Cost of reaching zero-dose children

Health Systems Insight (formerly Thinkwell Institute) implemented a project which generated high-quality evidence on the cost of interventions that target zero-dose children. In Ethiopia, Nigeria and Pakistan, we worked together with local research partners to analyze the cost and outputs of selected interventions, to support governments in improving equitable resource allocation for immunization programs.

The global community has set ambitious goals to look beyond national immunization coverage outcomes and prioritize communities that have been left behind from the advances made over the last decades. Reaching so-called zero-dose children, those that have missed out on all routine vaccines [1], is a central pillar of both WHO’s Immunization Agenda 2030 and Gavi’s 5.0 strategy, however, economic evidence to support decisionmakers in this is lacking.

Health Systems Insight (formerly Thinkwell Institute) is working in partnership with local research institutes to generate critical economic evidence on reaching zero-dose children. In each of the countries, we are working closely with local immunization program managers to identify the scope of the research, to ensure that the evidence fills their key priority knowledge gaps. We are following a set of shared principles across the countries, and deploying standardized, validated research methodologies to facilitate comparison of evidence across countries and settings. In all countries, we are analyzing the cost and number of zero-dose and other children reached both through routine immunization activities, as well as additional strategies implemented specifically to reach un- and undervaccinated communities.

In Ethiopia, we have partnered with Fenot Associates to analyze the cost and number of zero-dose children reached through of periodic intensification of routine immunization (PIRI), and mobile health and nutrition teams (MHNTs) implemented in the Somali and Afar regions. Read the study report here. 

In Pakistan, we partnered with PHC Global to analyze the cost of several strategies implemented in Punjab and Sindh: enhanced/integrated outreach, Clinics on Wheels which deliver primary healthcare in urban slums, and the leveraging of polio campaigns to identify zero-dose children. Read the study report here.

In Nigeria, we worked with Nnamdi Azikiwe University to analyze the cost and number of zero-dose children reached through additional outreach and mobile sessions being implemented in Kaduna, Jigawa, and Lagos. Read the study report here.

Health Systems Insight (formerly Thinkwell Institute) released an evidence synthesis, “What do we know about the economics of reaching zero-dose children?”, summarizing the latest findings from 13 studies across five countries. This brief brings together preliminary results presented during the Immunization Economics Pre-Congress 2025, held in Bali in July ahead of the IHEA World Congress.

In 2024, Health Systems Insight’s (formerly Thinkwell Institute) led a group to led a group to develop research principles that cut across not only our own work but also of that of others conducting costing work around the zero-dose topic. You can read more about the meeting of this group in April 2024, including a presentation on the key principles and methodological issues in zero-dose costing from Laura Boonstoppel and an overview of Health Systems Insight’s work on zero-dose costing from Flavia Moi. In September, Gavi hosted a webinar as part of their Zero-Dose Learning Week – you can see the presentations on costing and more here.