Bulletin of the World Health Organization

Estimating the costs of achieving the WHO–UNICEF Global Immunization Vision and Strategy, 2006–2015

Lara J Wolfson, François Gasse, Shook-Pui Lee-Martin, Patrick Lydon, Ahmed Magan, Abdelmajid Tibouti, Benjamin Johns, Raymond Hutubessy, Peter Salama, Jean-Marie Okwo-Bele

Volume 86, Number 1, January 2008, 27-39

Table 3. Basic assumptions and cost categories for system scale-up costs

Cost category	Ingredients	Basic assumption
Cold chain	Cold boxes, cold rooms, refrigerators, freezers, icepacks, generators, voltage stabilizers at national, provincial, district and health facility levels. Includes maintenance and running costs for new items purchased	Assume that countries have a cold chain of adequate capacity to meet the needs of their current immunization schedule, and estimates the size of the cold chain that would have to exist to support this schedule (based on standard cold room sizes, e.g.then assumes that any excess capacity is used first).Quantities are based on standard guidelines for equipping and managing cold chains at the central, provincial and peripheral levels in the Expanded Programme on Immunization⁵¹^,⁵²^,⁵³ by calculating the volume of vaccines that require different types of storage space at various levels and the type of equipment most suitable based on factors such as vaccine volume, reliability and availability of electricity, climate, the amount of time required to transport vaccines at various levels, and the condition of road infrastructure.
Waste management	Incinerators and recurrent costs	US$ 0.02 per additional injectable vaccine dose delivered.⁵⁴^,⁵⁵
Transport costs for outreach and vaccine distribution	Purchasing and operating costs of vehicles, including motorcycles. Includes maintenance costs for new items purchased, as well as fuel costs	Cold chain: the type (bicycle, motorcycle, small vans with different loading capacities, refrigerated vans) and quantities of vehicles used to transport vaccines from one level to the next is based on volume of vaccines to be transported,³³ transport conditions³³ (transportation index), distance and number of hours or days that transport would take.Outreach: number of additional vehicles required for outreach based on number of outreach contacts needed (see service delivery for basic assumption) and type of vehicle selected based on transportation index (4 wheel drive vehicles for categories 3 and 4, motorcycles for categories 1 and 2). Fuel costs based on estimated distances to be travelled.
Training of volunteers, refresher courses for current vaccines and training for new vaccines	Per diem, travel to training, printing training materials. For introduction of new and underused vaccines, includes development of training materials	Countries with McKinsey Classification of TU (Turnaround; lowest) and SI (Strategic Intervention; intermediate): additional training required for additional personnel only (the remainder is assumed to be covered under existing costs). Induction and refresher training costs are included.All countries: introduction training required when new or underused vaccines are introduced. Assumed to be included in annual refresher training after year of introduction.
Supervision	Salaries for supervisors and support staff, stationery, transportation and per diem for supervisory visits	All countries: districts with less than 50% coverage require additional supervisory visits.Number of districts that can be visited per supervisory visit is linked to the average distance between districts and the capital.
Media, information, education and communication (M&IEC), and social mobilization	M&IEC: Media (radio time, flyers, television time, booklets, newspaper adverts, communication strategy).Social mobilization: additional staff, resources for planning and administration, supervision, and bicycles	M&IEC, scaling up routine coverage:TU and SI: development costs of strategy only in countries where there are no plans within the vaccine national budgets for social advocacy and mobilization (e.g. strategy development, meetings). Additional media and IEC materials included in all TU and SI countries.Countries with McKinsey classification of SA (Stand-Alone; well-performing): None.M&IEC, introducing an underused or new vaccine:All countries: development of a full media advocacy packageSocial mobilization:All countries: additional volunteers and supervisors for districts with coverage less than 50%.
Monitoring, evaluation, surveillance, laboratory	Computer hardware (including maintenance and running), development of SOPs, training, meetings and international technical assistance; immunization cards, coverage surveys. Laboratories including equipment (plus maintenance and running costs), lab supplies, refresher training, quality control; field officer operations, meetings. Annual gross salaries for international and local staff for country implementation support	Infrastructure upgrade (computer, fax/telephone, voltage stabilizer)TU: 1 per districtSI: 1 for 50% of districtsImmunisation cardsTU and SI countries: cards for additional children above current coverage rates.International and Regional Technical AssistanceHealth system strength index was used as the basis for estimating number of minimum staff required for initial phase of scaling up (around 10% of total staff needs) in a joint consultation with WHO and UNICEF.⁵⁶Immunization coverage surveysEvery 3 yearsDevelopment of strategiesIf not already being done, costs for consultants and workshops to develop:- a 3–5 year strategic plan every 4 years- annual work plan for immunization services- plan for measles control every 4 years- plan for safe injection every 4 years- annual district microplans (for districts which do not already have one).LaboratoryCapital cost to equip a bacteriological lab (for meningococcal, pneumococcal and Hib): 2 years prior to introduction of vaccine. Training and annual lab supplies.Capital cost to equip a lab for ELISA-based testing: 2 years prior to introduction of rubella, rotavirus, yellow fever, HepB, JE. Training and lab supplies.
Service delivery	Per diem for outreach, additional personnel (salaries)	All countries:The annual number of outreach visits estimated by calculating 2005 capacity to deliver immunization visits, and assuming that 50% of the additional contacts will be delivered through outreach services, and the distribution of additional contacts across urban and rural areas.TU and SI countries:Annual estimates of the additional personnel at the district and health facility levels are estimated based on a regression model fit to FSP data,¹⁹ using as covariates the number of nurses, DTP3 coverage changes, birth cohort size, population density, and urban/rural population distribution. The average salary of immunization staff at these levels is taken from the FSP¹⁹ data where available, and from a regression model using FSP data to predict salaries from the size of the birth cohort, the proportion of the population living in urban areas, economic status, and government health expenditures where not available.

DTP3, Diphtheria-tetanus-pertussis, third dose; ELISA, enzyme-linked immunosorbent assay; FSP, Financial Sustainability Planning; HepB, hepatitis B; Hib, Haemophilus influenzae type b; JE, Japanese encephalitis; SOPs, standard operating procedures; UNICEF, United Nations Children’s Fund.