Abstract
Background
Despite the critical role of vaccine-preventable disease (VPD) surveillance in detecting and responding to disease outbreaks, cost estimates of such surveillance systems are understudied in low- and middle-income country contexts. This study aimed to evaluate VPD surveillance system costs in Ethiopia. Understanding these costs will contribute to future planning and budgeting, allowing national programs to include sufficient resources for VPD surveillance activities, especially in the context of decreasing donor funding.
Methods
This cross-sectional retrospective costing study collected primary and secondary data on resource utilization to conduct VPD surveillance during one fiscal year (2018-2019) in Ethiopia. The study covered 16 VPDs in the surveillance system, including costs from all involved government and partner offices at the federal level; a purposive sample of three regions (Addis Ababa, Amhara, Somali); and a stratified random sample of zones, woredas, and hospitals/health centers (with purposive selection of sentinel sites) within the regions. The sampled regions were selected based on urbanization rates and presence of regional laboratories. At least two health centers/hospitals per woreda were sampled to capture variability in costs at these levels. Data were collected between March and May 2022 from 47 sites across levels. Data from sampled sites were weighted at each administrative level and extrapolated to other regions based on similarities in wealth quintiles. Public health response and vaccination costs were excluded from the study. This study reported both economic (direct expenditures plus opportunity costs) and financial (direct expenditures) costs. All costs were converted from Ethiopian Birr to U.S. Dollars (US$) and inflated to March 2023 US$.
Results
The estimated economic costs of VPD surveillance activities in Ethiopia over the fiscal year 2018-19 were US$67.87 million or US$0.69 per capita, while financial costs were US$19.14 million or US$0.19 per capita. Country-wide, major drivers of economic costs by resource input included labor (41.3%), vehicles (22.8%), and supplies (14.6%), while major drivers of financial costs included vehicles (30.5%), per diem (28.2%), and supplies (20.1%). The main drivers of economic costs by support function included workforce capacity (24.8%), supervision (20.7%), and field logistics and communication (19.1%); and for financial costs, field logistics and communication (33.2%), supervision (25.4%), and program management (22.6%). By VPD, resources were mostly allocated to general VPD surveillance (not specific to one VPD; economic: 55.5%; financial: 58.9%), measles and rubella surveillance (economic: 16.1%; financial: 11.2%) and polio surveillance (economic: 11.0%; financial: 18.7%). Costs varied substantially across levels, regions, and facility types. The main funders were the Ethiopian Ministry of Health (economic: 71.1%; financial 58.2%) and the World Health Organization (economic 15.9%; financial 29.8%).
Conclusion
These VPD surveillance cost estimates show that human resources were major drivers of economic costs, followed by mobility support and supplies. Although the Ethiopian VPD surveillance system uses shared resources across multiple VPDs, resulting in scale efficiencies, and the Ethiopian government covers most of its economic costs, a portion of those costs still relies on external donor support. Such estimates may aid Ethiopia in planning for donor funding transition and investments in surveillance system strengthening.