Costs and Cost-Effectiveness of Existing Vaccination Programs
Brenzel and Claquin (1994) and GAVI (2004) estimate the cost per fully immunized child (FIC) for the traditional six EPI antigens as approximately US$20.3 We evaluated the cost per FIC for the childhood EPI cluster antigens by World Bank region on the basis of published and unpublished data. These studies used a standard costing approach that estimated the costs of labor, vaccines, supplies, transportation, communication, training, maintenance, and overhead and included the annualized value of equipment, vehicles, and building space (Khaleghian 2001; USAID, Asia-Near East Region 1988; WHO 1988). The number of FICs in these studies was measured using community-based sample surveys (Henderson and Sundaresen 1982).
Our literature review found 102 estimates of total and unit immunization program costs from 27 countries between 1979 and 2003 for different immunization delivery strategies (Berman and others 1991;1 Beutels 1998;1 Beutels 2001; Brenzel 2005; Brenzel and Claquin 1994; Brinsmead, Hill, and Walker 2004; Creese 1986; Creese and Dominguez-Uga 1987; Dominguez-Uga 1988; Edmunds and others 2000; Griffiths and others 2004; Levin and others 2001; Pegurri, Fox-Rushby, and Walker 2005; Robertson and others 1992; Soucat and others 1997; Steinglass, Brenzel, and Percy 1993). All costs were converted to 2001 U.S. dollar equivalents. Because total and unit costs are related to population size, table 20.4 reports population-weighted results only. National immunization program refers to total national costs for all strategies.
[Table .]
The population-weighted mean cost per FIC for all regions and all strategies is approximately US$17, with a range of US$3 to US$31. The lowest mean population-weighted cost per FIC was for extended outreach services (US$5.81), perhaps because the strategy is a more targeted approach. Routine facility-based strategies had lower average costs (US$13.65 per FIC) than campaigns (US$26.82 per FIC) or mobile strategies (US$25.84 per FIC). Higher unit costs associated with these strategies are possibly attributable to a different mix of inputs as well as greater expenses for per diems, fuel, and social mobilization. The results also vary by World Bank region, with East Asia and the Pacific (US$13.25) and Sub-Saharan Africa (US$14.21) having lower estimates of cost per FIC than Europe and Central Asia (US$24.12) and the Middle East and North Africa (US$22.15).
The findings of our analysis are generally supported by the literature (Creese 1986; Brenzel and Claquin 1994; Khaleghian 2001), which has shown that variation in the cost per FIC is related to the mix of delivery strategies, the prices of key inputs such as vaccines, and the overall scale of programs. In addition, an analysis of 13 national financial sustainability plans for immunization reveals a wide range in the cost per FIC by region and strategy.4
Recurrent costs are the lion's share of total immunization costs (80 percent for fixed facility strategy and 92 percent for campaigns), which has implications for the need for continuous and predictable program financing. Labor costs account for the largest share (roughly 30 to 46 percent of total cost) for all strategies except extended outreach. Vaccine costs range from 8 percent for mobile strategies to 29 percent for extended outreach strategies. Transportation costs account for the second-largest share of EPI costs for mobile strategies, while building costs account for a greater share of fixed facility strategies.
Using data from table 20.4 on costs per FIC and multiplying by the size of the population covered, we estimate US$1.17 billion for the total cost of immunization programs in developing countries in 2001, with a range of US$717 million to US$1.48 billion. At US$20 per FIC, the cost of the six traditional vaccines in developing countries would have amounted to US$1.57 billion in 2001. Table 20.5 shows that the estimated cost per death averted ranges from US$205 in South Asia and Sub-Saharan Africa to US$3,540 in Europe and Central Asia. These results suggest that the cost per death averted rises with coverage rates. Europe and Central Asia, Latin America and the Caribbean, and the Middle East and North Africa had higher coverage rates in 2001, resulting in fewer deaths that could be averted. The table also shows that the cost per DALY from the traditional EPI vaccines ranges from US$7 to US$438, depending on region, mix of strategy, and levels of scale.
[Table .]
Our analysis highlights the variation in cost per FIC by region and strategy and demonstrates the value of more disaggregated results for making policy decisions. However, given the limited sample of estimates available for the regions and strategies, the results should be used as an indicative guide for policy making and not as a substitute for country-specific cost-effectiveness evaluations of strategies. In addition, our estimates do not take into account household costs, such as time spent seeking services, and other social costs. Our estimates also do not consider the direct and indirect costs of acute illnesses prevented by vaccination or the costs of long-term complications from disease and of adverse events associated with vaccination (though the latter are unlikely to have a significant impact on costs because rates of serious complications are extremely low). Furthermore, the analysis focuses on FICs and underemphasizes the benefits of partial immunization. Future economic evaluations of immunization program alternatives could consider these factors as a critical step in determining the allocation of scarce resources among high-priority health interventions.
