In Vaccine X researchers from PATH address a “dearth” of evidence on determinants of vaccine delivery costs for human papillomavirus (HPV) vaccine with an analysis to identify “programmatic and operational factors” that are associated with cost variations. The analysis drew on data from Ethiopia, Guyana, Rwanda, Senegal, Sri Lanka, and Uganda to provide evidence for programme stakeholders on which programme context variables affect costs. The authors hope that this can “inform programme adjustment to improve cost efficiency”. This is particularly important amid efforts to “revitalise and rebuild” HPV vaccine coverage after the COVID-19 pandemic.
Varying costs
The costs of delivering human papillomavirus (HPV) vaccines vary “within and across low- and middle-income countries” (LMICs). However, there is “limited evidence” on the factors behind these cost differences, and research from routine infant vaccine delivery can “fail to capture the drivers” of HPV vaccine delivery required for “effective and budget-conscious” planning. Indeed, many routine HPV vaccination services in LMICs are offered in school-based or outreach settings, so they differ from infant vaccines that are “predominantly provided in facility-based settings”.
Thus, factors like the number of schools served and distance travelled by health workers could affect programme costs. Other factors are “unique” to HPV vaccination programmes, such as per diem payment to vaccination teams and variation in timing of vaccination delivery.
Global HPV vaccine coverage dropped by 15% because of the COVID-19 pandemic; this was the most significant coverage decline during the pandemic. While HPV vaccination programmes attempt to “revitalise and expand coverage”, the authors suggest the need for evidence on cost drivers to improve cost efficiency “without compromising programme quality”. Their study evaluated the operational context and costs of HPV vaccine delivery in six LMICs.
The study
The researchers conducted secondary analysis of data from a primary mixed-methods study that evaluated the operational context and economic and financial costs of HPV vaccine delivery in Ethiopia, Guyana, Rwanda, Senegal, Sri Lanka, and Uganda. The programme activities included programme planning and management, social mobilisation, training, vaccine collection and storage, service delivery, crisis management, and waste disposal.
Economic costs were calculated for each activity conducted by health facilities, including financial and opportunity costs:
- Financial costs – expenditures with direct financial outlays like per diems paid, venue rentals, and meals for meetings, travel expenditures, and distribution of materials for social mobilisation.
- Opportunity costs – costs of using existing resources and including time costs for health workers/vaccinators, support staff, and non-health workers, annualised cost for vehicles and equipment.
What does the study find?
Like studies of routine infant vaccinations, the authors found in this research that total doses delivered were “positively and significantly associated with the economic costs”. This reflects “increasing resource use with an increase in service volume”, but the variables were not statistically significant in conditional regression.
The study also identified cost determinants that had not previously been explored. For example, the higher the number of HPV vaccination sessions conducted by the health facility, the higher the economic costs for that facility. The larger the number of activities or meetings held by the facility, the higher the economic costs.
“HPV vaccination programmes seeking to reduce costs may explore options to reduce the intensity of some programme activities, where possible, to increase cost efficiency.”
For some countries, moving from a two-dose schedule to a single-dose schedule may reduce the number of vaccination sessions held per health facility during the year and/or reduce the number of vaccination activities conducted. This would be “especially true” for countries like Rwanda, where the first dose is “almost exclusively” administered in the first half of the year and the second dose in the latter half. However, without a schedule change facilities can still “examine the activities being done and reduce intensity where possible”.
Health worker utilisation was “positively and significantly associated with costs” in both unconditional and conditional regressions. As human resource time is the “largest share” of economic costs, a reduction in the intensity and frequency of activities might reduce the total human resource time. For HPV vaccination programmes, human resource utilisation also includes non-health workers, like school staff or community stakeholders. Their engagement increases economic costs.
“In some countries, there may be a need to identify strategies to reduce the labour intensity of HPV vaccination programme activities to reduce programme costs.”
The primary analysis revealed that in countries where per diems were paid, the per diems comprised the largest share of financial costs at health facility level. Although per diems can “augment health worker salaries and incentivise travelling”, not paying per diems might reduce costs and increase cost efficiency.
The paper concludes that the findings offer evidence to stakeholders on the variables that affect costs.
“This evidence can be used to adjust programme characteristics to improve cost efficiency, especially in a context of programme revitalisation and coverage improvement after the pandemic.”
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