The challenge 

Low- and middle-income countries 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 which must all be managed at rapid speed if effective coverage is to be achieved.

Countries are considering many different delivery strategies designed to reach different priority target populations, which they have had to adapt to the uncertain influx of supply. These range from delivery at hospitals to reaching certain populations at their workplace, to mass delivery through large ad-hoc campaign sites to small, fixed sites in the community. In order to plan and budget for the roll-out in the most efficient manner possible, a better understanding of the costs and operational considerations associated with each of these delivery strategies 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 roll-out of COVID-19 vaccines.

In each country, bottom-up ingredients-based costing studies are being 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 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 roll-out and its challenges.

ThinkWell is working in partnership with local research institutions to strengthen capacity in each country. These are the Institute of Health Economics (Bangladesh), Université Félix Houphouët-Boigny (Côte d’Ivoire), the University of Kinshasa (DRC), Eduardo Mondlane University (Mozambique), Ateneo de Manila University School of Medicine and Public Health (the Philippines), Ndejje University (Uganda), and the Hanoi School of Public Health (Vietnam).

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 roll-out 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.

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.

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)

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