Elsevier

Vaccine

Volume 33, Supplement 1, 7 May 2015, Pages A40-A46
Vaccine

Costs of routine immunization and the introduction of new and underutilized vaccines in Ghana

https://doi.org/10.1016/j.vaccine.2014.12.081Get rights and content

Highlights

  • Total national costs for routine immunization amount to US$ 53.5 million (2011).

  • Variations emphasize additional efforts to reach children in different settings.

  • Immunization costs are often higher than generally appreciated.

  • The high cost is due largely to non-vaccine costs at the facility level.

Abstract

Background

Limited knowledge exists on the full cost of routine immunization in Africa. Ghana was the first African country to simultaneously introduce rotavirus, pneumococcal and measles second-dose vaccines. Given their high price, it would be beneficial to Ghanaian health authorities to know the true cost of their introduction.

Methods

The economic costs of routine immunization for 2011 and the incremental costs of new vaccines were assessed as part of a multi-country study on costing and financing of routine immunization known as the Expanded Program on Immunization Costing (EPIC). Immunization delivery costs were evaluated at the local facility, district, regional, and central levels. Stratified random sampling was used for district and facility selection. We calculated the allocation of nationwide costs to the four health-system levels.

Results

The total aggregated national costs for routine immunization – including vaccine costs – equaled US$ 53.5 million during 2011 (including central, regional, and district costs); this equated to US$ 60.3 per fully immunized child (FIC) when counting vaccine costs, or US$ 48.1 without. National immunization program delivery costs were allocated as follows: local facility level, 85% of total national cost; district, 11%; central, 2% and regional, 2%. Salaried labor represented 61% of total costs, and vaccines represented 17%. For new vaccine introduction, programmatic start-up costs amounted to US$ 3.9 million, primarily due to salaried labor (66%). The mean facility-level cost per vaccine dose administered in a routine immunization program was US$ 5.1 (with a range of US$ 2.4–7.8 depending on facility characteristics) and US$ 3.7 for delivery costs.

Discussion

We identified a high cost per fully immunized child, mostly due to non-vaccine costs at the facility level, which indicates that immunization program financing – whether national or donor-driven – must take a broad viewpoint. This substantial variation in overall costs emphasizes the additional effort associated with reaching children in various settings.

Introduction

Multiple additional vaccines are currently being introduced into routine immunization programs in countries that are eligible for funding from the Global Alliance for Vaccines and Immunization (GAVI). However, many countries are unable to raise sufficient resources, both domestic and external to achieve their objectives [1]. Furthermore, the full cost of new vaccines, plus their distribution and storage costs, remains high for many governments [2] and support for new vaccines in many developing countries remains overwhelmingly dependent on GAVI financing [3]. In addition, new vaccine introduction costings tend to overlook non-vaccine costs [4], [5].

In the African region, Ghana has been a leader in introducing new vaccines into routine immunization programs, expanding from 7 vaccines in 2002 to 12 vaccines in 2013. Ghana was one of the first countries to introduce the pentavalent vaccine (in 2002). Most recently, it has simultaneously introduced pneumococcal conjugate vaccine (PCV), rotavirus vaccine, and measles second-dose (MSD). It has also made substantial investments to ensure new vaccine delivery such as cold chain capacity expansion.

Nevertheless, costs have not been fully assessed, and have focused mainly on resource requirement projections. The latest official information available can be extracted from the 2010–2014 comprehensive multi-year plan (cMYP) [6]. The estimate of the projected cost for routine immunization in 2011 was US$ 32 million [6]. A costing study by Levin et al. [7] conducted in 2000 estimated the total cost for routine immunization at US$ 5.1 million, corresponding to US$ 9.7 for each fully immunized child (FIC) – i.e., three doses of diphtheria-tetanus-pertussis (DTP), hepatitis B, and Haemophilus influenzae type b (Hib) – and a cost of US$ 0.26 per capita, adjusted for inflation.

This study was part of the Expanded Program on Immunization Costing (EPIC), a multi-country analysis of the costs and financing of routine immunization programs and new vaccine introduction, which was supported by the Bill and Melinda Gates Foundation. The project encompassed Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This manuscript focuses exclusively on the costs of routine immunization and new vaccines introduction.

Section snippets

Methods

The study evaluated the national routine immunization program in 2011 and new vaccine introduction in Ghana from the perspective of the government health service. The following vaccines were part of Ghana's routine immunization schedule in 2011: Bacillus Calmette-Guerin (BCG), pentavalent DTP-hepatitis B-Hib, polio, measles first-dose, yellow fever, and tetanus toxoid (for pregnant women), which represent nine doses per FIC (see Appendix 1). With the introduction of pneumococcal conjugate

Results

The total national aggregated RI costs amounted to US$ 53.4 million in 2011, accounting for 5.21% of general government expenditure on health and 0.14% of the gross domestic product [16]. The aggregated RI cost per routine dose administered was US$ 5.7 (total doses administered: 9,464,165). In comparison, the cost per FIC was US$ 60.3 (the number of children that received a third dose of DTP-HepB-Hib: 887,086) [17]; the cost per infant population was US$ 52.9 (the infant population: 1,011,012);

Discussion

Our EPIC study represents one of the most thorough attempts to evaluate the costs of national routine immunization programs in Ghana and in other countries for the companion studies from this issue [5], [28], [29], [30], [31]. In Ghana, we found that total national costs and costs per FIC were high due mainly to delivery costs, and within non-vaccine costs mainly to employee salaries. Most non-vaccine costs were incurred at the facility level. Costs varied by a factor of three depending on the

Contributors

A common methodological approach and generic questionnaire was developed by the Bill and Melinda Gates Foundation (BMGF). JBLG adapted the questionnaire to the Ghana context following a pre-test of the questionnaire and meetings with Ghana EPI staff and the MOH. JBLG conducted the cost analysis, and report and manuscript writing. MA was in charge of survey implementation and data entry, supervised the interviewers, and provided input on sampling. FN was the interface between the country's

Acknowledgments

We would like to acknowledge the following individuals who contributed to the study: The Ghana Health Service, in particular, KO Antwi-Agyei (Ghana Health Service/EPI), John Frederick Dadzie (Ghana Health Service/EPI), and Dan Osei (Ghana Health Service, PPME), who facilitated and provided guidance for study implementation and analysis. We would also like to acknowledge the interviewers who collected the data: Gustav Togobo, Irene Hamba, Seth Adjei, Bernard Achampong, and Vida Gyasi. Darwin

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