippines
The Medical City
UNFPA Philippines

Since 2011, ThinkWell has expanded access to high quality health services to underserved populations in low- and middle-income countries by addressing health system challenges that rarely get the attention they need. Universal health coverage lies at the center of our work, and while there are hundreds of initiatives to address hundreds more health issues, diseases, and economic gaps, global immunization is a unique opportunity to save lives, increase productivity and economic gains, and improve quality of life for individuals and families. What’s more, immunization is considered one of the most cost-effective investments available, which means that limited financial resources are well spent and have high health returns when invested in vaccines. 

While national governments, especially those of low- and middle-income countries, seek to expand national immunization programs to include newer vaccines, like those for human papillomavirus and dengue fever, the financing rarely matches the desired scale of these programs. Financing should not only cover the cost of procuring vaccines, but it should also cover increased investments in cold chain management and logistics, training of providers, and social mobilization and awareness-building efforts. So, while strong immunization programming is considered a “good buy,” it isn’t cheap and requires sustained investment. 

As the world’s immunization experts fortify global health systems with knowledge gained from COVID-19, ThinkWell’s immunization projects have continued to generate economic evidence informing planning and investment in vaccine delivery for marginalized people across the globe. Every day, our world moves closer to global immunization standards. Following this World Immunization Week, we’d like to celebrate the progress we’ve made as a global health community and look ahead to the steps yet to be taken. 

The Investment of a Lifetime 

According to the World Health Organization, before COVID-19, only 11% of public spending on health was for prevention in low- and middle-income countries, and governments account for less than half of total spending on disease prevention. Policymakers may place a high value on immunization and public health, yet many immunization budgets remain flat, as prevention results are far less visible than curative intervention. 

Financing shortfalls mean low vaccine adoption rates and variable coverage which compromises the efficacy of lifesaving vaccines. ThinkWell’s Sustainable Immunization Financing team has seen these patterns time and again, but the economic evidence behind the health returns on vaccines is too large to ignore. Our teams work with local experts and government officials in geographically diverse countries to develop financing evidence and policy recommendations built to withstand evolving sociopolitical agendas and unpredictable events like global pandemics. 

Relative to other health initiatives, immunization has excellent value-for-money and has proven itself an unfailing investment in current and future generations. To this end, advocates, civil society organizations, immunization program managers, and researchers alike can take the following actions to raise awareness and galvanize support: 

  1. Tell the full story of vaccination success to generate societal and political demand. 
  2. Create and maintain a shared agenda across the health advocacy spectrum. 
  3. Articulate the shared needs of the products, systems, and people involved in immunization. 
  4. Integrate immunization into primary health care. 

To champion routine immunization in the long term, advocates and immunization program managers need to provide ministers of health and finance a clear picture of what their countries would be facing without immunization programs. These steps are a clear way to push the immunization financing agenda forward. 

Immunization Equity 

Immunization programs and budgets require continuous honing and nuanced understanding of local needs and capacities. Once budgets are built and funds are earmarked, nations need to ensure that there is local capacity for education and deployment. The global immunization economics community churns out data around costs per dose, campaign financing, and workforce shortages daily. The Immunization Economics community of practice, managed by ThinkWell, is a conglomerate of researchers from all over who make their research public so that policymakers and civil society organizations can create efficient budgets and advocate for mass immunization in local communities. 

A global network of experts ensures that underserved populations whose health needs rarely get the required attention can access vaccines from childhood and reap the long-term health and economic benefits of stopping a disease before it starts. And when populations are vaccinated, fewer need intensive health care services later in life, reducing the economic burden on national health coverage schemes. 

Our Global Responsibility 

Health professionals in every country work tirelessly to reach new populations and deliver essential health services like vaccines in areas where demand is the greatest, but without visibility and increased support from national stakeholders, immunization will fall short of global goals and people who need them will not receive lifesaving vaccines. 

As we rebound from COVID-19 with boundless new information on budgeting for health crises and rapid vaccine deployment, knowledge-sharing is an indispensable way to make sure low- and middle-income countries have evidence on which to build sustainable immunization financing policy. 

When governments are equipped with current data, digestible research, and clear health goals, the value of vaccines will be made abundantly clear and immunization financing will become a health priority. Following World Immunization Week 2022 and beyond, ThinkWell joins the global health community to share ideas, research, and support for health professionals and researchers around the world and ensuring every person has access to lifesaving vaccines. 

After a three-day convention, the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization announced that a single-dose schedule for the vaccine against human papillomavirus (HPV) “offers solid protection against cervical cancer.” 

This is a major development in the global movement to eliminate cervical cancer, which plagues women in low- and middle-income countries around the world. 

According to WHO, “more than 95% of cervical cancer is caused by sexually transmitted HPV.” Mass vaccination against HPV makes cervical cancer one of the most preventable diseases in global health. But as universal health coverage schemes around the world proliferate, cervical cancer services are often pushed to the side, leaving women and girls vulnerable. 

Last month, ThinkWell released four country profiles commissioned by the Union for International Cancer Control on financing challenges for cervical cancer elimination. Each profile includes analyses of current funding, key stakeholder interviews, and policy recommendations for improving national financing for cervical cancer elimination, including HPV vaccination. 

While each nation studied—Burkina Faso, Côte d’Ivoire, Guatemala, and the Philippines―has unique circumstances and most are pushing for increased visibility and infrastructure for cervical cancer elimination, a common theme spanned the four countries: insufficient funding. 

Though low- and middle-income nations are building programs to address this gap in services, the programs languish because they don’t receive the necessary resources, including to make the HPV vaccine available and accessible. In addition to limited fiscal space, education and advocacy for cervical cancer elimination at health facilities are often poor because facilities may not prioritize it as a major women’s health issue. 

A single-dose schedule for the HPV vaccine will not only ease the budgetary burden on national governments and incentivize financing vaccine programs, but it will also simplify mass vaccination for women and girls who may face physical and economic barriers associated with a two-dose schedule. 

This WHO recommendation is an enormous step towards streamlined and widely accessible HPV vaccines and, broadly, cervical cancer elimination. This World Immunization Week, ThinkWell celebrates this announcement and what it means for improved universal health coverage, but the work doesn’t stop here. Continued advocacy and pressure on national governments to take advantage of this development, establish and finance cervical cancer service programs, and raise awareness of the danger of HPV are crucial in the fight to eliminate cervical cancer. 

A single dose means fewer costs and wider access, but it’s up to advocates, governments, and practitioners to make sure that every woman everywhere has the means to get the jab. 

Following on from studies conducted in India and Sierra Leone, the ICAN team released the report of the campaign costing study conducted in Nigeria as part of efforts to standardize campaign costing. 

The study in Nigeria aimed to estimate the delivery cost of the yellow fever campaigns in Anambra, Katsina, and Rivers states, with Meningitis A vaccines also being co-delivered as part of the campaign in Anambra. The study estimated the full financial and economic costs of the campaigns and costs were collected at ward, LGA, and state-level, and from federal level government offices and development partners. Costs were aggregated to estimate the volume and sampling probability-weighted average cost per dose delivered, and the total cost of the campaign. 

Per dose delivered, the financial delivery cost was US$0.29 in Rivers, US$0.34 in Katsina, and US$0.35 in Anambra, mostly driven by per diem and allowances, vaccine injection supplies, and transport and fuel costs. The economic cost per dose delivered was US$0.62 in Katsina, US$0.71 in Anambra and US$0.85 in Rivers, and paid and volunteer labor were the key cost drivers among economic cost.  

View the full report here and more information on ICAN is available here. 

As part of efforts through ICAN to standardize campaign costing, the team has released a policy brief with findings from three costing studies of immunization campaigns conducted in India, Nigeria, and Sierra Leone. Two of these campaigns were integrated (more than one intervention was delivered), a mode of delivery that is more of a priority than ever due to the COVID-19 pandemic. However, evidence is lacking on how integration affects delivery cost.

The policy brief presents the findings from costing studies of three campaigns:

  • Measles-rubella catch-up campaign in India
  • Yellow Fever campaigns in three states in Nigeria (Anambra, Katsina, and Rivers), co-delivered with meningitis A vaccine in Anambra
  • Measles-rubella catch-up campaign in Sierra Leone that was co-delivered with oral polio vaccine nationwide, and vitamin A and deworming tablets in half of the country

The financial delivery cost per targeted person—including costs for all administrative levels, net of capital costs, vaccines, syringes, and safety boxes—for sampled vaccination campaign sites in India, Sierra Leone, and Nigeria ranged from US$0.15 to US$0.42. However, there was significant variation in operational costs across sampled sites, and low-volume sites appeared to have higher operational costs per targeted person, suggesting a need for more sophisticated subnational planning and financing of campaigns.

Financial efficiencies were evident in districts in Sierra Leone which co-delivered all interventions, though higher labor costs were also found in these areas, suggesting that integration may require greater use of existing resources. In Nigeria, results painted a more complex picture, and higher financial unit cost in the co-delivery state of Anambra was likely due to differences in volume delivered across sites, existing capacity, and the way the campaigns were funded.

The studies in Nigeria and Sierra Leone are the first on the cost of integrated campaigns and can form the basis for future research on the cost and policy implications of integration.

View the policy brief here and more information on ICAN is available here.

Low- and middle-income countries (LMIC) are standing at the beginning of an incredibly challenging vaccine roll-out. COVID-19 vaccine delivery poses unprecedented challenges in terms of delivery volume, reaching new target populations, diversity of delivery strategies, and sometimes complex product profiles—elements that must all be managed at rapid speed if effective coverage is to be achieved. ThinkWell contributed to global level modeled estimates which indicate that the delivery cost of COVID-19 vaccines in LMIC-settings could be several times greater than for routine childhood vaccines. However, these estimates are based on crude assumptions and global level parameters, and real cost evidence from countries is lacking.

ThinkWell is conducting costing studies of COVID-19 vaccine delivery in Bangladesh, Côte d’Ivoire, and Mozambique, and 3-4 other countries to generate rapid economic evidence to support the sustainable roll-out of COVID-19 vaccines. In each country, bottom-up ingredients-based costing and top-down analysis of financial expenditure budgets and reports will be conducted to estimate the cost of delivering COVID-19 vaccines through various delivery strategies, reaching different target populations, and using products with varying cold chain requirements. The studies will also map out the service delivery process and funding flows and capture the source and use of different types of paid and volunteer health workers mobilized to deliver COVID-19 vaccines. Semi-structured interviews will also be conducted with stakeholders to assess the roll-out and its challenges. The studies will follow a common research protocol based on guidance on routine immunization costing methods and the standardized campaign costing methodology developed by ThinkWell.  You can read about previous immunization costing studies here. The first results are expected by April/May 2022.

This work is supported by funding from the Bill & Melinda Gates Foundation. To find out more about this project, please click here.

Nearly 200 attendees convened on October 19th and 20th for the Second Annual Health Campaign Effectiveness Coalition Meeting. The goals of the meeting were to identify promising practices and build consensus around actions to foster learning, collaboration, and systems to effectively plan and implement campaigns to deliver health services to priority populations. More than 50 speakers, moderators, and presenters, including ThinkWell economist Laura Boonstoppel, came together to share their knowledge and experiences in health campaigns around malaria, NTDs, polio, vaccine-preventable diseases, and nutritional supplementation.

Laura was part of the panel for an open discussion on the economic aspects of campaign integration alongside Dr. Alan Hinman of the Task Force for Global Health and Dr. Deborah McFarland of Emory University. This session included a rich conversation on the implications of campaign integration for health worker incentives and motivation, and how benefits and costs for households and beneficiaries are included in economic analyses. The recording of this session can viewed below and recordings of all of the other presentations and discussions can be viewed here.

Christina Banks and Flavia Moi presented a poster on findings from two costing studies on immunization campaigns in Nigeria and Sierra Leone which showed the potential financial efficiencies of campaign integration and the effect of volume delivered on cost per dose. This presentation prompted interesting discussions on how the cost of campaigns with multiple antigens or integrated nutritional interventions compares to single-antigen or vaccine-only delivery and the different staffing requirements of both. The poster can be viewed here and the full Sierra Leone study report can be read here.

For more information on ThinkWell’s campaign costing work, please visit the Immunization Costing Action Network page on immunizationeconomics.org