Delivering 270M+ COVID-19 vaccines at just $0.29 per dose: The Bangladesh experience

Bangladesh launched its COVID-19 vaccination program in February 2021 with the ambitious aim of reaching 80% of the population with two doses. The program used a phased approach, initially targeting priority groups, and expanding eligibility over time as supply ramped up. By June 2022, the country had achieved its goal—having delivered over 270 million COVID-19 vaccine doses.

How did the Bangladesh manage to successfully deliver such an incredibly large vaccine volume in such a short period of time? What delivery strategies did the program adopt to ensure effective vaccine delivery, and what did these cost?

To address this knowledge gap, ThinkWell conducted a retrospective, bottom-up costing study to estimate the financial and economic costs of delivering COVID-19 vaccines in Bangladesh. The costing analysis was complemented with a qualitative assessment of enabling factors and operational challenges from the implementation of the C19 vaccination effort, as well as a mapping of key funding sources and funding flows.

Key Findings

• The financial cost of COVID-19 vaccine delivery was $0.29 per dose in Bangladesh, primarily driven by volunteer allowances, which accounted for 31-62% of the cost per dose across delivery strategies. This is much lower than was found in other countries of this multi-country project.

• The economic cost per dose was $1.05 per dose, with the opportunity costs consisting primarily of salaries of existing staff and the value of volunteers’ labor, which is also lower than found in most other countries.

• Delivery costs in Bangladesh were low primarily due to the extremely high volume delivered per day (201-983 doses per day per site, depending on the delivery strategy), as well as by the low levels of financial support provided at implementation level, and a high reliance on the existing health workforce.

• The delivery cost varied greatly across delivery strategies, generally driven by the average number of COVID-19 vaccines delivered per site per day. The financial cost of fixed site delivery varied from $0.29 to $0.44, depending on the type of facility, and the financial cost of delivery through temporary sites varied from $0.27 at schools to $0.33 per dose through mass campaigns. The economic cost varied even more across delivery strategies, from $0.74 per dose at schools to $2.15 per dose at government hospitals managed by other institutions than the Ministry of Health.

• Beneficiaries spent an average of $1.63 to receive a single dose of C19 at urban fixed sites. Most of the costs were related to transport to and from the vaccination site. In addition to incurring direct financial expenses, beneficiaries spent time obtaining the vaccination at fixed sites—2 hours and 20 minutes on average, most of which was spent reaching the vaccination site. Including the opportunity cost of their time, the economic cost incurred by beneficiaries averaged at $4.78 per dose received.

Key takeaways

• The successful roll-out of the C19 vaccination program was made possible by leveraging resources and infrastructure of the regular EPI program, which is reflected in low financial costs but high opportunity costs, underscoring the value of investing in robust health systems.

• Mass campaign sites and school-based sites were the most cost-efficient and equitable modalities among those evaluated in this study, though a comprehensive delivery strategy mix should consider the equity, cost, and scale of all possible delivery modalities.

• The discontinuation of the vaccinators’ honorariums after the first year was as a departure from a commitment to support its health workforce through a particularly challenging time that could have lasting implications for the health system.

• Though government financial management regulations were rigid and restrictive, optimized public financial management processes for development partners ensured timely access to donor funding at lower administrative levels.

• Exceptional political prioritization and strong local commitment were key to the success of the C19 vaccination program in Bangladesh, though routine EPI will likely not be able to count on the same going forward. To ensure the long-term success of vaccination initiatives beyond the emergency-driven dynamics witnessed during the C19 response, it is crucial to strengthen the health system.

This study is part of a multi-country project that utilizes standardized methods to generate cost evidence on the delivery of C19 vaccines in low- and middle-income countries. The project is led by ThinkWell, and supported by the Bill & Melinda Gates Foundation, and covers studies in Bangladesh, Côte d’Ivoire, the Democratic Republic of Congo, Mozambique, Uganda, Vietnam, and The Philippines.