Abstract
The cost of conducting immunization campaigns in Sierra Leone is not well understood, and there is no evidence available on the cost of co-delivering more than one antigen or health intervention through campaigns. Ahead of introducing the measles-rubella (MR) vaccine into the routine immunization program, a nationwide catch-up campaign was conducted in June 2019 to cover children aged under 15, co-delivered with oral polio vaccines (OPV) in order to boost coverage. Vitamin A supplements and albendazole deworming tablets were also delivered in half of the country’s districts which had the lowest coverage levels. The campaign was largely financed by Gavi, the Vaccine Alliance, complemented by funding from the Sierra Leonean government and other donors. The post-campaign coverage survey found the MR coverage level achieved to be 93.2%. The aim of this study was to estimate the cost of the integrated MR campaign and assess whether integration had any impact on costs.
We conducted an ingredients-based costing study of the campaign from a payer perspective, including 30 facilities across six districts. Three districts delivered MR and OPV only while the other three also delivered the nutritional interventions. Costs were collected from the health system at facility, district and national levels, and also from development partners who were involved in campaign implementation. Unit costs are presented in 2020 USD, weighted by the probability of sampling and volume delivered. Variance in the unit costs was calculated using 95% confidence intervals. Two-sample t-tests and bootstrap regression were used to test for significant differences between subgroups.
The average financial and economic costs per dose delivered were $0.34 and $0.74 respectively. The main financial cost driver was per diem and travel allowances, followed by transport and fuel, and vaccine injection and safety supplies. The economic cost was driven by paid and volunteer labor costs. We found large variation in unit cost estimates across sites. The financial costs ranged from $0.14 to $1.12, with sites that delivered greater volume reporting lower unit costs. The financial delivery cost was $0.42 per dose delivered in MR and OPV only districts as opposed to $0.30 in the co-delivery districts, suggesting efficiencies from co-delivery. A similar trend was observed for the economic unit cost. However, these differences were not statistically significant and likely influenced by the higher volume of doses delivered at sites in co-delivery districts.
This study found that co-delivery may be associated with financial cost efficiencies as the increased delivery volume reduced the unit cost of delivery. However, due to integration not being randomized and the many other differences in characteristics between districts it was not possible to quantify the precise impact of integration on each aspect of the delivery costs. The substantial subnational variation in costs observed highlights that planning and budgeting must be tailored to reach populations across all different settings. The cost evidence can be used by the governments of Sierra Leone and other countries plus donors to support budgeting and planning for future campaigns.