The challenge

Delivering COVID-19 vaccines has posed unprecedented challenges in terms of delivery volume, reaching new target populations, diversity of delivery strategies, and sometimes complex product profiles—elements which must all be managed rapidly in order to achieve effective coverage.

Countries have had to adapt delivery strategies due to the gaps in vaccine supply and reach different priority target populations. In order to plan and budget for future phases of vaccine delivery for COVID-19 or a potential future pandemic vaccine, an accurate understanding of the costs and operational considerations associated with the vaccination program so far is urgently needed.

The approach

ThinkWell is conducting costing studies of COVID-19 vaccine delivery in Bangladesh, Côte d’Ivoire, DRC, Mozambique, the Philippines, Uganda, and Vietnam to generate economic evidence to the support the sustainable rollout of COVID-19 vaccines and help governments plan for future vaccine delivery.

In each country, bottom-up ingredients-based costing studies are being conducted in collaboration with local research institutions 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 are also mapping out the service delivery process and funding flows, and capturing the source and use of different types of paid and volunteer health workers mobilized to deliver COVID-19 vaccines. Semi-structured interviews are being conducted with stakeholders to assess the rollout and its challenges.

ThinkWell has developed a general research protocol for the country studies to describe the generalized approach, scope, methods, and expected outputs. While recognizing that the diverse range of vaccine rollout modalities will require tailored research approaches in each of the countries, this general research protocol is aimed at ensuring comparability across countries and facilitating cross-country learnings. Preliminary results were presented at the IHEA 2023 Immunization Economics Pre-Congress in July 2023, and you can see below for more information and findings from each country when available.

Côte d’Ivoire

In Côte d’Ivoire, Genesis Analytics and ThinkWell implemented the costing study, with a team from Université Felix Houphouet Boigny collecting data on the cost of delivering COVID-19 vaccines from March to May 2022. The study found a relatively low financial cost for delivering vaccines in 2022 (US$0.67 per dose delivered) which likely reflected a lack of funding rather than low financial requirements to support vaccination. The higher economic cost (US$3.16 per dose delivered) highlights the important role of both existing paid staff as well as volunteers. Read the full study report here and see the poster presented at the IHEA 2023 Immunization Economics Pre-Congress.

Vietnam

ThinkWell worked with the Hanoi University of Public Health in Vietnam to estimate the cost of delivering COVID-19 vaccines in 2021. The financial cost was found to be low at US$0.59 per dose delivered, though this masked shortages in staffing and other resources that the vaccination program had to work around. Limited investments to expand capacity for the rollout meant that a significant burden was placed on the existing health system resources. Read the full study report here and see the poster presented at the IHEA 2023 Immunization Economics Pre-Congress.

Overview

ThinkWell is launching a new project to generate high-quality economic evidence on the delivery of immunization and other essential health services to zero-dose children and missed communities. This project will bring together global and country level institutions to close these evidence gaps, and strengthen capacity at local research institutes to produce actionable economic evidence to inform policy making and program management.

Background

The global community has set ambitious goals to look beyond national immunization coverage outcomes and prioritize communities that have been left behind from the advances made over the last decades. Reaching so-called zero-dose children, those that have missed out on all routine vaccines¹, is a central pillar of both WHO’s Immunization Agenda 2030 and Gavi’s 5.0 strategy, however, economic evidence to support decisionmakers in this is lacking.

Estimating the costs and benefits of reaching zero-dose children will require a new way of thinking, including novel research design, methods, and metrics. Economic evidence for immunization programs is usually focused on estimating the average costs and benefits of reaching a broad population group, but reaching zero-dose children likely comes with increasing marginal costs.

Implementation

ThinkWell will work with research institutions in three countries to generate critical economic evidence on reaching zero-dose children. In each of the countries, these local research institutes will facilitate the development of the scope of the study and work with the ministry of health to frame the research question. The researchers will lead the study design, implementation, and analysis, with coaching and mentoring support from ThinkWell, from global level methodological experts, and from each other.

¹As measured by the proxy indicator: number of children that lack the first dose of diphtheria-tetanus-pertussis containing vaccine (DTP1)

Summary

With support from the Bill & Melinda Gates Foundation, ThinkWell’s Bangladesh team implements the Enhancing Essential Services Provision for Universal Health Coverage (EESPUHC), in the context of Covid-19 activity, which supports the Government of Bangladesh (GoB), including Directorate General of Health Services, Directorate General of Family Planning, and the Health Economics Unit (HEU) at the Ministry of Health and Family Welfare (MOHFW), to prioritize and execute on planning and investments for regularizing and improving access to essential health services. This is based on deeper understanding and knowledge of essential health services trends, gaps, and resulting Covid-19 impact.

Breaking New Ground

This activity is the one of the first few evidence-generating activities in Bangladesh to explore the essential service delivery context during the Covid-19 pandemic from both the supply and demand side. In addition, it is the first activity to assess the health financing bottlenecks that the health system faced during the coronavirus health emergency. During the lockdowns of the pandemic’s initial months, anecdotal data suggested that essential health services were disrupted, however no reliable data is available. Following an initial decline in service delivery, the GoB is attempting to recover and to return to the service delivery state of 2019. To support this attempt, we’re generating evidence on service status and factors that need to be addressed to recover from the initial decline.

Challenges

Bangladesh has a robust primary health care (PHC) system, with a high density of community clinics and associated community health workers to provide essential health services to the population. The combination of limited documented evidence on Covid-19’s impact on essential health service provision, low service coverage, and inequitable health financing in Bangladesh created an uncertain state in health service uptake. Moreover, Bangladesh has one of the highest levels of out-of-pocket (OOP) spending in health in the world.

Formal documentation of the changes in use of essential services and the associated potential impact is not yet available, although various analyses might be ongoing. Preliminary estimates by different experts suggest decreases of 30-40% for some maternal and child health services and up to 60% for tuberculosis services (no published analyses are available yet). There is also evidence from previous global health emergencies of significant drops in essential service utilization and increase in maternal and newborn deaths. Immediate action is needed to avert this.

The MOHFW’s Health Economics Unit developed the “Health Care Financing Strategy 2012-2032” to address high out-of-pocket and catastrophic expenditures through social protection, contracting, and provider payment options. Irrespective of formally moving forward with the health financing strategy, there is limited availability for the health insurance system and contracting out essential services delivery through the private/NGO sector. We will explore these challenges to better understand their root causes. We also will try to define the way forward on health financing solutions for essential services and the country’s Covid-19 response.

Approach

We will conduct a rapid situational assessment of essential services provision (with a primary healthcare focus) and utilization. Our insights and actional recommendations will help ensure a comprehensive overview of PHC service delivery challenges and priority reform areas. We’ll also undertake qualitative assessments from the perspective of both service providers (supply-side) and service users (demand-side) to close key evidence gaps on essential health services trends, gaps, and Covid-19 impact.

Efforts under this area of work include:

• Qualitative field assessment with primary data collection in eight districts: a combination of key informant interviews, focus group discussions, and consultative dialogues
• Mapping of partner support on Covid-19 response and primary healthcare/essential services provision with a focus on partners and interventions directly involved in Covid-19 response and supporting essential service provision
• Desk review and quantitative analyses on development partners who support the GoB to undertake quantitative assessments of service provision and utilization using routine data sources
• Develop solutions, jointly with MOHFW, to mitigate the identified challenges in essential services provision service delivery

To explore healthcare provider and service user perspectives on healthcare financing bottlenecks in the context of Covid-19, we will review health financing bottlenecks, including insurance, contracting, and provider payment mechanisms. We’ll then provide actionable recommendations focused on the delivery of essential services and the Covid-19 response. Our research will contribute to better understanding of health financing bottlenecks and provider’s perceptions of promising strategies, like service contracting.

Efforts under this area of work include:

• Rapid review of health financing bottlenecks and mapping of existing health financing approaches
• Review options for contracting with private sector (not-for-profit and for-profit providers) for essential services and accordingly design/propose alternate options, if needed
• Develop solutions, with MOHFW, to mitigate the identified health financing challenges at primary health care or related to essential services provision

Results

1. Bangladesh’s health system rapidly addressed and mostly recovered from the initial shock of the COVID-19 pandemic in its provision of essential health services.
   • Bangladesh’s health system rapidly addressed and mostly recovered from the initial shock of COVID-19 pandemic in provision of essential health services
   • Service utilization has been increasing in recent months across services, though utilization is still below 2019 levels for most services
   • Further stakeholder consultations should be focused in order to understand the key drivers of this recovery to inform future resilience efforts
2. During the COVID-19 pandemic, the government of Bangladesh proactively mitigated workforce shortages by recruiting pre-qualified doctors and nurses
   • Mechanisms of maintaining a pre-qualified pool of doctors and nurses should be explored to enable rapid deployment during any such future shocks
   • The inclusion of other cadres (e.g., lab staff and support workers) should be considered as currently these are not included in the pre-qualified pool of health workers
3. Budget reallocations were extended to facilities to support COVID-related activities, though administrative and technical barriers meant these were largely not accessed
   • Capacity development of the health managers on administrative, public financial management, and leadership skills may help to improve utilization of budget reallocations
4. Care seeking from community clinics increased at the community level as many people could not go to distant upazila or district facilities
   • Strengthening community clinics and their commodity supplies will serve some basic primary health care needs during emergency periods

Summary

In May 2020, the Asian Development Bank (ADB) launched the activity “Support to Address Outbreak of COVID-19 and Strengthen Preparedness for Communicable Diseases in South Asia.” With coronavirus cases rapidly climbing throughout the region, the outbreak is undermining health systems and disrupting all aspects of society. To help reduce the pandemic’s negative impacts on health and human capital, ADB launched the project to provide technical assistance in Bangladesh, Bhutan, India, Maldives, Nepal, and Sri Lanka as the countries fight and attempt to recover from the pandemic.

ThinkWell supports this project’s work in Bangladesh. With our health expertise, we help develop health policy actions in response to the Covid-19 pandemic in Bangladesh. Specifically, we support the Government of Bangladesh to improve and develop relevant policy actions with a focus on the response to the Covid-19 crises. We also support the ADB to prepare relevant policy actions for the ADB’s social protection program.

Challenges

The proposed ABD loan advances policy-based lending (PBL) for social protection due to Covid-19 pandemic. This result-based loan mechanism is new for both Bangladesh’s Ministry of Finance (MOF) and Ministry of Health and Family Welfare (MOHFW). Through this project, we are identifying relevant health policy actions in consultation with MOHFW for the loan document.

Approach

ADB is processing a budget loan for the Government of Bangladesh as part of Covid-19 response with a primary focus on social protection programs in Bangladesh. The loan will cover the issues of (i) response to the Covid-19 crises, (ii) improvement in social protection programs and schemes (along with health-related social protections), and (iii) a financial inclusion strategy. ThinkWell’s Bangladesh team will work on the health policy actions that are related to the Covid-19 response and social protection.

ThinkWell’s team collaborates with the ABD team as well as with the MOF and the MOHFW of Bangladesh to identify and formulate reasonable health policy action for the ADB’s proposed loan document. The health policy actions need to be realistic, impactful, and achievable as well as related to social protection programs.

Breaking New Ground

This activity is one of the first of its kind to include health policy actions for loan disbursement in Bangladesh. The Ministry of Health and Family Welfare is new to developing policy actions for loan documents.

In Bangladesh, ThinkWell is delivering locally-generated evidence and contextual expertise to transform the Surjer Hashi Network (SHN) – one of the largest private healthcare network in Bangladesh – into a self-sustainable, pro-poor social enterprise.

The guiding vision for the SHN is to become “a sustainable network of clinics, offering high quality, customer-oriented, and affordable healthcare services for the poor.” With funding from USAID, and with a network of local and international partners, ThinkWell is supporting the development a business strategy, revenue generation plan, and an innovative service delivery model to maximize both client impact and cost recovery.

Breaking New Ground

We lead a social enterprise incubator for the SHN, helping to cultivate, nurture, and prototype ideas, strategies and approaches with the potential to increase the sustainability and impact of the network.

Challenges

The long-term sustainability and growth of SHN depends on its ability to provide reliable and affordable high-quality services. Building on this base, it will be necessary for SHN to attract outside investments (from both private capital and the Government of Bangladesh), to develop strategic partnerships, to establish referral linkages to higher level health services, and to diversify its income streams.

One of the key challenges facing SHN is striking a balance between increasing the rate of cost recovery (to ensure the long-term sustainability of the network) and ensuring that services remain accessible to clients, regardless of their ability to pay. ThinkWell has provided cross-spectrum support to identify operational costs savings, as well as identify opportunities for increased revenue generation.

Approach

Using innovative, context-specific strategies to test, evaluate, and iterate system improvements, we are strengthening the social enterprise’s capacity to respond to marginalized people’s needs. All efforts to improve services within the network are developed through a rigorous prototyping process in a range of business-critical areas including: service package design, equitable pricing, customer satisfaction and business growth.

To support SHN on the road to sustainability, we help through activities such as creating different revenue diversification strategies and implementation plans as well as establishing partnerships with government and private organizations.

We bring evidence-based insights to SHN’s leadership to help inform critical business decisions, including, for example, modelling the financial and health impacts of extending clinic opening hours or introducing specialist doctors within higher volume facilities. Our practical, embedded approach also includes supporting the SHN to develop work plans, financial projects and service development budgets for the future to help support sustainable growth.

Through these and many other areas of support, ThinkWell uses innovation, evidence, and a close partnership with front-line stakeholders to help deliver sustainable, smart growth for the Sujer Hashi Network and impact for the clients who rely on its affordable services.

In 2012, ThinkWell was contracted by the World Bank to lead Bangladesh’s Health Nutrition and Population Sector Development Program (HPNSDP) Annual Program Reviews (APRs), which monitor progress in the health sector program in Bangladesh. ThinkWell conducted a full analysis of 32 operational plans across the health sector in Bangladesh, wrote an executive summary and recommendations report, and generated a presentation summarizing overall findings.

This review assessed progress in seven thematic areas: procurement; urban health; disease control; maternal, newborn, and child health (MNCH); information, education, and communication/behavior change communication (IEC/BCC), nutrition, and public financial management. The results of the analysis was presented to more than 300 stakeholders, including ministers, secretaries, and other senior government officials from across the Bangladeshi public sector.

Based on the findings and recommendations of the review, the Ministry of Health and Social Welfare made strategic modifications to accelerate improvements across each of the 32 operational plans that guide the Ministry’s work.

ThinkWell provided technical expertise, analysis, and managerial and logistical support to a Joint Donor Technical Assistance Fund (JDTAF) in Bangladesh. JDTAF participants hailed from a wide range of bilateral and multilateral donor agencies.

The fund financed technical assistance in support of the Ministry of Health and Family Welfare’s (MOHFW’s) 32 operational plans. Reporting to the Senior Secretary for Health, ThinkWell staff identified and documented technical assistance needs across the health sector, developed scopes of work for the assistance, worked closely with the MOHFW Planning Wing line directors to prepare for presentations to the multi-donor Technical Assistance Committee, and supported Committee meetings.

ThinkWell provided technical assistance to the Third Primary Education Development Programme (PEDP3) of Bangladesh by examining the use of sector budget support disbursements. This was done through reviewing and verifying the backup for audit reports. We also conducted a risk-monitoring analysis for a basket fund for PEDP3. The fund involved the Ministry of Primary and Mass Education (MOPME) and other ministries working in the education sector. ThinkWell additionally supported strengthening the public financial management around vulnerabilities to ultimately ensure a strong use of the funds.

ThinkWell made recommendations based on the analysis and provided technical assistance and capacity development to implement those recommendations. As a result, the government has strengthened its fiduciary management of the United Kingdom’s Department for International Development (DFID) funds for education.