The Immunization Costing Action Network (ICAN) was a research and learning network for increasing the visibility, availability, understanding and use of immunization delivery cost information. The ICAN worked with countries to build capacity around the generation of costing evidence and to improve the interpretation and translation of this data so that it is used in country decision-making processes and informs planning and budgeting. ICAN was supported by the Bill & Melinda Gates Foundation.
As more low- and middle-income countries transition to self-financed immunization programs, governments need accurate and reliable cost information to ensure they mobilize adequate resources to meet coverage goals, address challenges of health equity, effectively manage the introduction of new vaccines and the implementation of campaigns and achieve efficiencies. However, cost data is often of variable quality, hard to compare, and is difficult to access and use by policymakers, program planners, and other global and country-level stakeholders. The goal of ICAN was to help planners and decision-makers generate, access, understand, and use evidence on the cost of delivering vaccines.
Global research and analytics
ThinkWell completed a systematic review of over 17,000 articles and reports presenting immunization delivery cost data for a variety of vaccines, delivery strategies, types of cost analysis, and low-and middle-income country settings. The purpose of the review was to answer the question “What are the unit costs of vaccine delivery across different low-and middle-income countries and through a variety of delivery strategies?” To make the data accessible and easy to understand, ThinkWell developed the Immunization Delivery Cost Catalogue (IDCC) and methodology note, analytic report, and how-to user guides. ThinkWell also published the methods and findings in Vaccine: X.
Country research and evidence to policy
The ICAN was comprised of three-member countries—Indonesia, Tanzania, and Vietnam—with country teams that include health economist researchers and immunization managers and planners from Ministries of Health. The country teams have conducted costing studies that explored the cost of delivering vaccines through different delivery strategies to diverse geographies and to distinct target populations. ThinkWell and John Snow, Inc. (JSI) facilitated knowledge sharing around effective strategies for generation of cost evidence and its use in decision-making processes and in routine policy and planning. The full study reports for Indonesia, Tanzania, and Vietnam can be accessed here. A publication with the findings from the study in Vietnam can be accessed here.
ICAN identified 8 key factors that increase the likelihood that health policy makers will use evidence for policy making or planning and used a 6-step evidence to policy and practice (EPP) facilitated process in each country to increase the likelihood of generating policy and program-relevant cost evidence and improving its uptake and use. This work was published in Global Health: Science and Practice.
Standardizing campaign costing
Immunization campaigns are increasingly used to improve coverage and decrease morbidity and mortality from vaccine-preventable diseases. Underfunded campaigns can result in a low impact and thus are an inefficient use of resources. Accurate financial planning is required to ensure that campaigns achieve coverage targets, but evidence of what it costs to conduct campaigns is limited, somewhat outdated, and varies greatly. The extent to which cost variation is driven by differences in costing study methodologies or campaign operations is not clear. To address this issue, the ICAN developed methodological guidance to standardize campaign costing which was informed by learnings from three campaign costing studies and can be downloaded here. A policy brief with findings from the three campaign costing studies and a discussion of the effect of integration on delivery cost can be viewed here. The full reports for the studies in India, Nigeria, and Sierra Leone can be viewed here and a publication of the findings from India can be viewed here.
A three-minute overview of ICAN
Evidence on immunization delivery costs is essential for countries to better advocate, plan, budget and make programmatic decisions to improve the sustainability and performance of national immunization programs. However, delivery cost data is fragmented and of variable quality, making it difficult for policymakers, planners, and other stakeholders to understand and use.
ThinkWell completed a systematic review of over 17,000 articles and reports presenting immunization delivery cost data for a variety of vaccines, delivery strategies, types of cost analysis, and low-and middle-income country settings. The purpose of the review was to answer the question: “What are the unit costs of vaccine delivery across different low- and middle-income countries and through a variety of delivery strategies?” The reviewed covered the period from 2005 to 2019. To make the data accessible and easy to understand and compare, ThinkWell extracted unit costs from the articles and catalogued them in the Immunization Delivery Cost Catalogue (IDCC). To help interpret the data, ThinkWell developed a methodology note, analytic report, and how-to user guides. ThinkWell also published the methods and findings in Vaccine: X.
From the systematic review, over 650 immunization delivery unit costs from 68 resources and covering more than 30 countries have been incorporated into the Immunization Delivery Cost Catalogue (IDCC), making it the most comprehensive, current, and standardized global evidence on immunization delivery costs. Analysis of the cost catalogue data led to the development of immunization delivery cost ranges for specific vaccines, by different delivery strategies, and for different country contexts. Based on the IDCC data, a Harvard-led study modeled estimates of the delivery cost per dose for routine childhood immunization services which may be used when more accurate local data are unavailable. To facilitate the publication of immunization costing evidence that is more easily interpreted and compared, we also leveraged learnings from the systematic review to define a standard of practice for writing up an immunization costing study to increase the quality of reporting and the comparability of results. Our recommendations along with an easy to follow checklist were published in Vaccine: X.
Country Research & Evidence to Policy
ICAN’s three-member countries—Indonesia, Tanzania, and Vietnam—generated cost evidence to address challenges at the top of their immunization financing agendas to ensure program and policy relevance. Each country team included health economist researchers, immunization managers, and planners from Ministries of Health. Technical facilitators from ThinkWell and JSI helped guide the country teams in generating, interpreting, and translating cost evidence to ensure its use in country decision-making processes, fundraising and advocacy efforts, and routine planning and budgeting.
What are the costs of delivering vaccines using different delivery strategies in high coverage areas in Indonesia?
The study used ingredients-based costing to retrospectively estimate the full financial immunization delivery costs incurred by the government at the district/city, sub-district, and village levels in 2016. School delivery was found to be least costly, followed by outreach, primarily due to high volumes. Facility-based delivery was most costly due to low volumes. There was a strong relationship between cost and volume across districts and cities: as the number of doses delivered increased, the cost per dose decreased. Study findings have been used to inform the National Medium-Term Development Plan, and the Health Operational Cost Guidelines for subnational annual budgeting and planning. Results were presented at the Joint Appraisal and Total System Effectiveness workshops in 2019. This study was implemented by the Universitas Indonesia and the National Institute for Health Research and Development (NIHRD), with oversight and technical guidance from ThinkWell. The full study report can be viewed here.
What does it cost to immunize children up to 18 months of age using the current mix of delivery strategies in rural and urban areas in Tanzania?
The study used ingredients-based costing from a government perspective to retrospectively estimate the full, economic and financial immunization-related delivery costs incurred at the facility, district, region and national levels during the period July 2016 to June 2017. The cost per dose was found to be lowest at rural facilities with nomads in their catchment population, followed by urban facilities, and then rural facilities without nomads. Outreach delivery was more than three times as expensive as facility-based delivery, but the magnitude of the difference varied immensely by geography. Vaccine delivery costs represented 16% of the total immunization program cost. Study findings have been used by the Tanzania Ministry of Health (MoHCDGEC) to update national guidelines to support Comprehensive Council Health Plan (CCHP) budgeting for operational activities, and to inform the next five-year National Health Plan and immunization comprehensive multi-year plan (cMYP). This study was implemented by the Ifakara Health Institute, with oversight and technical guidance from ThinkWell. The full study report can be viewed here.
What are the costs associated with introducing Tetanus-Diphtheria vaccine and ceasing delivery of Tetanus-Typhoid vaccine in Vietnam?
This study estimated the costs of introducing tetanus-diphtheria (Td) vaccination of 7-year-old children into the routine immunization program, to replace the current delivery of tetanus vaccine (TT) for women of childbearing age and Td campaigns for outbreak control. School-based delivery was found to be cheapest and outreach and campaign delivery to be most expensive. Study findings helped the Vietnam Ministry of Health understand the budget impact of introducing Td. When compared with the cost of the current TT program from 2018-2025, the findings showed that a cost saving of US$6.9 million could be realized if introducing Td in schools, compared with a cost saving of US$4.2 million for facility-based introduction. An additional cost of US$2.3 million would be incurred over that period if a combination of facility and outreach delivery would be used. The Ministry of Health subsequently piloted Td delivery through school- and facility-based strategies, leveraging the results of the costing study. This study was implemented by the Hanoi University of Public Health, with oversight and technical guidance from ThinkWell. The full study report can be viewed here, and a publication of the findings can be viewed here.
Evidence to policy and practice
From conducting semi-structured interviews with key informants and a literature review on other initiatives and research to summarize the existing evidence around factors that influence the uptake of costing evidence, ICAN identified 8 key factors that increase the likelihood that health policy makers will use evidence for policy making or planning. Based on the identification of these critical success factors, the team used a 6-step evidence to policy and practice (EPP) facilitated process in each country to increase the likelihood of generating policy and program-relevant cost evidence and improving its uptake and use. Click here to read.
Standardizing Campaign Costing
Campaigns which are not adequately funded can result in lower coverage and are therefore an inefficient use of resources. Accurate financial planning is essential for ensuring that campaigns achieve their coverage targets, but the evidence available on what it costs to conduct campaigns is limited, outdated, and varies greatly. The extent to which cost variation is driven by differences in costing study methodologies or campaign operations is not clear.
ICAN has developed standardized methodological guidance for estimating the cost of immunization campaigns, accompanied by practical study tips, frequently asked questions and notes on the key differences from a routine costing study. We also developed data collection tools for facility, district, state and national level along with an accompanying user manual on how to use these tools. Additionally, we provided practical examples for how to calculate unit costs, annualizing capital costs and use the calibration method in R with a guide to the code. You can download R using this link. The methodology addresses all the steps of designing a campaign costing study, considerations for co-delivery campaigns and guidance for data analysis. The guidance and tools were informed by and refined during three immunization campaign costing studies in various settings in 2018-2021. We released a policy brief with findings from the three campaign costing studies and a discussion of the effect of integration on delivery cost.
Campaign costing studies
What are the costs of delivering Measles-Rubella (MR) vaccines through campaigns in India?
This study estimated the cost of delivering the MR catch-up campaign in four states in India (Assam, Gujarat, Himachal Pradesh and Uttar Pradesh). From 2017 to 2020, the India undertook a large-scale vaccination campaign during which more than 324 million children aged between 9 months and 15 years were vaccinated with a dose of MR vaccine. The financial delivery cost per dose ranged from US$0.16 to US$0.34, including costs incurred by the government, WHO and UNICEF. The economic cost per dose incurred by the government in Uttar Pradesh state was estimated at US$0.87. The key financial delivery cost drivers were incentives and travel allowances for record keeping, social mobilization and advocacy, and service delivery. The estimated financial delivery cost per dose was higher than the government pre-fixed budget per child for the campaign, though the study also found underutilization of the MR budget in two states, and use of other sources of funding for the campaign. This indicates a potential need for more flexibility around the use of campaign budgets in Indian states. The cost estimates generated in this study can help inform planning, budgeting, and cost projections for future immunization campaigns in India and other countries. A publication of the findings from this study can be viewed here and the full report can be found here.
How much did the integrated measles-rubella catch-up campaign in Sierra Leone cost?
This study estimated the full financial and economic cost of the integrated MR catch-up campaign held in Sierra Leone in June 2019. Nationwide, MR was co-delivered with oral polio vaccines (OPV), while vitamin A supplements and albendazole de-worming tablets were also delivered in half of the country. The financial cost of US$0.39 per vaccine dose delivered and an economic cost of US$0.84 per vaccine dose delivered were estimated. The study found financial cost efficiencies in areas that co-delivered both vaccines and nutrition interventions compared to areas that only delivered vaccines, though the opportunity costs of labor in areas which co-delivered the nutritional interventions were greater, indicating an increased burden on the health system. This study is the first to analyze the cost of an integrated campaign and the cost evidence generated can be used for future planning and budgeting of campaigns in Sierra Leone and similar settings. The full report of this study can be viewed here.
What are the costs of delivering yellow fever and meningitis A through campaigns in Nigeria?
This study estimated the full financial and economic cost of yellow fever campaigns in three states in Nigeria (Anambra, Katsina and Rivers), including one state where meningitis A (MenA) vaccines were delivered alongside yellow fever (Anambra). The campaigns were held between September 2019 and October 2020 and data was collected from federal, state, local government authority and facility levels from October 2020 until May 2021. This study aimed to identify the cost profiles and cost drivers of the campaigns in the three states as well as the cost of integrating MenA delivery with yellow fever immunization. The full report of the study can be viewed here.
The COVID-19 pandemic has caused widespread disruption to health systems and affected the provision of immunization services. Many immunization campaigns planned for 2020 were suspended, and routine immunization coverage rates declined. It was imperative that immunization services were resumed with additional measures in place to ensure the safety of health workers and communities, though the cost of making these adjustments was unclear. In addition, COVID-19 vaccine delivery poses unprecedented challenges in terms of delivery volume, reaching new target populations, and diversity of delivery strategies. Meanwhile, what it costs to deliver these vaccines is highly uncertain.
ThinkWell has rapidly responded with analyses estimating the additional operational cost of implementing campaigns and conducting routine outreach services during the pandemic while incorporating a range of protective measures, and collaborated with Harvard T.H. Chan School of Public Health on an analysis for routine fixed site delivery. Based on data from published immunization costing studies, ThinkWell estimated the additional cost while implementing precautionary measures various scenarios, such as providing personal protective equipment, personnel and equipment for physical distancing, strategy changes and other operational cost increases. ThinkWell conducted a further analysis estimating the potential additional operational cost of a house-to-house oral polio vaccine (OPV) supplemental immunization activity (SIA) held during the COVID-19 pandemic. ThinkWell also contributed to a global-level modelling of COVID-19 vaccine delivery costs in COVAX countries.
ThinkWell’s analysis showed that the operational cost per dose of campaigns conducted in the context of COVID-19 could increase by between 55% and 144%. For routine outreach, the additional measures could increase the cost per dose by 23-51% in high volume facilities and 99-251% in low volume facilities. The cost per dose for routine fixed-site delivery could increase by 31-72% at low volume facilities and 49-74% at high volume facilities. The publication of these findings in Vaccine can be found here. The full reports of the campaign and outreach analyses can be found here and here respectively. The analysis estimating the impact on costs for house-to-house OPV SIAs found that the operational cost of campaigns could increase by 26-171% depending on the intensity and type of measures implemented. The full report can be found here. The report on the cost of delivering COVID-19 vaccine through COVAX in 92 advanced market commitment countries can be found here.