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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 and the study report will be published soon.

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.