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The challenge

Delivering COVID-19 vaccines posed unprecedented challenges for low- and middle-income countries in terms of scale and complexity—from managing the piece-meal vaccine supply for a small priority group to rolling out the largest mass campaign in history to reach the general population as quickly as possible. Countries had to continuously adapt to the rapidly changing context, and efficiently manage extremely scarce resources for the vaccination program, while the costs of delivering COVID-19 vaccines through different modalities were unknown.

The approach

ThinkWell is conducting costing studies of COVID-19 vaccine delivery in Bangladesh, Côte d’Ivoire, the Democratic Republic of the Congo (DRC), Mozambique, the Philippines, Uganda, and Vietnam to generate economic evidence to the support governments to plan for future delivery of COVID-19 vaccines and other immunization services.

We developed a standardized approach to conduct bottom-up costing studies in each of the seven countries. In collaboration with ministries of health and local research institutions, we are estimating the cost of delivering COVID-19 vaccines at various points in time, through various delivery strategies, and at varying levels of delivery volume, including costs incurred at all levels of the health system. Our teams have also mapped out the service delivery process and funding flows, and conducted an assessment of operational and financial challenges encountered by stakeholders at all levels.  

In addition to individual country analyses, our standardized approach allows us to analyze findings across countries, and develop recommendations for global and country stakeholders to inform planning and financing of future vaccine roll-outs, particularly in the context of a global pandemic.

Cross-country analysis

Preliminary results were presented at the International Health Economics Association (IHEA) 2023 Immunization Economics Pre-Congress in July 2023, and final results will be published following the publication of all individual country studies.

Bangladesh

In Bangladesh, ThinkWell and the Institute for Health Economics (IHE) worked closely with the Expanded Program on Immunization (EPI) to estimate the cost of delivering and receiving COVID-19 vaccines for fixed and temporary site delivery modalities between February 2021 and November 2022. Bangladesh managed to achieve high coverage rapidly at a much lower cost per dose than other countries, thanks to the large number of doses that vaccination sites managed to deliver daily, and the trust in and robustness of the EPI program’s infrastructure.

The financial cost varied greatly across strategies—from US$0.29 at Ministry of Health hospitals to $0.44 at outreach EPI centers. We also found that beneficiaries spent an average of $1.63 to receive one dose of COVID-19 at urban fixed sites. Assumptions and findings were validated through a series of workshops at the local and national level, and the results were disseminated with the Ministry of Health and partners at the national event in Dhaka. Read the full study report here.

Côte d’Ivoire

In Côte d’Ivoire, Genesis Analytics and ThinkWell implemented a costing study, with a team from Université Felix Houphouet Boigny, to collect 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 ($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.

Democratic Republic of the Congo

In collaboration with the national immunization program, ThinkWell and the Kinshasa School of Public Health estimated the cost of delivering COVID-19 vaccines in the Democratic Republic of the Congo (DRC) through routine and campaign delivery between April and June 2022. The rollout in the DRC was characterized by very high vaccine hesitancy, inadequate cold chain equipment and transport, low motivation among health workers due to lack of payments, and an insufficient number of vaccination sites. This meant that by the time of data collection, only 4% of the population had received at least one dose of the vaccine. Despite the extreme lack of resources, the financial cost per dose delivered was high (US$3.12 for routine and $1.91 for campaigns) due to the very low volume delivered. Findings from this study were shared with the Ministry of Health and partners in Kinshasa. Read the full study report here.

Mozambique

In partnership with the immunization program at the Ministry of Health, ThinkWell worked with the University Eduardo Mondlane (UEM) to estimate the cost of delivering COVID-19 vaccines in Mozambique during the start of the rollout in March and April 2021, and a later high-volume phase of December 2021 to February 2022. We found that the cost per dose decreased dramatically as delivery volume ramped up, from an economic cost of US$3.56 per dose to $0.85 per dose. Despite the lack of additional resources—reflected in a financial cost per dose dipping as low as $0.43 during the high-volume period—Mozambique achieved high coverage thanks to political prioritization and the commitment of existing health workers. However, as no additional health workers were hired for COVID-19 vaccination, this likely impacted the provision of other health services. Read the full study report here.

Philippines

ThinkWell and the Ateneo School of Medicine and Public Health conducted a costing study on the delivery of COVID-19 vaccines at public and private sites during a mass vaccination campaign in November and December 2021 and period of routine style delivery from May to July 2022. The financial delivery cost varied across the different types of delivery sites from US$0.90-$1.79 per dose delivered during the campaign and $2.06-$3.53 during the later routine-style period. This is higher than what was found in other countries, primarily due to additional hiring of health workers at a level not observed elsewhere. Read the full study report here.

Uganda

ThinkWell and Ndejje University are working directly and in close partnership with Kampala Capital City Authority (KCCA) to estimate the cost of delivering COVID-19 vaccines in the urban capital in 2021. The study examines the initial vaccination rollout period between March and June 2021 when priority populations were targeted, and the highervolume period between July and December 2021 when the target population was extended to the general population. Through an extensive capacity-strengthening approach, KCCA has been directly engaged in supporting tool development, data collection, analysis, and continuous validation. A dissemination meeting was held at the end of January 2024 with key stakeholders. Read the full study report here.

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.

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.

For more information on our zero-dose costing work, visit our page on the Immunization Economics Community of Practice website here.


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

Reconciling devolution with health financing and public financial management: Challenges and policy options for the health sector

May 2024

In most countries, reforms to strengthen health financing arrangements and streamline public financial management (PFM) processes to accelerate progress toward universal health coverage (UHC) are happening alongside or against the backdrop of devolution. While a lot has been written about devolution in the health sector in low- and middle-income countries, how devolution interacts with health financing and PFM processes in the health sector has not been explored rigorously.

ThinkWell and the World Health Organization (WHO) launched a learning collaboration in 2019 seeking to fill in this gap; the collaboration yielded case studies on seven Asian and African countries and two related synthesis reports. This journal article published in May 2024 in BMJ Global Health draws on this body of work to highlight key issues at the nexus of devolution, health financing, and PFM; discusses challenges posed by the current state of play; and suggests policy options that decision-makers can consider as they design UHC-oriented reforms.

Reconciling devolution with health financing and public financial management: Challenges and policy options for the health sector

May 2024

In most countries, reforms to strengthen health financing arrangements and streamline public financial management (PFM) processes to accelerate progress toward universal health coverage (UHC) are happening alongside or against the backdrop of devolution. While a lot has been written about devolution in the health sector in low- and middle-income countries, how devolution interacts with health financing and PFM processes in the health sector has not been explored rigorously.

ThinkWell and the World Health Organization (WHO) launched a learning collaboration in 2019 seeking to fill in this gap; the collaboration yielded case studies on seven Asian and African countries and two related synthesis reports. This journal article published in May 2024 in BMJ Global Health draws on this body of work to highlight key issues at the nexus of devolution, health financing, and PFM; discusses challenges posed by the current state of play; and suggests policy options that decision-makers can consider as they design UHC-oriented reforms.

Reconciling devolution with health financing and public financial management: Challenges and policy options for the health sector

May 2024

In most countries, reforms to strengthen health financing arrangements and streamline public financial management (PFM) processes to accelerate progress toward universal health coverage (UHC) are happening alongside or against the backdrop of devolution. While a lot has been written about devolution in the health sector in low- and middle-income countries, how devolution interacts with health financing and PFM processes in the health sector has not been explored rigorously.

ThinkWell and the World Health Organization (WHO) launched a learning collaboration in 2019 seeking to fill in this gap; the collaboration yielded case studies on seven Asian and African countries and two related synthesis reports. This journal article published in May 2024 in BMJ Global Health draws on this body of work to highlight key issues at the nexus of devolution, health financing, and PFM; discusses challenges posed by the current state of play; and suggests policy options that decision-makers can consider as they design UHC-oriented reforms.

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