Written by Matt Boxshall and Jennifer Santisi at ThinkWell, this blog summarizes expert discussions on family planning and national health insurance at the recent ThinkWell Counterpoint webinar, access the recording here.

“I’m passionate about family planning; empowering women to have children by choice, not by chance, can transform societies for the better,” said Matt Boxshall, Program Director at ThinkWell. “To achieve this, it’s clear that governments must invest in improving access to quality family planning (FP) services.  But it’s also clear that the way those investments are made – how that money is spent – is critical.  As more governments choose national health insurance (NHI) to support the drive to universal health coverage (UHC), we ask if NHI is the right tool to ensure that those most in need have access to quality FP services.”

Matt opened the first webinar, “Putting the ‘Universal’ into ‘UHC Schemes’ for Family Planning,” in ThinkWell’s Counterpoint series. Health professionals from around the world attended the webinar on June 3, 2021, to hear from leading experts in health financing and FP.

When deciding whether to finance FP through health insurance, first ask “Who will benefit?”

“UHC is a goal, not a scheme,” said Joe Kutzin, who leads the World Health Organization’s Health Financing Team in Geneva. He reiterated that every country can make progress towards the goals of UHC, reducing the gap between need and utilization, improving quality, and increasing financial protection. To do so, however, it is important to consider the performance of the health system as a whole, rather than focusing on a particular scheme in isolation.  With this framing, Joe described a cascade of decisions about whether to include a specific service (like FP) within a health insurance scheme. The first, and critical, decision is based on whether the entitlement to services under the insurance scheme is universal or restricted to those who contribute to the scheme. If entitlement is linked to contributions, as in social health insurance schemes, integration should not be considered.

Beware early financing decisions that ignore sexual and reproductive health and rights – they may be hard to undo.

Brendan Hayes, a Senior Health Specialist at the Global Financing Facility, picked this up in his comments; “UHC is not a scheme, it’s a series of goals we’re trying to achieve…It’s really important we’re keeping those goals front of mind, so we’re constantly sense checking the theory of change.” Initial decisions made by policymakers shape the pathway toward UHC.  If those decisions are based on the desire to raise revenue, for example through formal sector contributions to health insurance, they are unlikely to be responsive to the sexual and reproductive health needs of women and girls – and those initial decisions can inadvertently lock in certain priorities.  “Too often, we’re coming in at a later stage to reappraise those initial policy decisions,” said Brendan.

Poor women and girls rarely benefit from health insurance in sub-Saharan Africa.

In sub-Saharan Africa (SSA), countries are “turning to public contributory health insurance as a mechanism to remove financial barriers to accessing health care services,” explained Jacob Kuzungu, a Research Officer at KEMRI Wellcome Trust. Over the last 10 years, 38% of SSA countries have established national health insurance (NHI) schemes. In an analysis of 36 SSA countries, data shows that on average, only 8 in 100 people are covered by any health insurance, and only 4 of the 36 countries currently cover more than 20% of their population. Disparities exist across socioeconomic status, location, gender, and employment status – poor women and girls are amongst those least likely to be covered. Hence, SSA countries should reconsider voluntary contributory health insurance mechanisms, Kazungu argued. They should instead reorient health financing toward non-contributory tax-funded arrangements to increase coverage and reduce inequalities.

Indonesia has good health insurance coverage, but this hasn’t helped improve the uptake of FP.

In contrast to most of SSA, Indonesia’s national health insurance, JKN, covers 80% of the population. JKN began in 2014 with a comprehensive benefits package that includes FP. However, data shows that despite FP services offered, modern contraceptive prevalence rate has decreased since 2014, shared Prastuti Soewondo, a Special Advisor to Indonesia’s Minister of Health. Including FP in the benefit package did not solve the challenge of access to services. In Indonesia, injectable contraceptives are most used, often accessed through private midwives who are not contracted by JKN. The Government of Indonesia is committed to improving access to FP, incorporating more midwives into JKN, and clarifying the responsibilities of the national FP program (BKKBN) and JKN.

Translating health insurance cover into FP choice is complex and difficult.

“There are many challenges in terms of getting equitable coverage for national health insurance,” said Sophie Witter, Professor of International Health Financing and Health Systems at Queen Margaret University, Edinburgh. Only 45% of women are employed compared to 71% of men and 90% of employed women in SSA work in the informal sector, which poses huge challenges to countries where health care is based on formal employment status. Other barriers include age, education, religion, and refugee status. Even if someone is covered, can they access health services? The answer depends on many factors, but challenges in accessing benefits from formal insurance schemes include awareness of benefits, provider attitudes, stigma, safety, and practical issues like access to health insurance ID cards.

Financial protection is a key goal to UHC, every speaker emphasized. But a recent systematic review concluded that only 26 out of 46 studies of health insurance schemes showed there were improvements in financial protection for members. Financial commitment to health has been too limited to support equitable UHC in many settings. “When there is a mismatch between the promise and the reality, there is always a consequence to the user,” added Witter.

Community voices are needed to hold governments accountable, to ensure that national health insurance schemes benefit those most in need.

“One thing I haven’t heard yet is the role of communities and the end users of these services in holding governments accountable,” said Elisha Dunn-Georgiou, Vice President of Policy and Advocacy at PAI, in her reflection on the presentations. “Not in opposition to governments, but in partnership with them.” Insurance programs might have the potential to empower their members, but this can only work for women and girls if their voice is heard and their needs prioritized in the development of the schemes.

Better data, stronger evidence, and clearer messages are needed if health financing reforms are to benefit women and girls.

Nomi Rachael Fuchs-Montgomery, Deputy Director for Driving Impact at Scale at the Bill and Melinda Gates Foundation agreed that involving communities in decision-making processes, including in the development of insurance schemes, is an important piece of the puzzle. She added we must also push for better and more robust data in order to further understand FP integration and quality and equity issues, given the number of barriers women face. “When we decided to partner with ThinkWell, there wasn’t a collective effort to hone in on that evidence…. The information shared today is important to shedding light on providing access at scale,” said Fuchs-Montgomery.

“Repetition is very important. By the time members of parliament cannot hear the debate anymore, that’s probably when the general public is hearing the message for the first time,” said Caitlin Mazzilli, Senior Program Officer from the Bill & Melinda Gates Foundation in her closing remarks. It is important to repeat the message and continue educating others.

We need to work together to challenge the status quo and to find better solutions.

Several participants reiterated the need for the FP community and health financing specialists to work together to find solutions that will help women and girls access quality family planning services in the UHC era. We at ThinkWell could not agree more. We believe that health financing reform is a critical step on the road to UHC, and also for the sexual and reproductive health and rights that are an essential part of UHC. Improvements in the way that governments spend money to pay for services –making purchasing more strategic – is central to these reforms and can send strong signals to providers about the importance of offering high quality, rights-based family planning choices.  Purchasing reforms can also remove user fees for those most in need, and expand access by contracting private providers.

But if getting FP into nascent contributory health insurance schemes isn’t the best way to secure universal access to FP, then where does that leave us as we seek to use strategic purchasing to improve FP service delivery? And what is the right mix of purchasing approaches for FP services in countries with more mature NHI schemes like Indonesia?  Perhaps breaking the link between formal membership and benefits is an important step, and we can learn a lot from the UHC Law in the Philippines, which has made PhilHealth benefits a right for all.  What about other national schemes where benefits are universal for targeted population groups like pregnant women, or children under 5, but payments are linked to performance?  Schemes like Gratuité in Burkina Faso, or Linda Mama in Kenya hold important lessons.

One thing is for sure – to solve these puzzles we will need strong partnerships across different communities of practice, the openness to learn from each other, and the courage to examine evidence that challenges our own preconceptions.

The global family planning (FP) community gathered this February under the banner “UHC: not without FP” to demonstrate why integrating FP into universal health coverage (UHC) is essential for success. As passionate believers in the power of FP, we couldn’t agree more – but there is a trap here. Progress towards UHC is often wrapped up in rhetoric about “UHC schemes.” And many countries are choosing to rely on national health insurance (NHI) to deliver a defined package of benefits to contributors and pay providers based on outputs. Are NHI approaches best suited to reaching those most in need with quality FP services? Our webinar seeks to explore this important question.

We invite you to join our webinar on the latest research and best practices from a range of low- and middle-income countries actively undertaking purchasing reforms. This is the first webinar in the Counterpoint series, hosted by ThinkWell.


Joe Kutzin, Coordinator for Health Financing, World Health Organization

Joe Kutzin leads the WHO’s health financing team in Geneva. In that capacity, he works closely with WHO’s six Regional Offices, addressing a diverse set of critical topics including fiscal sustainability, public financial management, strategic purchasing, financing of public goods, expenditure tracking, assessing progress on health financing reforms, and, most recently, the health financing dimensions of the COVID-19 response.

He is a health economist with 35 years’ experience, working in Africa, Asia, the Caribbean, Europe, and the United States. Since joining WHO in 1994, he has served as WHO policy advisor to the Ministry of Health of Kyrgyzstan, and also as the European Region’s Lead Advisor on Health Financing. Prior to that he worked at the World Bank and a private health foundation in the United States. He was a contributor to the World Health Report 2010 on financing for universal coverage and has published numerous conceptual and empirical articles on health systems, health financing and Universal Health Coverage.

Jacob Kazungu, Research Officer, KEMRI Wellcome Trust

A health economist with a keen research interest in health financing, choice modelling, economic evaluation of interventions, analytical modelling for decision making, economics of sex work, equity and inequalities in health and health systems strengthening. Jacob is also a NEMA licensed Lead Expert for Environmental Impact Assessment and Environmental Audits (NEMA Reg No: 8431).


Prastuti Soewondo, Special Advisor to the Minister of Health, Ministry of Health Indonesia

Prastuti Soewondo currently serves as Special Advisor to the Minister of Health at the Ministry of Health in Indonesia. Prior to that, Prastuti joined ThinkWell. Dr Soewondo was also an academic at the School of Public Health Administration and Health Policy, University of Indonesia.


Sophie Witter, Professor of International Health Financing and Health Systems, Queen Margaret University of Edinburgh

Professor Sophie Witter (BA, MA, PhD) is a Professor of International Health Financing and Health Systems in the Institute for Global Health and Development. She is also a member of the Institute for Global Health and Development Research Centre. She is a health economist specializing in health financing policy and health systems research in low and middle income countries. She has 30 years experience in these areas, working first in development agencies and then in the universities of York, Aberdeen and QMU Edinburgh.


Brendan Hayes, Senior Health Specialist, Global Financing Facility, World Bank

Brendan Hayes is a sexual and reproductive health expert currently working as a Health Specialist with the World Bank and the Global Financing Facility secretariat. He has 10 years experience in Southern and East Africa working on health and development programs including 4 years in Malawi working on HIV prevention and family planning service delivery in the private sector.

Prior to joining the World Bank, he was a Channel Development Director working for Marie Stopes International with responsibility to design and implementation of private-sector RH service delivery through in-country support in Philippines, Pakistan, Vietnam, Kenya, Uganda, Ethiopia, Ghana, Senegal, Mali, Madagascar, Swaziland, Zambia, and Zimbabwe.

Originally from upstate-NY, Brendan has a BA from St. Lawrence University and a MSc from University College Dublin.

Elisha Dunn-Georgiou, Vice President of Policy and Advocacy, PAI

Elisha oversees the programmatic work of PAI, ensuring that the organization’s research and advocacy agendas are in alignment with PAI’s mission and strategic plan. Elisha has more than 15 years of experience in the fields of sexual and reproductive health and international development.

She holds a master’s degree in epidemiology and a JD from the State University of New York at Buffalo. Elisha is also a returned Peace Corps volunteer, having served in Morocco.

Nomi Fuchs-Montgomery, Deputy Director for Driving Impact at Scale, Bill and Melinda Gates Foundation

Nomi Rachel Fuchs-Montgomery, is a Deputy Director for Driving Impact at Scale, for the Family Planning strategy team at the Bill and Melinda Gates Foundation. In this capacity, she is responsible for leading the downstream initiatives of the family planning strategy, collaborating with country and regional offices, and fostering partnerships with a wide range of actors across the family planning and reproductive health ecosystem.

Nomi joined the Bill and Melinda Gates Foundation in January 2015, initially serving as the Deputy Director leading the Contraceptive Technology and Evidence and Innovation Initiatives, as well as providing oversight for the family planning team’s approach to adolescents and gender equitable programming. Prior to joining the Foundation, Nomi was the Director of Global Partnerships & US Country Director for Marie Stopes International-US (MSI-US), where she was responsible for the launch and development of MSI’s US office and growing global partnerships.  Nomi has over 24 years of professional experience in the field of reproductive health, family planning and HIV/AIDS. She has extensive experience collaborating with international bilateral donors, private foundations, UN agencies, leading NGOs, feminist and youth lead organizations, the World Bank and other finance partners.  Her first professional assignment was as a Peace Corps volunteer in south east Nigeria, where she worked on guinea worm eradication and developed a passion for public health.


Matt Boxshall, Program Director, ThinkWell

Matt Boxshall joined ThinkWell to drive forward work on strategic purchasing for primary health care. Building from frontline service delivery experience in Africa and Asia, Matt has become increasingly involved in policy and health financing, and is passionate about unlocking the potential of systems to deliver quality care to those most in need.  Matt is a director on the Strategic Purchasing for Family Planning project for ThinkWell.

Nirmala Ravishankar, Program Director, ThinkWell

Nirmala Ravishankar is a health systems specialist with over 15 years of experience in Africa, Asia, and Latin America. She has worked on a range of health financing and health systems strengthening projects, including leading a research initiative to measure development assistance for health at the Institute for Health Metrics and Evaluation; managing a technical assistance program at Abt Associates to assist country governments measure and analyze health spending; and coordinating a multi-partner initiative to link the delivery of primary care services through franchised private providers with government health insurance in Kenya.

Nirmala joined ThinkWell in 2018 to lead a project to improve financing for primary healthcare services.  She has a PhD in political science from Harvard University, but picked a career in global health over psephology.

Closing Remarks

Caitlin Mazzilli, Senior Program Officer, Bill & Melinda Gates Foundation

Caitlin Mazzilli is a senior program officer at the Bill & Melinda Gates Foundation in the Health Systems team, managing a portfolio of grants to advance strategic purchasing of health services and service delivery innovation. She works closely with the Maternal Newborn Child Health and Family Planning teams to support integration within primary health care delivery.

Note: This is an update of a post that was published on the 15th of May. This update reflects newly published guidance from WHO on the implementation of campaigns in the context of COVID-19.

Many immunization campaigns have been suspended to prevent increased COVID-19 transmission, but some campaigns will nevertheless need to go ahead, with additional precautionary measures in place to ensure the safety of health workers and the community.

With support from the Bill & Melinda Gates Foundation, ThinkWell has estimated the added cost per dose of several potential precautionary measures: personal protective equipment (PPE) for vaccination teams, additional infection prevention and control (IPC) measures at immunization sites, extra staff and supplies to ensure physical distancing and triaging at campaign sites, additional per diems due to potential changes in delivery strategies, and estimates of an increase of other operational cost components (such as additional social mobilization and training). The analysis uses data from 10 studies on the cost of conducting an immunization campaign to model each scenario at a low, medium and high intensity level, as well as the combined effect on the cost per dose.

The results of this analysis of the additional delivery cost of conducting campaigns during COVID-19 show that:

  • The cost per dose could increase by 5% when placing hand washing stations at campaign sites and 9-20% when adding PPE for health workers.
  • Adding crowd controllers to vaccination teams to manage physical distancing and screening at campaign sites could imply a 10-26% increase in the operational cost per dose.
  • Per diems associated with a longer campaign duration could result in a 8-32% increase.
  • An increase in other operational aspects of the campaign, such as social mobilization and transport, could increase the operational cost of a campaign by 10-40%.
  • All protective measures and operational changes combined could increase the operational cost of a campaign by 49% in the low scenario up to 154% in the high scenario.

This rapid analysis is meant to illustrate a range of potential cost implications to provide general guidance for the direction of policies and potential cost expectations that would require the mobilization of additional resources.

To read the full report, click here.

Follow-up analyses conducted by ThinkWell and the Harvard T.H. Chan School of Public Health will assess the cost implications for routine and routine outreach immunization service delivery.

“The coronavirus spreads like wildfire, and thanks to us, it’s spreading now to other regions [of Indonesia]. Social distancing acts like the fire extinguisher, but it must be readily implemented in affected areas. It is the responsibility of regional government to provide the fire extinguisher for places in need. Question is: is government financially ready to provide it?” asked Hasbullah Thabrany, Chief of Party for USAID Health Financing Activity (HFA) led by ThinkWell.

Indonesia is currently battling high numbers of confirmed COVID-19 cases. As of June 1, there are 26,940 confirmed cases, with 1,641 deaths. Numbers are expected to continue increasing. Worldwide, experts agree that social distancing could help to stem the tide, but there have been barriers to adoption of these strategies in Indonesia.

Major challenges in Indonesia, including mobilizing resources and communicating about the outbreak, are rooted in decentralization of the health system, and much of the execution of preparedness efforts is being done at the regional and local level. Messages delivered to local communities about the pandemic and effectiveness of social distancing are disorganized and unclear, posing risks to gaining public trust.

“To avoid the spread of wildfire, it is imperative that local government take measures needed to allocate fund. This needs advocacy especially, even at the district level, if needed – to educate and raise awareness of local leaders of the urgency of the matter, and to act quickly,” Dr. Thabrany added.

In every part of the world, this is a litmus test for health systems capacity. There is a lack of capacity to prevent and detect COVID-19 cases early enough for intervention in Indonesia, while providers are bearing the impact of supply-side limitations. It is an unmerciful exposure of long-standing neglect to the health systems backbone of the country.

ThinkWell is committed to providing support for reliable measures for health financing in relation to COVID-19, especially financing care for patients. USAID HFA, with ThinkWell, is seeking ways to illuminate the cost associated with of COVID-19, by looking at costs associated with the infection beyond clinical care. We also plan to collect additional data from National COVID-19 Task Force officials to provide COVID-19 case estimation and projections in country. The study aims to provide better evidence for claim reimbursement of COVID-19 cases, as well as provide input to the budget scheme related to the pandemic. The study is in partnership with the Center of Health Financing and Insurance of the MOH (CHFI/PPJK MOH GOI) and the National Institute for Health Research and Development (NIHRD MOH GOI).

Dr. Thabrany presented during a webinar in April 2020, a collaboration between the Indonesian Association of District Indonesian Association of District Health Office and USAID HFA. Speakers included Dr Edhie Rahmat, MSc, USAID Office for Health; Dr. Bayu Teja Mulyawan, Apt., M. Pharm, MM, The Head of the Bureau of Planning of the Ministry of Health; Purwanto, SE, MSc, Director, the Budget of the Human Development and and Culture, Ministry of Finance; Hasbullah Thabrany, MPH, DrPH, ThinkWell. Participants included directors of primary health care services and district health official staff all over the region.

Annette Ozaltin, ThinkWell

The Immunization Costing Action Network (ICAN) participated in a number of sessions during the 2019 iHEA World Congress in Basel, Switzerland. The ICAN, supported by the Bill & Melinda Gates Foundation, is working to increase the visibility, availability, understanding, and use of evidence on the cost of delivering vaccines.

ICAN’s main Congress session showcased the latest global and country evidence on the costs of delivering vaccines in low- and middle-income countries. The ICAN shared consolidated and standardized global evidence on immunization costs, in addition to detailed data and results from costing studies in Indonesia, Tanzania, and Vietnam. Presenters included Kelsey Vaughan, ThinkWell; Fatuma Manzi, Ifakara Health Institute, Tanzania; Amila Megraini, Universitas Indonesia; Hoang van Minh, Hanoi University of Public Health, Vietnam; Logan Brenzel, Bill & Melinda Gates Foundation. The session was moderated by Annette Ozaltin, ThinkWell.

Laura Boonstoppel and Kelsey Vaughan, ThinkWell

Lessons shared during the session included data challenges due to inconsistent reporting and different costing methodologies, making comparison or benchmarking of costs across contexts difficult. Additional lessons covered challenges in estimating the cost of different delivery strategies, and estimating the cost to reach the last mile. They also identified some gaps in knowledge and a future research agenda, focused on costs to: reach the last mile; reach specific target populations; reach populations over a lifecourse (i.e. beyond infant vaccination schedules); and achieve integration with other services (primary health care).

The other ICAN session presented lessons on developing an immunization cost data repository. This presentation was part of a broader session in collaboration with colleagues from the Global Health Cost Consortium, Avenir Health and the World Health Organization, focused on developing cost repositories for HIV/TB, immunization, malaria, and social and behavior change. Kelsey Vaughan, ThinkWell, presented the methods and lessons of developing the Immunization Delivery Cost Catalogue (IDCC).

The ICAN was also heavily involved in the preparations and delivery of the Immunization Economics pre-Congress sessions, presenting on methods and costing results, discussing the need for standardization of costing approaches, debating stakeholder engagement in generating and using data and evidence, and shaping an agenda for improving the availability of immunization costing data. The ICAN also displayed five posters presenting the latest global and country evidence. More information on ICAN, in addition to the latest global evidence (and country evidence coming soon!), i available on the Immunization Economics website.

Dr. Marife Yap

“PhilHealth offers neither a carrot nor stick approach to convince private midwives to provide family planning services,” shared Dr. Marife Yap, during a session at the 2019 iHEA World Congress in Basel, Switzerland. Dr. Yap discussed the experience in the Philippines to expand access to family planning (FP) services by encouraging private providers to expand their service offering, and explored the constraints private providers face, especially with respect to access FP commodities.

Dr. Yap’s presentation was part of the session “Strategic Purchasing of Sexual and Reproductive Health Services on the Path to Universal Health Coverage in Low and Middle-Income Countries.” The session showcased experiences and challenges associated with strategic purchasing of FP, and maternal, newborn and child health (MNCH) services in Indonesia, Kenya, and the Philippines, as part of ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) program.

Dr. Hasbullah Thabrany

Dr. Hasbullah Thabrany described the process of using Jaminan Kesehatan Nasional (JKN) – the single national health insurance scheme in Indonesia – to promote quality of maternity services through private midwives, who currently face significant barriers to participation in the scheme including an onerous contracting and claims reimbursement process.

In Kenya, Dr. Nirmala Ravishankar explained the fragmented purchasing landscape in the context of a newly-devolved system of government in the country, and how the signal from the Linda Mama free maternity scheme is diluted by purchasing practices at the sub-national level.

The audience engaged in discussion around the findings and work in each of the three countries. The issue of fragmentation in purchasing and its implications for individual purchasers drew comments from audience members, who identified this as a common problem across most low- and middle-income countries. A large delegation from Indonesia, which included representatives from the Ministry of Health, were keen to use this work as a starting point for exploring how Badan Penyelenggara Jaminan Sosial (BPJS-K), which administers JKN,  engages with a broad range of private providers.

ThinkWell will be hosting sessions at the 2019 iHEA World Congress in Basel, Switzerland, July 13-17, showcasing work from the Immunization Costing Action Network (ICAN) and Strategic Purchasing for Primary Health Care (SP4PHC) program.

Strategic Purchasing for Primary Health Care

Many low and middle-income countries are embracing national health insurance and other government financing schemes to strategically purchase priority health services as part of health financing reforms to achieve universal health coverage. The Strategic Purchasing for Primary health Care project funded by the Bill & Melinda Gates Foundation and implemented by ThinkWell is focused on improving how sexual and reproductive health services are positioned within these schemes to ensure improved access, equity, and quality. These services have historically been funded through vertical programs, but the momentum around strategic purchasing is calling these vertical approaches into question.  How reproductive health services are positioned within broader health financing schemes is critical to ensure that gains in health outcome made in the past decades are not lost and the needs of vulnerable populations are met.

The session “Strategic Purchasing of Sexual and Reproductive Health Services on the Path to Universal Health Coverage in Low and Middle-Income Countries” will present learnings and data from three project countries: Dr. Maria Eufemia C. Yap will share her reflections on the seismic health financing reforms that are unfolding in the Philippines and what that means for reproductive health; Dr. Joanne Ondera will explore how devolution has conditioned the implementation of financing schemes targeting reproductive health services and created opportunities for strategic purchasing reforms in Kenya; and Dr. Hasbullah Thabrany will discuss how the national health insurance program in Indonesia is designing strategic purchasing reforms to attract the right mix of providers to deliver priority reproductive health services.

The Immunization Costing Action Network

The ICAN, supported by the Bill & Melinda Gates Foundation, is working to increase the visibility, availability, understanding, and use of evidence on the cost of delivering vaccines. This is done globally through the project’s Immunization Delivery Cost Catalogue (IDCC) and locally through a network of research and policy partners in four countries – India, Indonesia, Tanzania, and Vietnam – that are facing the challenge of transitioning from donor aid. Together the countries are finding solutions to common problems in financing vaccine delivery and using cost evidence to inform resource mobilization efforts and routine planning and budgeting.

The session “Fighting Infectious Diseases through Immunization: The Latest Global and Country Evidence on the Costs of Delivering Vaccines in Low- and Middle-Income Countries” will present the latest global and country-specific evidence on the costs of delivering vaccines. The session will focus on delivery through a variety of strategies (facility, outreach, school, campaign) and to different target populations, including those that are hard to reach. The session will be moderated by Annette Ozaltin, ThinkWell. Panelists include Kelsey Vaughan, ThinkWell; Hoang Van Minh; Amila Megraini; and Fatuma Manzi.

The ICAN will also be presenting in two other iHEA sessions, as well as a pre-Congress event on immunization economics organized by the iHEA Immunization Economics Special Interest Group (SIG).

Session Information

Developing Cost Data Repositories: Lessons Learned from HIV/TB, Immunization, Malaria, and Social and Behavior Change

Monday, July 15, 2019, 08:30 – 10:00

Universität Basel – Kollegienhaus – Seminarraum 212

Fighting Infectious Disease through Immunization: The Latest Global and Country Evidence on the Costs of Delivery Vaccines in Low- and Middle-Income Countries

Monday, July 15, 13:30 – 15:00

Universität Basel – Kollegienhaus – Fakultätenzimmer 112

Producing Standardized Country-Level Immunization Delivery Unit Cost Estimates

Tuesday, July 16, 10:50 – 11:10

Universität Basel – Kollegienhaus – Hörsaal 115

Strategic Purchasing of Sexual and Reproductive Health Services on the Path to Universal Health Coverage in Low and Middle-Income Countries

Wednesday, July 17, 13:00 – 14:30

Universität Basel – Versalianum – Grosser Hörsaal EO.16

For more information about the 2019 iHEA World Congress, visit

The United States Agency for International Development (USAID) has awarded a $14.9 million contract to ThinkWell to implement “Sustainable Financing for a Healthy Indonesia,” a bold, innovative project in Indonesia focused on sustainable health financing and strategic health purchasing over five years. In keeping with ThinkWell’s mission, the goal is to ensure Indonesia’s health system is sustainable and accessible to all.

Our partnership includes Results for Development (R4D) a leader in strategic purchasing, and Indonesia’s premier institutions in health financing – the Center for Health Economics and Policy Studies (CHEPS), and Gadjah Mada University – Center for Health Policy and Management (UGM-CHPM).

The project will further USAID’s health systems strengthening agenda to support the Government of Indonesia (GOI) to sustain and increase efficiency in health financing to improve financial protection, equitable access to quality health services, and health outcomes in the priority areas of HIV, tuberculosis, and maternal and newborn health.

Through strengthening local capacity to generate evidence and engage in meaningful policy dialogue, we will support the GOI to build a robust policy process that effectively engages key stakeholders, routinely incorporates high-quality evidence, and delivers sound policies for sustainable universal health coverage.

Despite widespread use of private providers for the diagnosis and treatment of tuberculosis (TB), the quality of care in the private sector is hindering efforts to improve TB outcomes. TB remains the ninth leading cause of death worldwide, and efforts to drive improvements have been largely focused on the public sector. Across the top 30 high-burden countries (HBCs), the private sector plays a significant role in the diagnosis and treatment of patients with both drug-sensitive and drug-resistant TB. Yet quality of TB care provided in the private sector is inconsistent and inadequate, negatively influencing TB outcomes.

ThinkWell, with the support of the Bill & Melinda Gates Foundation, has released a report offering a global review of high-level programmatic challenges seen in private sector TB care and the ways in which financing mechanisms can be used to address these challenges, drawing from lessons learned from other health areas. By identifying gaps in the status quo and proposing a theory of change to systematically influence how TB care is delivered in the private sector, there is significant opportunity to harness the private sector for quality service delivery. Catalytic investment to support governments in using strategic purchasing mechanisms, coupled with deliberate investment to purchase high-quality TB services from targeted private providers in alignment with national quality and regulatory standards, will lead to improved TB outcomes.

To read our full report and recommendations, click here.

Have you ever wondered what it costs to deliver the HPV vaccine in schools in Indonesia? Are you looking for evidence on operational costs to inform your country’s immunization program? Have you been searching for the cost of mobile vaccine delivery in Uganda, Peru, or Bangladesh? Our new and improved set of resources has this information and more. Explore it all on our website, Here you’ll find:

  • A standardized and richly annotated Immunization Delivery Cost Catalogue (IDCC) of the data extracted. The IDCC (Excel workbook and web tool) includes 410 unit costs (i.e. cost per capita, dose, fully immunized child, full immunization of a vaccine, or person in the target population), all presented in 2016 US dollars for easy referencing and use.
  • A summary report of immunization delivery cost findings. The report describes the spread and scope of the evidence, methods, and resources, including a quality assessment of the resources captured in the systematic review.
  • A set of immunization delivery cost ranges for vaccine delivery through a variety of strategies and in a range of contexts. These estimates of cost per dose and cost per fully immunized child combine four or more comparable unit cost estimates into a single cost range with other descriptive statistics noted.
  • Companion interpretive products (e.g., detailed methodology note and user guides)

Across these resources, we’ve added new data, addressed feedback obtained from user research, and considered new approaches to analyzing the data. The changes are meant to better equip you—whether you’re a policymaker, researcher, or international partner—with evidence to guide country and global immunization and health system policy, planning, advocacy, etc.


In May 2018, ThinkWell released findings from a systematic review of the evidence base on immunization delivery costs (IDC) in low- and middle-income countries (LMICs). The review aimed to answer a question frequently asked by global and country immunization stakeholders: What are the unit costs of vaccine delivery across different LMICs and through a variety of delivery strategies?

The review and a subsequent refresh considered over 15,000 resources published between January 2005 and January 2018 on the topic. Ultimately, the review drew from 61 resources with IDC data on a variety of vaccines, delivery strategies, types of cost analysis, and settings.

Want to Learn More?

How-to guides and videos with instructions on using all tools and products are also available at

Immunization Costing Action Network (ICAN)

Led by ThinkWell and John Snow, Inc. (JSI), the Immunization Costing Action Network (ICAN) is a project focused on increasing the visibility, availability, understanding, and use of data on the cost of delivering vaccines. ICAN aims to build country capacity around generation and use of cost information to work towards sustainable and predictable financing for vaccine delivery.

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