Health system cost of delivering routine vaccination in low- and lower-middle income countries: what is needed over the next decade?

Evaluation of vaccine storage and distribution practices in rural healthcare facilities in Kenya

BACKGROUND

Vaccines require cold chain storage conditions, and good distribution practices throughout the supply chain to maintain their quality and potency. However, in the last mile of the vaccines supply chain, these requirements may not be guaranteed resulting in reduced effectiveness which could lead to an upsurge in vaccine preventable morbidity and mortality. The aim of this research was to evaluate vaccine storage and distribution practices in the last mile of vaccine supply chain in Turkana County.

METHODS

A descriptive cross-sectional study was conducted from January 2022 to February 2022 across seven sub-counties in Turkana County, Kenya, to assess vaccine storage and distribution practices. The study sample size was 128 county health professionals across 4 hospitals, 9 health centers, and 115 dispensaries. The respondents were selected using simple random sampling within the facilities strata. Data were collected using a structured questionnaire, adapted, and adopted from a standardized WHO questionnaire on effective vaccines management and administered to one healthcare personnel working in the immunization supply chain per facility. Data were analyzed using excel and presented as percentages in table forms.

RESULTS

A total of 122 health care workers participated in the study. Most respondents (89%, n = 109) had utilized a vaccine forecasting sheet, but only 81% did have an established maximum-minimum level inventory control system. Many of the respondents had sufficient knowledge of ice pack conditioning although 72% had adequate vaccine carriers and ice packs. Only 67% of respondents had a complete set of twice-daily manual temperature records at the facility. Most refrigerators complied with the WHO specifications but only 80% of them had functional fridge-tags. The number of facilities that had a routine maintenance plan was below average while only 65% had an adequate contingency plan.

CONCLUSION

Rural health facilities have suboptimal supply of vaccine carriers and icepacks for effective storage and distribution of vaccines. In addition, some vaccine fridges lack functional fridge-tags for proper temperature monitoring. Routine maintenance and contingency plans remain a challenge to ensure optimal service delivery.

The costs of introducing a vaccine in sub-Saharan Africa: a systematic review of the literature

Purpose

This study provides a systematic literature review and categorization of the costs reported in the literature for the introduction of new vaccines, focusing on sub-Saharan Africa within LMICs, where vaccines are highly needed, financial resources are scarce and data are lacking and scattered.

Design/methodology/approach

A systematic literature search of PubMed and Web of Science databases was conducted according to the PRISMA requirements. Searches also included the relevant grey literature. In total, 39 studies were selected and nine cost categories were investigated to build a comprehensive framework.

Findings

The paper considers nine cost categories that cover the whole life of the vaccine, from its initial study to its full implementation, including for each of them the relevant subcategories. The systematic review, besides providing specific quantitative data and allowing to assess their variability within each category, points out that delivery, program preparation, administration and procurement costs are the most frequently estimated categories, while the cost of the good sold, costs borne by households and costs associated to AEFI are usually overlooked. Data reported on R&D costs and investment in the production plant differ significantly among the selected contributions.

Originality/value

The literature contributions on cost estimation tend to focus on a precise vaccine, a specific geographic area, or to adopt a narrow approach that captures only a subset of the costs. This article presents a rich and inclusive set of the economic quantitative data on immunization costs in limited-resource countries.

Resource allocation for different types of vaccines against COVID-19: Tradeoffs and synergies between efficacy and reach

Objective

Vaccine shortage and supply-chain challenges have caused limited access by many resource-limited countries during the COVID-19 pandemic. One of the primary decisions for a vaccine-ordering decision-maker is how to allocate the limited resources between different types of vaccines effectively. We studied the tradeoff between efficacy and reach of the two vaccine types that become available at different times.

Methods

We extended a Susceptible-Infected-Recovered-Deceased (SIR-D) model with vaccination, ran extensive simulations with different settings, and compared the level of infection attack rate (IAR) under different reach ratios between two vaccine types under different resource allocation decisions.

Results

We found that when there were limited resources, allocating resources to a vaccine with high efficacy that became available earlier than a vaccine with lower efficacy did not always lead to a lower IAR, particularly if the former could vaccinate less than 42.5% of the population (with the selected study parameters) who could have received the latter. Sensitivity analyses showed that this result stayed robust under different study parameters.

Conclusions

Our results showed that a vaccine with lower resource requirements (wider reach) can significantly contribute to reducing IAR, even if it becomes available later in the pandemic, compared to a higher efficacy vaccine that becomes available earlier but requires more resources. Limited resource in vaccine distribution is significant challenge in many parts of the world that needs to be addressed to improve the global access to life-saving vaccines. Understanding the tradeoffs between efficacy and reach is critical for resource allocation decisions between different vaccine types for improving health outcomes.

Cost-effectiveness and public health impact of RTS,S/AS01 E malaria vaccine in Malawi, using a Markov static model

Background: The RTS,S/AS01 _E malaria vaccine is being assessed in Malawi, Ghana and Kenya as part of a large-scale pilot implementation programme. Even if impactful, its incorporation into immunisation programmes will depend on demonstrating cost-effectiveness. We analysed the cost-effectiveness and public health impact of the RTS,S/AS01 _E malaria vaccine use in Malawi.

Methods: We calculated the Incremental Cost Effectiveness Ratio (ICER) per disability-adjusted life year (DALY) averted by vaccination and compared it to Malawi’s mean per capita Gross Domestic Product. We used a previously validated Markov model, which simulated malaria progression in a 2017 Malawian birth cohort for 15 years. We used a 46% vaccine efficacy, 75% vaccine coverage, USD5 estimated cost per vaccine dose, published local treatment costs for clinical malaria and Malawi specific malaria indicators for interventions such as bed net and antimalarial use. We took a healthcare provider, household and societal perspective. Costs were discounted at 3% per year, no discounting was applied to DALYs. For public health impact, we calculated the DALYs, and malaria events averted.

Results: The ICER/DALY averted was USD115 and USD109 for the health system perspective and societal perspective respectively, lower than GDP per capita of USD398.6 for Malawi. Sensitivity analyses exploring the impact of variation in vaccine costs, vaccine coverage rate and coverage of four doses showed vaccine implementation would be cost-effective across a wide range of different outcomes. RTS,S/AS01 was predicted to avert a median of 93,940 (range 20,490–126,540) clinical cases and 394 (127–708) deaths for the three-dose schedule, or 116,480 (31,450–160,410) clinical cases and 484 (189–859) deaths for the four-dose schedule, per 100 000 fully vaccinated children.

Conclusions: We predict the introduction of the RTS,S/AS01 vaccine in the Malawian expanded programme of immunisation (EPI) likely to be highly cost effective.

Costs of Immunization Programs for 10 Vaccines in 94 Low- and Middle-Income Countries From 2011 to 2030

OBJECTIVES

Understanding the level of investment needed for the 2021-2030 decade is important as the global community faces the next strategic period for vaccines and immunization programs. To assist with this goal, we estimated the aggregate costs of immunization programs for ten vaccines in 94 low- and middle-income countries from 2011 to 2030.

METHOD

We calculated vaccine, immunization delivery and stockpile costs for 94 low- and middle-income countries leveraging the latest available data sources. We conducted scenario analyses to vary assumptions about the relationship between delivery cost and coverage as well as vaccine prices for fully self-financing countries.

RESULTS

The total aggregate cost of immunization programs in 94 countries for 10 vaccines from 2011 to 2030 is $70.8 billion (confidence interval: $56.6-$93.3) under the base case scenario and $84.1 billion ($72.8-$102.7) under an incremental delivery cost scenario, with an increasing trend over two decades. The relative proportion of vaccine and delivery costs for pneumococcal conjugate, human papillomavirus, and rotavirus vaccines increase as more countries introduce these vaccines. Nine countries in accelerated transition phase bear the highest burden of the costs in the next decade, and uncertainty with vaccine prices for the 17 fully self-financing countries could lead to total costs that are 1.3-13.1 times higher than the base case scenario.

CONCLUSION

Resource mobilization efforts at the global and country levels will be needed to reach the level of investment needed for the coming decade. Global-level initiatives and targeted strategies for transitioning countries will help ensure the sustainability of immunization programs.

Covering the last mile for vaccination: Feasibility and acceptability of traditional birth attendant-based referral system in hard-to-reach areas in rural Pakistan

Background

Pakistan has a decent network of community-based workers including lady health workers (LHWs) and vaccinators. However, a major section of the population is not covered by LHWs/vaccinators, labeled here as hard-to-reach (HTR) areas, where immunization coverage is also considerably low. This study explored the feasibility of engagement of traditional birth attendants (TBAs) to improve EPI vaccination coverage in HTR areas in rural Sindh, Pakistan.

Methods

This implementation research was conducted in two sub-districts of Sukkur (a district in Sindh Province). In an HTR selected intervention arm, TBAs were trained for vaccination and monetary incentives were provided to counsel and refer mothers for vaccination. While LHWs covered areas in the adjacent sub-district were provided with refresher training for vaccination only without any monetary incentive, and were considered as control arm. Considering the inherent differences in intervention and comparison group (HTR intervention area being worse regarding infrastructure and access), between groups and within group change in knowledge of TBA/LHWs and vaccination coverage was assessed before and after the intervention. Furthermore, focus group discussions were conducted with vaccinators, TBAs and LHWs and in-depth interviews with supervisors of vaccinators.

Results

TBAs and LHWs' vaccine related knowledge increased significantly after training (pretest vs post test score: 10.5 to 15.4). The BCG coverage improved 74.1% (percentage change) in TBA arm. While completion of vaccination (ie, Penta-3 coverage) increased by 147% from baseline following the intervention. The TBAs, LHWs, vaccinators and their supervisors all welcomed the initiative and considered it as a feasible option.

Conclusions

Involvement of TBAs' to form a referral system has potential to improve vaccine coverage and completion in HTR areas in Pakistan. The system is acceptable to the population and implementation is feasible due to availability of TBAs. However, in order to sustain the initiative minimal incentive need to be provided to TBAs to improve the vaccination coverage. Compared to establishing the infrastructure in HTR the intervention seems less costly however, it requires formal cost-effective or cost-benefit analysis.

Cost-effectiveness and public health impact of RTS,S/AS01E malaria vaccine in Malawi, using a Markov static model

Background: The RTS,S/AS01E malaria vaccine is being assessed in Malawi, Ghana and Kenya as part of a large-scale pilot implementation programme. Even if impactful, its incorporation into immunisation programmes will depend on demonstrating cost-effectiveness. We analysed the cost-effectiveness and public health impact of the RTS,S/AS01E malaria vaccine use in Malawi. Methods: We calculated the Incremental Cost Effectiveness Ratio (ICER) per disability-adjusted life year (DALY) averted by vaccination and compared it to Malawi’s mean per capita Gross Domestic Product. We used a previously validated Markov model, which simulated malaria progression in a 2017 Malawian birth cohort for 15 years. We used a 46% vaccine efficacy, 75% vaccine coverage, USD5 estimated cost per vaccine dose, published local treatment costs for clinical malaria and Malawi specific malaria indicators for interventions such as bed net and antimalarial use. We took a healthcare provider, household and societal perspective. Costs were discounted at 3% per year, no discounting was applied to DALYs. For public health impact, we calculated the DALYs, and malaria events averted. Results: The ICER/DALY averted was USD115 and USD109 for the health system perspective and societal perspective respectively, lower than GDP per capita of USD398.6 for Malawi. Sensitivity analyses exploring the impact of variation in vaccine costs, vaccine coverage rate and coverage of four doses showed vaccine implementation would be cost-effective across a wide range of different outcomes. RTS,S/AS01 was predicted to avert a median of 93,940 (range 20,490–126,540) clinical cases and 394 (127–708) deaths for the three-dose schedule, or 116,480 (31,450–160,410) clinical cases and 484 (189–859) deaths for the four-dose schedule, per 100 000 fully vaccinated children. Conclusions: We predict the introduction of the RTS,S/AS01 vaccine in the Malawian expanded programme of immunisation (EPI) likely to be highly cost effective.

A, R. K. Influence of unmanned aerial vehicle in medical product transport

Purpose

The purpose of this paper is to discuss the special applications of unmanned aerial vehicles (UAVs) for the transport of medical goods.

Design/methodology/approach

Experimental work has been carried out to predict the performance characteristics of UAVs.

Findings

The results have been obtained to predict the range and endurance of UAVs, which can be optimized based on the payload and source of power.

Originality/value

Real-time applications. As the medical products are necessary in the real time life saving events.

Strengthening Care Delivery in Primary Care Facilities: Perspectives of Facility Managers on the Immunization Program in Kenya

BACKGROUND

Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as 'street-level bureaucrats,' their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery.

METHODS

We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision.

RESULTS

The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness.

CONCLUSION

Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.

Challenges for nationwide vaccine delivery in African countries

Vaccines are very effective in providing individual and community (herd) immunity against a range of diseases. In addition to protection against a range of diseases, vaccines also have social and economic benefits. However, for vaccines to be effective, routine immunization programmes must be undertaken regularly to ensure individual and community protection. Nonetheless, in many countries in Africa, vaccination coverage is low because governments struggle to deliver vaccines to the most remote areas, thus contributing to constant outbreaks of various vaccine-preventable diseases. African governments fail to deliver vaccines to a significant percentage of the target population due to many issues in key areas such as policy setting, programme management and financing, supply chain, global vaccine market, research and development of vaccines. This review gives an overview of the causes of these issues and what is currently being done to address them. This review will discuss the role of philanthropic organisations such as the Bill and Melinda Gates Foundation and global partnerships such as the global alliance for vaccines and immunizations in the development, purchase and delivery of vaccines.

Cost-effectiveness analysis of introducing universal childhood rotavirus vaccination in Bangladesh

Diarrhea is one of the world's leading killers of children, and globally, rotavirus is the most common cause of severe diarrhea among under 5 children. In Bangladesh, rotavirus kills nearly 6,000 under 5 children in each year. To reduce the burden of childhood rotavirus diseases, universal rotavirus vaccination is recommended by World Health Organization. The objective of this study is to assess the cost-effectiveness of introducing universal childhood rotavirus vaccination with the newly developed ROTAVAC vaccine in national Expanded Programme of Immunization in Bangladesh. We developed a decision model to examine the potential impact of vaccination in Bangladesh and to examine the effect if the vaccination is applied in the nationwide immunization program schedule. Introduction of childhood universal rotavirus vaccination in Bangladesh scenario appears as highly cost-effective and would offer substantial future benefits for the young population if vaccinated today. The cost per DALY averted of introducing the rotavirus vaccine compared with status quo is approximately US$ 740.27 and US$ 728.67 per DALY averted from the health system and societal perspective respectively which is "very cost-effective" using GDP threshold level according to World Health Organization definition. The results of this analysis seek to contribute to an evidence-based recommendation about the introduction of universal rotavirus vaccination in national Expanded Programme of Immunization (EPI) in Bangladesh.

Aiming at the Global Elimination of Viral Hepatitis: Challenges Along the Care Continuum

A recent international workshop, organized by the authors, analyzed the obstacles facing the ambitious goal of eliminating viral hepatitis globally. We identified several policy areas critical to reaching elimination targets. These include providing hepatitis B birth-dose vaccination to all infants within 24 hours of birth, preventing the transmission of blood-borne viruses through the expansion of national hemovigilance schemes, implementing the lessons learned from the HIV epidemic regarding safe medical practices to eliminate iatrogenic infection, adopting point-of-care testing to improve coverage of diagnosis, and providing free or affordable hepatitis C treatment to all. We introduce Egypt as a case study for rapid testing and treatment scale-up: this country offers valuable insights to policy makers internationally, not only regarding how hepatitis C interventions can be expeditiously scaled-up, but also as a guide for how to tackle the problems encountered with such ambitious testing and treatment programs.

Succeeding in New Vaccine Introduction: Lessons Learned From the Introduction of Inactivated Poliovirus Vaccine in Cameroon, Kenya, and Nigeria

Introducing a new vaccine is a large-scale endeavor that can face many challenges, resulting in introduction delays and inefficiencies. The development of national task teams and tools, such as prelaunch trackers, for the introduction of new vaccines (hereafter, "new vaccine introductions" [NVIs]) can help countries implement robust project management systems, front-load critical preparatory activities, and ensure continuous communication around vaccine supply and financing. In addition, implementing postlaunch assessments to take rapid corrective action accelerates the uptake of the new vaccines. NVIs can provide an opportunity to strengthen routine immunization, through strengthening program management systems or by reinforcing local immunization managers' abilities, among others. This article highlights key lessons learned during the introduction of inactivated poliovirus vaccine in 3 countries that would make future NVIs more successful. The article concludes by considering how the Immunization Systems Management Group of the Global Polio Eradication Initiative has been useful to the NVI process and how such global structures could be further enhanced.

The economic and operational value of using drones to transport vaccines

BACKGROUND

Immunization programs in low and middle income countries (LMICs) face numerous challenges in getting life-saving vaccines to the people who need them. As unmanned aerial vehicle (UAV) technology has progressed in recent years, potential use cases for UAVs have proliferated due to their ability to traverse difficult terrains, reduce labor, and replace fleets of vehicles that require costly maintenance.

METHODS

Using a HERMES-generated simulation model, we performed sensitivity analyses to assess the impact of using an unmanned aerial system (UAS) for routine vaccine distribution under a range of circumstances reflecting variations in geography, population, road conditions, and vaccine schedules. We also identified the UAV payload and UAS costs necessary for a UAS to be favorable over a traditional multi-tiered land transport system (TMLTS).

RESULTS

Implementing the UAS in the baseline scenario improved vaccine availability (96% versus 94%) and produced logistics cost savings of $0.08 per dose administered as compared to the TMLTS. The UAS maintained cost savings in all sensitivity analyses, ranging from $0.05 to $0.21 per dose administered. The minimum UAV payloads necessary to achieve cost savings over the TMLTS, for the various vaccine schedules and UAS costs and lifetimes tested, were substantially smaller (up to 0.40L) than the currently assumed UAV payload of 1.5L. Similarly, the maximum UAS costs that could achieve savings over the TMLTS were greater than the currently assumed costs under realistic flight conditions.

CONCLUSION

Implementing a UAS could increase vaccine availability and decrease costs in a wide range of settings and circumstances if the drones are used frequently enough to overcome the capital costs of installing and maintaining the system. Our computational model showed that major drivers of costs savings from using UAS are road speed of traditional land vehicles, the number of people needing to be vaccinated, and the distance that needs to be traveled.

The composition of demand for newly launched vaccines: results from the pneumococcal and rotavirus vaccine introductions in Ethiopia and Malawi

Understanding post-launch demand for new vaccines can help countries maximize the benefits of immunization programmes. In particular, low- and middle-income countries (LMICs) should ensure adequate resource planning with regards to stock consumption and service delivery for new vaccines, whereas global suppliers must produce enough vaccines to meet demand. If a country underestimates the number of children seeking vaccination, a stock-out of commodities will create missed opportunities for saving lives. We describe the post-launch demand for the first dose of pneumococcal conjugate vaccine (PCV1) in Ethiopia and Malawi and the first dose of rotavirus vaccine (Rota1) in Malawi, with focus on the new birth cohort and the ‘backlog cohort’, comprised of older children who are still eligible for vaccination at the time of launch. PCV1 and Rota1 uptake were compared with the demand for the first dose of pentavalent vaccine (Penta1), a routine immunization that targets the same age group and immunization schedule. In the first year, the total demand for PCV1 was 37% greater than that of Penta1 in Ethiopia and 59% greater in Malawi. In the first 6 months, the demand of Rota1 was only 5.9% greater than Penta1 demand in Malawi. Over the first three post-introduction months, 70.7% of PCV1 demand in Ethiopia and 71.5% of demand in Malawi came from children in the backlog cohort, whereas only 28.0% of Rota1 demand in Malawi was from the backlog cohort. The composition of demand was impacted by time elapsed since vaccine introduction and age restrictions. Evidence suggests that countries’ plans should account for the impact of backlog demand, especially in the first 3 months post-introduction. LMICs should request for higher stock volumes when compared with routine needs, plan social mobilization activities to reach the backlog cohort and allocate human resources and cold chain capacity to accommodate high demand following vaccine introduction.

Costs of vaccine programs across 94 low- and middle-income countries

While new mechanisms such as advance market commitments and co-financing policies of the GAVI Alliance are allowing low- and middle-income countries to gain access to vaccines faster than ever, understanding the full scope of vaccine program costs is essential to ensure adequate resource mobilization. This costing analysis examines the vaccine costs, supply chain costs, and service delivery costs of immunization programs for routine immunization and for supplemental immunization activities (SIAs) for vaccines related to 18 antigens in 94 countries across the decade, 2011-2020. Vaccine costs were calculated using GAVI price forecasts for GAVI-eligible countries, and assumptions from the PAHO Revolving Fund and UNICEF for middle-income countries not supported by the GAVI Alliance. Vaccine introductions and coverage levels were projected primarily based on GAVI's Adjusted Demand Forecast. Supply chain costs including costs of transportation, storage, and labor were estimated by developing a mechanistic model using data generated by the HERMES discrete event simulation models. Service delivery costs were abstracted from comprehensive multi-year plans for the majority of GAVI-eligible countries and regression analysis was conducted to extrapolate costs to additional countries. The analysis shows that the delivery of the full vaccination program across 94 countries would cost a total of $62 billion (95% uncertainty range: $43-$87 billion) over the decade, including $51 billion ($34-$73 billion) for routine immunization and $11 billion ($7-$17 billion) for SIAs. More than half of these costs stem from service delivery at $34 billion ($21-$51 billion)-with an additional $24 billion ($13-$41 billion) in vaccine costs and $4 billion ($3-$5 billion) in supply chain costs. The findings present the global costs to attain the goals envisioned during the Decade of Vaccines to prevent millions of deaths by 2020 through more equitable access to existing vaccines for people in all communities. By projecting the full costs of immunization programs, our findings may aid to garner greater country and donor commitments toward adequate resource mobilization and efficient allocation. As service delivery costs have increasingly become the main driver of vaccination program costs, it is essential to pay additional consideration to health systems strengthening.

Microneedle patches for vaccination in developing countries

Millions of people die of infectious diseases each year, mostly in developing countries, which could largely be prevented by the use of vaccines. While immunization rates have risen since the introduction of the Expanded Program on Immunization (EPI), there remain major challenges to more effective vaccination in developing countries. As a possible solution, microneedle patches containing an array of micron-sized needles on an adhesive backing have been developed to be used for vaccine delivery to the skin. These microneedle patches can be easily and painlessly applied by pressing against the skin and, in some designs, do not leave behind sharps waste. The patches are single-dose, do not require reconstitution, are easy to administer, have reduced size to simplify storage, transportation and waste disposal, and offer the possibility of improved vaccine immunogenicity, dose sparing and thermostability. This review summarizes vaccination challenges in developing countries and discusses advantages that microneedle patches offer for vaccination to address these challenges. We conclude that microneedle patches offer a powerful new technology that can enable more effective vaccination in developing countries.

Costing the supply chain for delivery of ACT and RDTs in the public sector in Benin and Kenya

Background

Studies have shown that supply chain costs are a significant proportion of total programme costs. Nevertheless, the costs of delivering specific products are poorly understood and ballpark estimates are often used to inadequately plan for the budgetary implications of supply chain expenses. The purpose of this research was to estimate the country level costs of the public sector supply chain for artemisinin-based combination therapy (ACT) and rapid diagnostic tests (RDTs) from the central to the peripheral levels in Benin and Kenya.

Methods

A micro-costing approach was used and primary data on the various cost components of the supply chain was collected at the central, intermediate, and facility levels between September and November 2013. Information sources included central warehouse databases, health facility records, transport schedules, and expenditure reports. Data from document reviews and semi-structured interviews were used to identify cost inputs and estimate actual costs. Sampling was purposive to isolate key variables of interest. Survey guides were developed and administered electronically. Data were extracted into Microsoft Excel®, and the supply chain cost per unit of ACT and RDT distributed by function and level of system was calculated.

Results

In Benin, supply chain costs added USD 0.2011 to the initial acquisition cost of ACT and USD 0.3375 to RDTs (normalized to USD 1). In Kenya, they added USD 0.2443 to the acquisition cost of ACT and USD 0.1895 to RDTs (normalized to USD 1). Total supply chain costs accounted for more than 30% of the initial acquisition cost of the products in some cases and these costs were highly sensitive to product volumes. The major cost drivers were found to be labour, transport, and utilities with health facilities carrying the majority of the cost per unit of product.

Conclusions

Accurate cost estimates are needed to ensure adequate resources are available for supply chain activities. Product volumes should be considered when costing supply chain functions rather than dollar value. Further work is needed to develop extrapolative costing models that can be applied at country level without extensive micro-costing exercises. This will allow other countries to generate more accurate estimates in the future.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-014-0530-1) contains supplementary material, which is available to authorized users.

The future of routine immunization in the developing world: challenges and opportunities

Vaccine costs in the developing world have grown from < US$1/child in 2001 to about $21 for boys and $35 for girls in 2014, as more and costlier vaccines are being introduced into national immunization programs. To address these and other challenges, additional efforts are needed to strengthen 8 critical components of routine immunization: (1) policy, standards, and guidelines; (2) governance, organization, and management; (3) human resources; (4) vaccine, cold chain, and logistics management; (5) service delivery; (6) communication and community partnerships; (7) data generation and use; and (8) sustainable financing.

Valuing vaccination

Vaccination has led to remarkable health gains over the last century. However, large coverage gaps remain, which will require significant financial resources and political will to address. In recent years, a compelling line of inquiry has established the economic benefits of health, at both the individual and aggregate levels. Most existing economic evaluations of particular health interventions fail to account for this new research, leading to potentially sizable undervaluation of those interventions. In line with this new research, we set forth a framework for conceptualizing the full benefits of vaccination, including avoided medical care costs, outcome-related productivity gains, behavior-related productivity gains, community health externalities, community economic externalities, and the value of risk reduction and pure health gains. We also review literature highlighting the magnitude of these sources of benefit for different vaccinations. Finally, we outline the steps that need to be taken to implement a broad-approach economic evaluation and discuss the implications of this work for research, policy, and resource allocation for vaccine development and delivery.