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.

Summary

In the Democratic Republic of Congo (DRC), ThinkWell explored how the Bill & Melinda Gates Foundation could invest in improving the delivery of affordable family planning (FP) to vulnerable populations in Kinshasa. Through an assessment in 2018 and 2019, ThinkWell uncovered how the DRC’s ongoing strategic health purchasing reforms could be leveraged to improve access to FP services for women and girls in Kinshasa. Based on an extensive literature review and stakeholder interviews, we analyzed the FP financing landscape in DRC broadly and in the Kinshasa region specifically. Our final report recommends strategic purchasing arrangements for FP services that would be feasible in the short, medium, and long-term and presents a theory of change and a plan of action to help inform the foundation’s investment decisions.

Challenges

There are severe unaffordability and unavailability of FP services issues in Kinshasa, which poses a major barrier to the uptake and continuation of FP methods. Women mainly access family planning services in Kinshasa from private drug shops or private facilities, and since both public and private providers charge fees for FP services, poor women and girls face a significant financial barrier to access, especially for long acting reversible contraceptives (LARCs). In terms of policy, the DRC government recently launched its strategic purchasing strategy and is launching a performance-based financing (PBF) pilot in Kinshasa. Based on this, how can we leverage the current initiatives to develop a coherent approach to buying FP services in a way that strengthens women’s access to FP services?

Approach 

We anchored our assessment in examining how to strengthen the way that FP is positioned within government-owned strategic purchasing reform in Kinshasa. We strongly believe that partners should refrain from starting additional, parallel purchasing schemes and instead work to improve, strengthen, and harmonize ongoing strategic health purchasing reforms.

Results

Based on our report, the Bill & Melinda Gates Foundation is currently considering how to best implement our proposed solutions in Kinshasa.