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.


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.

Project Summary

Global cervical cancer elimination is achievable by 2030 if sufficient resources can be mobilized, and effectively and equitably used to accelerate implementation and uptake of national programs. The Union for International Cancer Control (UICC) engaged ThinkWell to conduct an assessment and stakeholder interviews to examine the status of health financing for cervical cancer elimination in four project countries: Guatemala, Philippines, Burkina Faso, and Côte d’Ivoire. This work was done within the context of the Scale-Up Cervical Cancer Elimination with Secondary Prevention Strategy (SUCCESS) project, funded by Unitaid, led by Expertise France and implemented together with UICC and Jhpiego.

ThinkWell brings knowledge to the CCE advocacy community on the health financing ecosystem for each of the project countries and how it applies to cervical cancer, including comprehensive and realistic perspectives on what it will take to advocate for sustainable financing approaches for CCE. The profiles outline policy actions for advocates and stakeholders to utilize in addressing the need for CCE financing.


Country Context

Why does financing for cervical cancer elimination matter?

Cervical cancer is a leading diagnosis among women in each country profiled. For example, cervical cancer is the second leading cancer diagnosis in Burkina Faso and takes the lives of over 2,000 Burkinabe women each year, but fewer than 1 in 10 Burkinabe women have been screened for cervical cancer, and the HPV vaccine is not currently included in the national immunization program (WHO 2021). Financing cervical cancer services is a vital step to ending these preventable deaths.

Taking Actionable Steps

By reviewing the current health system structures of each country, ThinkWell found that there is ample opportunity to take health financing-related actions towards the elimination of cervical cancer. As shown in the figure below, these actions are part of a continuum that spans the macro and micro contexts of any given country. Additionally, each country assessment includes policy action suggestions tailored to each country’s context.

ThinkWell provides technical assistance to the Ministry of Health in Zambia on performance management, health financing, and governance as part of the USAID Family Health and Nutrition project. The FHN project is implemented by a consortium of partners led by Jhpiego to improve reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH&N) services by addressing the quality of clinical care, health systems, and community participation. ThinkWell leads the health systems strengthening work of the project with a team of nine experts who provide direct technical assistance at the national, provincial, and district levels, focusing on Eastern, Luapula, Muchinga, and Southern provinces. Working with MOH counterparts as part of the annual planning and budgeting process, ThinkWell strives to improve the quality of available data, strengthen analysis, and improve the selection of high-impact interventions that will reduce maternal and neonatal mortality.


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.


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.


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)