To determine the cost of Zimbabwe’s human papillomavirus (HPV) vaccination demonstration project.
The government of Zimbabwe conducted the project from 2014–2015, delivering two doses of HPV vaccine to 10-year-old girls in two districts. School delivery was the primary vaccination strategy, with health facilities and outreach as secondary strategies. A retrospective cost analysis was conducted from the provider perspective. Financial costs (government expenditure) and economic costs (financial plus the value of existing or donated resources including vaccines) were calculated by activity, per dose and per fully immunized girl.
The project delivered 11 599 vaccine doses, resulting in 5724 fully immunized girls (5540 at schools, 168 at health facilities and 16 at outreach points). The financial cost for service delivery per fully immunized girl was United States dollars (US$) 5.34 in schools, US$ 34.90 at health facilities and US$ 288.63 at outreach; the economic costs were US$ 17.39, US$ 41.25 and US$ 635.84, respectively. The mean financial cost per dose was US$ 19.76 and per fully immunized girl was US$ 40.03 (economic costs were US$ 45.00 and US$ 91.19, respectively). The largest number of doses delivered (5788) occurred during the second vaccination round (the second group’s first dose concurrently delivered with the first group’s second dose), resulting in the lowest financial and economic service delivery costs per dose: US$ 1.97 and US$ 6.79, respectively.
The mean service delivery cost was lower in schools (primary strategy) and when more girls were vaccinated in each round, demonstrating scale efficiency.
Déterminer le coût du projet de démonstration de la vaccination contre le papillomavirus humain (PVH) au Zimbabwe.
Le gouvernement du Zimbabwe a mené ce projet de 2014 à 2015, en administrant deux doses de vaccin contre le PVH aux filles de 10 ans de deux districts. La stratégie de vaccination principale a consisté à intervenir dans les écoles, puis dans des établissements de santé et des centres de proximité comme stratégies secondaires. Une analyse rétrospective des coûts a été effectuée du point de vue des prestataires. Les coûts financiers (dépenses du gouvernement) ainsi que les coûts économiques (coûts financiers plus valeur des ressources existantes ou mises à disposition, y compris les vaccins) ont été calculés par activité, par dose et par fille totalement immunisée.
Le projet a permis d'administrer 11 599 doses de vaccins et d'immuniser totalement 5724 filles (5540 à l'école, 168 dans des établissements de santé et 16 dans des centres de proximité). Le coût financier de la prestation de services par fille totalement immunisée était de 5,34 dollars des États-Unis ($ US) pour la vaccination réalisée à l'école, de 34,90 $ US dans des établissements de santé et de 288,63 $ US dans des centres de proximité; les coûts économiques étaient respectivement de 17,39 $ US, 41,25 $ US et 635,84 $ US. Le coût financier moyen était de 19,76 $ US par dose et de 40,03 $ US par fille totalement immunisée (les coûts économiques étaient respectivement de 45,00 $ US et de 91,19 $ US). Le plus grand nombre de doses (5788) a été administré durant la deuxième série de vaccinations (première dose du second groupe administrée en même temps que la deuxième dose du premier groupe), où ont été relevés les plus faibles coûts financiers et économiques de la prestation de services par dose: respectivement 1,97 $ US et 6,79 $ US.
Le coût moyen de la prestation de services était plus faible lors de la vaccination dans les écoles (stratégie principale) et lorsque l'on vaccinait un grand nombre de filles dans chaque série de vaccinations, ce qui révèle des économies d'échelle.
Determinar el coste del proyecto de demostración de vacunación contra el virus del papiloma humano (VPH) en Zimbabwe.
El gobierno de Zimbabwe llevó a cabo el proyecto entre 2014 y 2015, administrando dos dosis de la vacuna contra el VPH a niñas de 10 años en dos distritos diferentes. La estrategia de vacunación primaria fue la administración de la misma en colegios, con los centros sanitarios y la difusión como estrategias secundarias. Se realizó un análisis retrospectivo de los costes desde la perspectiva del proveedor. Los costes financieros (gasto público) y los costes económicos (los costes financieros más el valor de los recursos existentes o donados, incluidas las vacunas) se calcularon por actividad, por dosis y por niña totalmente inmunizada.
El proyecto administró 11 599 dosis de la vacuna, lo que dio como resultado 5724 niñas totalmente inmunizadas (5540 en los colegios, 168 en los centros sanitarios y 16 en los puntos de difusión). El coste financiero de la prestación de servicios por niña totalmente inmunizada fue de 5,34 dólares estadounidenses en los colegios, 34,90 USD en los centros de salud y 288,63 USD en las actividades de difusión; los costes económicos fueron de 17,39 USD, 41,25 USD y 635,84 USD, respectivamente. El coste financiero medio por dosis fue de 19,76 dólares estadounidenses y por niña totalmente inmunizada de 40,03 USD (los costes económicos fueron de 45,00 USD y 91,19 USD, respectivamente). El mayor número de dosis administradas (5788) se produjo durante la segunda ronda de vacunación (la primera dosis del segundo grupo administrada simultáneamente con la segunda dosis del primer grupo), lo que dio lugar a menores costes financieros y económicos de prestación de servicios por dosis: 1,97 USD y 6,79 USD, respectivamente.
El coste medio de la prestación de servicios fue menor en los colegios (estrategia primaria) y cuando se vacunó a más niñas en cada ronda, lo que demuestra la eficiencia de la escala.
تحديد تكلفة المشروع التوضيحي للتطعيم (HPV) ضد فيروس الورم الحليمي البشري في زمبابوي.
قامت حكومة زيمبابوي بتنفيذ المشروع خلال الفترة من 2014 إلى 2015، حيث قدمت جرعتين من لقاح فيروس الورم الحليمي البشري للفتيات في سن العاشرة من العمر في مقاطعتين. كان تقديم التطعيم في المدرسة هو إستراتيجية التطعيم الأولية، حيث كانت المرافق الصحية والتوعية استراتيجيات ثانوية. تم إجراء تحليل للتكاليف بأثر رجعي من وجهة نظر مقدم الخدمة. تم احتساب التكاليف المالية (النفقات الحكومية) والتكاليف الاقتصادية (المالية بالإضافة إلى قيمة الموارد الحالية أو التي تم التبرع بها بما في ذلك اللقاحات) حسب النشاط ، لكل جرعة ولكل فتاة محصنة بالكامل.
قدم المشروع 11599 جرعة من اللقاح، مما نتج عنه 5724 فتاة محصنة بالكامل (5540 في المدارس، و168 في المرافق الصحية، و16 في مراكز التوعية). وبلغت التكلفة المالية لتقديم الخدمات لكل فتاة محصّنة كلياً 5.34 دولاراً أمريكياً في المدارس، و34.90 دولاراً أمريكياً في المرافق الصحية، و288.63 دولاراً أمريكياً في مجال التوعية؛ وبلغت التكاليف الاقتصادية 17.39 دولاراً أمريكياً، و41.25 دولاراً أمريكياً، و635.84 دولار أمريكي على التوالي. بلغ متوسط التكلفة المالية لكل جرعة 19.76 دولاراً أمريكياً، ولكل فتاة محصّنة بالكامل 40.03 دولاراً أمريكياً (كانت التكاليف الاقتصادية 45.00 دولاراً أمريكياً و91.19 دولاراً أمريكياً على التوالي). كان أكبر عدد من الجرعات التي تم تسليمها (5788) خلال الجولة الثانية من التطعيم (الجرعة الأولى للمجموعة الثانية تم تسليمها في وقت متزامن مع الجرعة الثانية للمجموعة الأولى)، مما أدى إلى انخفاض تكاليف تقديم الخدمات المالية والاقتصادية لأقصى حد لكل جرعة: 1.97 دولار أمريكي و6.79 دولاراً أمريكياً على التوالي.
كان متوسط تكلفة تقديم الخدمة أقل في المدارس (الاستراتيجية الأولية)، وعندما تم تلقيح المزيد من الفتيات في كل جولة، مما يدل على كفاءة المقياس.
确定津巴布韦人乳头瘤病毒 (HPV) 疫苗接种示范项目的成本。
津巴布韦政府于 2014 年至 2015 年进行该项目，在两个地区向 10 岁的女孩提供了两剂 HPV 疫苗接种。基于学校的疫苗接种是主要的疫苗接种战略，基于医疗机构和外展疫苗接种作为次要战略。从提供者的角度进行回顾性成本分析。财政成本（政府支出）和经济成本（财政加上现有的或捐赠的资源，包括疫苗）是根据活动、单位剂量和每名获得完全免疫的女孩计算得出。
该项目提供了 11599 剂疫苗，令 5724 名女孩获得了完全免疫 （5540 名通过学校的疫苗接种，168 名通过医疗机构的疫苗接种，另外 16 名通过外展疫苗接种点进行接种）。每名获得完全免疫的女孩所需的财务成本为：基于学校的疫苗接种为 5.34 美元 ，基于医疗机构的疫苗接种为 34.90 美元，通过外展疫苗接种点的疫苗接种为 288.63 美元；经济成本分别为 17.39 美元、41.25 美元和 635.84 美元。每剂疫苗的平均财务成本为 19.76 美元，每名获得完全免疫的女孩的平均财务成本为 40.03 美元（经济成本分别为 45.00 美元和 91.19 美元）。第二次疫苗接种（第二组的第一剂疫苗与第一组的第二剂疫苗同时接种）期间接种的剂量最多 （5788 剂），导致每剂接种的财政和经济服务成本最低：分别为 1.97 美元和 6.79 美元。
基于学校进行疫苗接种的平均服务接种成本较低（主要战略），而且每一轮进行疫苗接种的女孩数量越多，规模效益越显著。
Определение затрат на демонстрационный проект вакцинации против вируса папилломы человека (ВПЧ) в Зимбабве.
Правительство Зимбабве осуществляло проект с 2014–2015 гг., вводя по две дозы вакцины против ВПЧ 10-летним девочкам в двух районах страны. Основная стратегия распределения вакцины подразумевала участие школ, а учреждения здравоохранения и пропаганда вакцинации рассматривались как стратегии второго порядка. Был проведен ретроспективный анализ затрат с точки зрения поставщика услуг. Финансовые расходы (государственные расходы) и экономические издержки (финансовые расходы плюс стоимость имевшихся или пожертвованных ресурсов, включая вакцины) рассчитывались с разбивкой по роду деятельности из расчета на дозу и на одну полностью иммунизированную девочку.
В ходе проекта было поставлено 11 599 доз вакцины и были полностью иммунизированы 5724 девочки (5540 в школах, 168 в учреждениях здравоохранения и 16 в пунктах распространения информации). Финансовые расходы на оказание услуг из расчета на одну полностью иммунизированную девочку составили в долларах США: 5,34 в школах, 34,90 в учреждениях здравоохранения и 288,63 в пунктах распространения информации. Экономические издержки составили 17,39; 41,25 и 635,84 доллара США соответственно. Средний показатель финансовых расходов составил из расчета на дозу 19,76 доллара США и из расчета на одну полностью иммунизированную девочку 40,03 доллара США (соответственные экономические издержки составили 45,00 и 91,19 доллара США). Наибольшее количество доз (5788) было поставлено в ходе второго тура вакцинации (первая доза второй группы поставлялась одновременно со второй дозой первой группы), что позволило достичь минимальных финансовых и экономических затрат на оказание услуг из расчета на дозу: 1,97 и 6,79 доллара США соответственно.
Средняя стоимость оказания услуг была ниже для школ (основная стратегия) и в тех случаях, когда в каждом туре вакцинировалось большее количество девочек, что демонстрирует зависимость уровня эффективности от масштаба охвата.
Each year 266 000 women worldwide die of cervical cancer due to human papillomavirus (HPV) infection.
Zimbabwe is a low-income country with an estimated 4.9 million women aged 15 years and older at risk of developing cervical cancer.
In 2013, Zimbabwe’s Ministry of Health and Child Care proposed an HPV vaccination demonstration project supported financially by Gavi, the Vaccine Alliance. Gavi support for HPV vaccination demonstration projects was intended to allow countries to better understand the strategies and costs to deliver vaccine to a target population of girls aged 9–13 years.
The existing literature on the cost of HPV vaccination demonstration projects has mostly focused on three-dose schedules and single cohorts.
The HPV vaccination project delivered vaccines to 10-year-old girls in two districts in 2014 and 2015 (
Beitbridge district in Matabeleland South province (district population: 122 553)
Marondera district in Mashonaland East province (district population: 178 547)
Peri-urban (two-thirds rural) districts
Two major ethnic groups represented (Ndebele and Shona)
High diphtheria–tetanus–pertussis vaccination coverage: > 90%
Experience of schoolchildren vaccination programmes that would provide a potential platform for integrated delivery of HPV vaccine and other health interventions in the future
10-year-old girls residing in the selected districts
Beitbridge district: 2628 (1700 first group, 928 second group)
Marondera district: 3880 (2043 first group, 1837 second group)
Bivalent vaccine
Two doses
Primary schools
Health facilities; outreach points
HPV: human papillomavirus.
a The method of enumeration, based on school registers, likely underestimated the number of out-of-school girls.
Data sources: Government of Zimbabwe, 2013.
Both the selected districts in Zimbabwe implemented the project to reach an initial group of girls using three vaccination rounds (
| Vaccination round | Aim | Group | Dose | Date of dose 1 | Interval between dose 1 and dose 2, months | ||
|---|---|---|---|---|---|---|---|
| Beitbridge | Marondera | Beitbridge | Marondera | ||||
| First | To deliver dose 1 to the target population of 10-year-old girls in two districts | 1 | 1 | Sep 2014 | Sep 2014 | NA | NA |
| Second | To deliver dose 2 to girls from the first vaccination round and dose 1 to girls who missed the first round or who had recently turned 10 years old | 1, 2 | 2, 1 | Jun 2015 | Mar 2015 | 9 | 6 |
| Third | To complete the vaccination series for girls from either of the previous rounds | 2 | 2 | Nov 2015 | Nov 2015 | 6 | 8 |
NA: not applicable.
We used a retrospective, ingredients-based approach to estimate the incremental, or additional, costs of implementing the HPV vaccination project. Costs were collected from the provider perspective, which included all costs of implementing the project from the government and donors, and were further categorized into financial and economic costs. Financial costs were defined as actual monetary payments or expenditure by the government, while economic costs were defined as financial costs plus the value of resources already paid for or owned by government or provided by other sources (opportunity cost), including the value of donated vaccines. We based costs on the resources (ingredients) used for each major activity as defined by the WHO Cervical Cancer Prevention and Control Costing tool user guide.
Financial costs included expenditure by the health ministry.
For each activity, we calculated the value of the resources used based on actual expenditure, or the quantity of the resource used multiplied by that resource’s unit cost and then summed across all resources. We estimated the daily value of personnel time using annual salary plus benefits by cadre divided by 222 working days per year; volunteer time was valued using a minimum wage estimate provided by the health ministry.
Since there were no major improvements made to the existing cold-chain infrastructure for the project (e.g. purchasing additional vaccine carriers or refrigerators), we calculated opportunity costs by using existing vaccine carriers and cold packs, as these were borrowed from routine vaccination sessions. We did not report the cost of vaccination waste disposal because the central medical stores and implementing districts were not able to provide an estimate of the share of waste disposal specific to HPV vaccination waste. Some aspects of service delivery costs (e.g. fuel) were reported by the health ministry as lump-sum costs. We divided these costs by the total number of vaccination sites reached in the vaccination round during which the expense was incurred to obtain cost per site, and then multiplied by the number of sites for each strategy (school, health facility or outreach) to obtain cost per strategy in the absence of information on resources used to reach each individual site.
We designated costs as introduction or recurrent costs based on the WHO Cervical Cancer Prevention and Control Costing tool user guide,
This analysis considers the incremental resources needed to add HPV vaccination to an existing immunization programme. We excluded the costs of routine operation of the health system and immunization programme.
We collected the data through in-person consultations and by phone and email from 25 individuals from NGOs and the health ministry at the national, provincial, district and health-facility levels. Follow-up consultations were held with the same individuals to clarify and validate the initial information. We reviewed relevant programmatic and financial documents (e.g. annual reports, work plans, programme budgets and Zimbabwe’s Gavi application
All resources recommended by the WHO Cervical Cancer Prevention and Control Costing tool were included in the data collection design for financial and economic costs by type of activity. Activities for which costs were reported in Zimbabwe are presented in
| Activity | Items included in financial costs a | Additional items included in economic costsb |
|---|---|---|
| Microplanning | • Venue rental; | • Venue rental; |
| Vaccines | • Vaccination supplies (safety boxes, cotton) | • Vaccines; |
| Training | • Per diem payments (lodging, meals); | • Personnel time (share of salaries and benefits) |
| Social mobilization and information materials | • Per diem payments (lodging, meals); | • Fuel; |
| Service delivery | • Per diem payments; and | • Fuel and transportation fees; |
| Supervision, monitoring and evaluation | • Per diem payments (lodging, meals) | • Vehicle use (share of time); |
| Other | • National and district launch of vaccination; | • HPV strategic advisory group meetings; |
HPV: human papillomavirus; NGO: nongovernmental organization.
a Financial costs were defined as actual monetary payments or expenditure by the government
b Economic costs were defined as financial costs plus the value of resources already paid for or owned by government or provided by other sources (opportunity cost), including the value of donated vaccines.
The HPV vaccination project resulted in an estimated 11 599 doses delivered (11 251 at schools, 321 at health facilities and 27 at outreach points) and 5724 fully immunized girls (5540 at schools, 168 at health facilities and 16 at outreach points). The mean financial cost per dose for the overall project was US$ 19.76 and the mean economic cost per dose (which included the cost of the vaccine) was US$ 45.00 (
| Cost category | Financial cost, US$ | Economic cost, US$ | |||||
|---|---|---|---|---|---|---|---|
| Total | Per dosea | Per fully immunized girlb | Total | Per dosea | Per fully immunized girlb | ||
| Introduction costsc | 120 981 | 10.43 | 21.14 | 214 637 | 18.50 | 37.50 | |
| Recurrent costsd | 108 163 | 9.33 | 18.90 | 307 309 | 26.49 | 53.69 | |
| Total costs | 229 144 | 19.76 | 40.03 | 521 946 | 45.00 | 91.19 | |
| Total costs (without vaccine and vaccine-related suppliese) | 228 981 | 19.74 | 40.00 | 463 242 | 39.94 | 80.93 | |
HPV: human papillomavirus; US$: United States dollars.
a Total number of doses delivered: 11 599.
b Total number of fully immunized girls: 5724.
c Introduction costs are initial investments that are expected to last longer than 1 year, and include the activity categories of microplanning, training, and sensitization and information materials.
d Recurrent costs are expected to last less than 1 year. This includes activity categories of vaccines (i.e. cost of vaccine,
e Vaccine procurement and injection supplies includes the procurement and distribution of vaccine, syringes, safety boxes, vaccine carriers and cold packs, and cotton. Note that for specific cost calculations, the financial cost includes safety boxes and cotton; economic cost additionally includes the cost of the vaccine including freight and transportation, vaccine carriers and cold packs, and syringes.
Note: We collected costs in current prices from 2014, 2015 and 2016, adjusted for inflation to 2016 US$ using the Zimbabwe consumer price index.
The overall financial cost of the project was US$ 229 144 and the overall economic cost was US$ 521 946. Among activity categories, the share of financial cost was highest for social mobilization and information materials (24.1%; US$ 55 170) and lowest for vaccines, including vaccination-related supplies (0.1%; US$ 162;
| Activity | US$ (%) | ||
|---|---|---|---|
| Financial cost | Economic cost | Net economic cost (economic–financial) | |
| Microplanning | 2 619 (1.1) | 50 306 (9.6) | 47 687 (16.3) |
| Vaccine | 162 (0.1) | 58 704 (11.3) | 58 542 (20.0) |
| Training | 53 204 (23.2) | 69 662 (13.4) | 16 458 (5.6) |
| Social mobilization, and information materials | 55 170 (24.1) | 67 568 (12.9) | 12 398 (4.2) |
| Service delivery | 40 053 (17.5) | 113 444 (21.7) | 73 391 (25.1) |
| Supervision, monitoring and evaluation | 35 166 (15.3) | 100 611 (19.3) | 65 445 (22.4) |
| Othera | 42 770 (18.7) | 61 651 (11.8) | 18 881 (6.4) |
| Cold-chain supplementation | NA | NA | NA |
| Total | 229 144 (100.0) | 521 946 (100.0) | 292 802 (100.0) |
HPV: human papillomavirus; NA: not applicable; US$: United States dollars.
a Other activity includes items relevant to introduction and recurrent cost categories that did not fit into the specific activity categories including launch of vaccination (national and district), review of monitoring tools, stakeholders meeting, report-writing meeting, HPV strategic advisory group meetings, service of nongovernmental organization vehicles, office communications and networking meeting.
Note: We collected costs in current prices from 2014, 2015 and 2016, adjusted for inflation to 2016 US$ using the Zimbabwe consumer price index.
During the project, the mean number of girls vaccinated per school ranged between 12 and 36, which was higher than the mean number of girls vaccinated at health facilities (between 0 and 10) or outreach points (between 0 and 1;
| Vaccination round and district | Schools | Health facilities | Outreach points | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. offering vaccination | No. of girls vaccinated | Mean no. of girls vaccinated | No. offering vaccination | No. of girls vaccinated | Mean no. of girls vaccinated | No. of points reached | No. of girls vaccinated | Mean no. of girls vaccinated | |||
| Beitbridge | 69 | 1460 | 21 | 17 | 99 | 6 | 47 | 11 | < 1 | ||
| Marondera | 93 | 1830 | 20 | 22 | 12 | 1 | NA | NA | NA | ||
| Beitbridge | 70 | 2193 | 31 | 17 | 162 | 10 | 47 | 11 | < 1 | ||
| Marondera | 95 | 3416 | 36 | 23 | 6 | < 1 | NA | NA | NA | ||
| Beitbridge | 66 | 762 | 12 | 10 | 42 | 4 | 7 | 5 | 1 | ||
| Marondera | 96 | 1590 | 17 | 23 | 0 | 0 | NA | NA | NA | ||
NA: not applicable.
| Vaccination round and district | No. of doses given | Financial cost, US$ | Economic cost, US$ | ||
|---|---|---|---|---|---|
| Total | Per dose | Total | Per dose | ||
| Beitbridge | 1 570 | 8 195 | 5.22 | 16 617 | 10.58 |
| Marondera | 1 842 | 6 440 | 3.50 | 21 761 | 11.81 |
| Beitbridge | 2 366 | 6 770 | 2.86 | 16 129 | 6.82 |
| Marondera | 3 422 | 6 734 | 1.97 | 23 225 | 6.79 |
| Beitbridge | 809 | 5 167 | 6.39 | 12 513 | 15.47 |
| Marondera | 1 590 | 6 746 | 4.24 | 23 198 | 14.59 |
| Beitbridge | 4 745 | 20 132 | 4.24 | 45 260 | 9.54 |
| Marondera | 6 854 | 19 920 | 2.91 | 68 185 | 9.95 |
NA: not applicable; US$: United States dollars.
Note: Includes service delivery activity only. We collected costs in current prices from 2014, 2015 and 2016, adjusted for inflation to 2016 US$ using the Zimbabwe consumer price index.
The service delivery costs varied by vaccination strategy. The mean service delivery costs per fully immunized girl for school vaccination, the primary strategy, were US$ 5.34 (financial cost) and US$ 17.39 (economic cost;
| Strategy and cost categorya | No. of doses delivered | No. of fully immunized girls | Service delivery cost, US$ | Unit cost, US$ | |||||
|---|---|---|---|---|---|---|---|---|---|
| Per diem payments (lodging, meals) | Personnel time (share of salaries and benefits) | Fuel and transportation fees | Vehicle use (share of time) | Total | Cost per doseb | Cost per fully immunized girlb | |||
| Financial cost | 11 251 | 5 540 | 22 899 | NA | 6 672 | NA | 29 572 | 2.63 | 5.34 |
| Economic cost | 22 899 | 49 606 | 6 763 | 17 072 | 96 340 | 8.56 | 17.39 | ||
| Financial cost | 321 | 168 | 5 863 | NA | NA | NA | 5 863 | 18.26 | 34.90 |
| Economic cost | 5 863 | 1 016 | NA | 52 | 6 931 | 21.59 | 41.25 | ||
| Financial cost | 27 | 16 | 3 379 | NA | 1 239 | NA | 4 618 | 171.04 | 288.63 |
| Economic cost | 3 379 | 2 668 | 1 300 | 2 826 | 10 174 | 376.79 | 635.84 | ||
| Financial cost | 11 599 | 5 724 | 32 141 | NA | 7 911 | NA | 40 053 | 3.45 | 7.00 |
| Economic cost | 32 141 | 53 290 | 8 063 | 19 950 | 113 444 | 9.78 | 19.82 | ||
NA: not applicable; US$: United States dollars.
a Includes service delivery activity only, excluding vaccine.
b Unit cost per dose and per fully immunized girl represent an unweighted mean.
Note: We collected costs in current prices from 2014, 2015 and 2016, adjusted for inflation to 2016 US$ using the Zimbabwe consumer price index.
The largest contributor to service delivery costs across all strategies was per diem payments (
The service delivery financial costs per dose and per fully immunized girl were consistently higher in the health facility and outreach strategies. The higher costs are probably because both strategies were primarily geared towards supporting the school vaccination strategy and because of the small number of doses delivered in these settings (348 doses; 3% of the total). There were fewer out-of-school girls than predicted and some of them were taken to be vaccinated at schools rather than via the expected health facility and outreach points. Costs for outreach and health facility strategies could be reduced if the size of mobile teams or command centre teams were reduced or if personnel were engaged without per diem payments. Any such changes in the composition of vaccination teams should be considered not only in terms of costs, but also the programmatic implications such as coverage and quality of the vaccination campaign. For school delivery, the financial cost per dose was lower when a larger number of girls was vaccinated in a single round (the second round, reaching overlapping groups of girls).
Introduction costs in this project may not be representative of national introduction costs in Zimbabwe since the country revised its plans for a three-dose vaccination series after preparations had begun, prompted by the change in WHO recommendations.
Zimbabwe’s implementation of a two-dose schedule delivered to two overlapping groups of girls differs from the strategies used in all previously published HPV cost studies,
The findings from Zimbabwe reflect the cost to deliver HPV vaccine to two peri-urban districts and may not be directly comparable to settings represented by previous demonstration projects. For example, Zimbabwe’s economic cost per fully immunized girl was US$ 91.19, including vaccine at US$ 4.60 per dose, while in the United Republic of Tanzania the economic cost per fully immunized girl in a rural setting was estimated at US$ 115.11 (presented in 2016 US$
We found that the financial cost per dose decreased as the number of girls vaccinated increased. In the second round of vaccination when reaching overlapping groups of girls, the lowest financial costs per dose for vaccination service delivery were found when the most girls were vaccinated overall and on average per school. Other researchers found that the financial cost per dose decreased as the number of girls vaccinated increased;
Our study has several limitations. The analysis was conducted retrospectively, requiring the HPV vaccination implementation staff to recall information. No written records were available for some information (e.g. personnel time); these estimates may therefore be subject to recall bias. Salary information was given by cadre, not by specific personnel involved in programme activity; therefore, the salary levels assumed may be different from actual salaries.
This project was largely executed with Gavi support and supplemental donor funding, so our results do not permit conclusions about the costs of HPV vaccination in the absence of donor support. Furthermore, our findings are based on the cost analysis of a demonstration project and do not consider underlying programmatic factors such as the performance of the routine immunization programme. Other considerations not investigated as part of our cost analysis are also important for a country’s decision on vaccination strategy. For example, the prevalence of human immunodeficiency virus (HIV) in the target population could affect decisions on HPV vaccine schedule, since a three-dose and not a two-dose schedule is recommended for people living with HIV.
Following the demonstration project, Gavi approved financial support to the government of Zimbabwe to introduce the HPV vaccine nationally.
In conclusion, this cost analysis provides new evidence regarding the resources required to deliver a two-dose vaccination schedule of the HPV vaccine using an overlapping delivery strategy to a new target population (adolescent girls) in Zimbabwe. As part of the country’s first efforts to reach this population, the project provided an opportunity to understand the costs of various delivery strategies including health facility and outreach vaccination supplementing school-based vaccination to reach out-of-school girls. The use of health facilities and outreach points as secondary vaccination strategies likely resulted in a higher mean service delivery cost for these strategies. A lower service delivery cost per girl was found when a larger number of girls was vaccinated in each round, demonstrating scale efficiency with these larger numbers. Countries will need to reach a larger number of girls for national scale-up of the HPV vaccine, necessitating increased financial resources. Therefore, the most important lesson from this study is the potential cost savings offered by vaccinating overlapping groups.
We thank Raymond Hutubessy, Siobhan Botwright, Monica Mbawa, Marian Fadzi, Taurai Chikutye, Clara Mashiringo and Sikhanyiso Mbengano.
This work was supported by Gavi, The Vaccine Alliance and the United States Centers for Disease Control and Prevention from contract number 200-2015-63464-0001.
None declared.