Reaching zero-dose children—those that have missed out on all routine vaccines—is a central pillar of both WHO’s Immunization Agenda 2030 and Gavi’s 5.0 strategy; however, economic evidence to support decision-makers in this is lacking. During the IHEA Immunization Economics Pre-Congress in July 2023, our community of practice identified this knowledge gap as a key research priority: Generating evidence on cost, cost-effectiveness, and efficiency of reaching zero dose children in different contexts, including targeted local interventions, campaigns, but also strengthening the PHC system.
In April 2024, the Zero Dose Costing Working Group—key stakeholders working on or about to launch work on estimating the cost of reaching zero-dose individuals—came together to discuss methods, approaches, and challenges. In August, the group published a set of research principles for studies aiming to estimate the cost of zero-dose children.
This page aims to summarize all planned, ongoing, and completed work focused on developing economics evidence around what it takes to reach zero-dose children.
In April 2024, the Zero Dose Costing Working Group, key stakeholders working on or about to launch work on estimating the cost of reaching zero-dose children, came together to discuss methods, approaches, and challenges. Click the button to the right to view the materials presented and agenda.
Presentation by Logan Brenzel, independent consultant for the Gates Foundation
Presentation by Laura Boonstoppel, ThinkWell
Presentation by Sarah Tougher, UNICEF
Set of research principles for studies that aim to estimate the cost of reaching zero-dose children.
Here we will be compiling research efforts on the economics of reaching zero-dose children. If you are working on a project related to this topic, please reach out to us at immunizationeconomics@thinkwell.global.
The Gates Foundation is exploring the additional costs of reaching zero-dose (ZD) children and communities through a Zero Dose Learning Agenda (ZDLA).
The ZDLA works with countries with the greatest numbers of ZD children (DR Congo, Ethiopia, Nigeria, India, and Pakistan) in selected subnational areas to achieve the following:
The ZDLA costing work intends to evaluate health care service or community-based interventions; the cost or cost savings to households; and, the cost of the learning approach adapting standardized methods.
The JSI-led ZDLH works to generate evidence and learning on effective methods and approaches for identifying and reaching under-immunized and zero-dose (ZD) children and missed communities in low- and middle-income countries (LMIC). Funded by Gavi, the ZDLH is composed of a global consortium that provides technical support to four country learning hubs (CLHs) that work to advance the uptake of research and evidence to improve immunization policy and programming.
There is growing interest in understanding how to reliably measure the incremental cost of reaching under-immunized and ZD children, as well as the cost effectiveness of different ZD interventions in LMIC. The CLHs in Bangladesh, Nigeria, and Uganda are currently working to collect costing data using costing indicators and study designs focused on targeted subnational areas and specific ZD contexts. The ZDLH is supporting the CLHs’ research design and selection of costing methods and indicators to measure the cost effectiveness of a range of ZD interventions tailored to different contexts and where possible, the incremental costs of reaching under-immunized and ZD children. As part of this support, the ZDLH is developing operational guidance for incorporating ZD costing activities into implementation research.
At the conclusion of this costing initiative, the CLHs will have evidence-based data on the cost for vaccination per child, including those who are categorized as under-immunized or ZD. The CLHs will share the findings of their costing activities, including key learnings and recommendations for future costing work.
ThinkWell is implementing a project to generate critical economic evidence on the cost of interventions that target zero-dose children in Ethiopia, Pakistan, and Nigeria. In each of the countries, ThinkWell is working 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.
In Ethiopia, ThinkWell has 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.
In Pakistan, ThinkWell is working with PHC Global to analyze the cost of several strategies implemented in Punjab and Sindh: Enhanced/integrated outreach, Clinics on Wheels which deliver primary health care in urban slums, and the leveraging of polio campaigns to identify zero-dose children.
In Nigeria, ThinkWell is working 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.
UNICEF’s work related to immunization economics in zero-dose settings is comprised of two workstreams. The first workstream involves assessing the financial sustainability of interventions targeted to zero-dose children in Equity Accelerator Fund and Health Systems Strengthening proposals to GAVI from 12 countries (Burundi, Central African Republic, Côte d’Ivoire, Djibouti, Ethiopia, Kenya, Lao PDR, Mali, Nepal, Tajikistan, Uganda, Zambia).
The second workstream involves costing studies embedded into projects implemented by UNICEF in three countries (Ethiopia, Kenya, and Uganda). The project in Ethiopia is a multi-sectoral initiative to reach vulnerable children in underserved population (internally displaced people, urban poor, and pastoralists) with immunization and nutrition services involving two delivery modalities, and a cash plus immunization social protection pilot in a subset of areas. The projects in Kenya and Uganda involves the development of strategies to reach zero-dose children in urban poor settings, particularly those living in slums and informal settlements.
VillageReach is conducting an economic evaluation to understand the cost-effectiveness of high-impact interventions aimed at reducing zero-dose outcomes in Tshopo and Haut-Katanga provinces in the DRC. These interventions are funded by the Equity Acceleration Fund (EAF) by Gavi. The specific interventions being evaluated are as follow:
The study aims to estimate the direct and indirect costs of each high-impact intervention, to assess the cumulative effectiveness of the high impact interventions in reducing zero-dose numbers, estimate the cost to reach each zero-dose child, understand if high-impact interventions are value for money and cost effective, and understand factors influencing the cost effectiveness of the interventions. The interventions will be evaluated as a package of interventions funded by the EAF and their collective/cumulative impact on zero-dose numbers will be measured at baseline and endline through household surveys and secondary review of immunization registers/records.
The Boston University School of Public Health is conducting modeling analyses to develop proxy estimates for the costs of delivering vaccines to zero-dose children in low- and middle-income countries. Leveraging previous work, this project will use multiple methodologies to approximate vaccine delivery costs for zero-dose populations, including quantitative synthesis of delivery costs for interventions to scale up immunization coverage and delivery costs for outreach efforts in the Immunization Delivery Cost Catalogue. This work may inform future fundraising and resource allocation efforts for interventions that target zero-dose children.
Any organization or individual working in the field of immunization economics can submit findings, opportunities, calls to action, or other relevant work below to be shared with our community.
