An Estimate Of The Return On Investment Of A Malaria Vaccine In 20 Sub-Saharan African Countries, 2021-30.

Malaria is a leading global health problem that was responsible for an estimated 619,000 deaths worldwide in 2021. We modeled the return on investment (ROI) for the introduction and continuation of a four-dose malaria vaccine, RTS,S/AS01, from 2021 to 2030 in twenty sub-Saharan African countries supported by Gavi, the Vaccine Alliance. We used the Decade of Vaccine Economics benefits and costing outputs to calculate an ROI using health impact data modeled by the Swiss Tropical and Public Health Institute (hereafter "Swiss") and Imperial College London (hereafter "Imperial"). The Swiss estimates with a base vaccine price of US$7.00 resulted in an ROI of 0.42, and the Imperial impact estimates with the same base vaccine price resulted in an ROI of 2.30. Inclusion of the fifth seasonal dose for ten countries exhibiting high seasonal disease burden increased the Swiss ROI by 143 percent, to 1.02, and the Imperial ROI by 23.5 percent, to 2.84. To improve ROI, decision makers should continue to improve delivery platforms, decrease vaccine delivery costs, deliver the malaria vaccine in fewer doses, and provide access to vaccine resources.

Multivariate assessment of vaccine equity in Nigeria: A VERSE tool case study using demographic and health survey 2018.

Nigeria experiences wide heterogeneity in vaccination rates by vaccine and region. However, inequities in vaccination status extend beyond just geographic covariates. Traditionally, inequity is represented by a single metric pertaining to socioeconomic status. A growing body of literature suggests that this view is limiting, and a multi-factor approach is necessary to comprehensively evaluate relative disadvantage between individuals. The Vaccine Economics Research for Sustainability and Equity (VERSE) tool produces a composite equity metric, which accounts for multiple factors influencing inequity in vaccination coverage. We apply the VERSE tool to Nigeria's 2018 Demographic and Health Survey (DHS) to cross-sectionally evaluate equity in vaccination status for national immunization program (NIP) vaccines over the following contributing covariates: age of child, sex of child, maternal education level, socioeconomic status, health insurance status, state of residence, and urban or rural designation. We also assess equity for zero-dose, fully immunized for age, and completion of NIP. Results show that socioeconomic status contributes substantially to variation vaccination coverage, but it is not the most substantial factor. For all vaccination statuses, except for NIP completion, maternal education level is the greatest contributor towards a child's immunization status among model variables. We highlight the outputs for zero-dose, fully immunized at infancy, MCV1 and PENTA1. The percentage point gap in vaccination status between the top and bottom quintiles of disadvantage, as ranked by the composite indicator is 31.1 (29.5-32.7) for zero-dose status, 53.1 (51.3-54.9) for full immunization status, 48.9 (46.9-50.9) for MCV1, and 67.6 (66.0-69.2) for PENTA1. Though concentration indices indicate inequity for all statuses, full immunization coverage is very low at 31.5% suggesting significant gaps in reaching children after initial doses for routine immunizations. Applying the VERSE tool to future Nigeria DHS surveys can allow decisionmakers to track changes in vaccination coverage equity, in a standardized manner, over time.

Comparing Multivariate with Wealth-Based Inequity in Vaccination Coverage in 56 Countries: Toward a Better Measure of Equity in Vaccination Coverage.

INTRODUCTION: Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study applies the Vaccine Economics Research for Sustainability and Equity (VERSE) vaccination equity toolkit to measure national-level inequity in immunization coverage using a multidimensional ranking procedure and compares this with traditional wealth-quintile based ranking methods for assessing inequity. The analysis covers 56 countries with a most recent Demographic & Health Survey (DHS) between 2010 and 2022. The vaccines examined include Bacillus Calmette-Guerin (BCG), Diphtheria-Tetanus-Pertussis-containing vaccine doses 1 through 3 (DTP1-3), polio vaccine doses 1-3 (Polio1-3), the measles-containing vaccine first dose (MCV1), and an indicator for being fully immunized for age with each of these vaccines. MATERIALS & METHODS: The VERSE equity toolkit is applied to 56 DHS surveys to rank individuals by multiple disadvantages in vaccination coverage, incorporating place of residence (urban/rural), geographic region, maternal education, household wealth, sex of the child, and health insurance coverage. This rank is used to estimate a concentration index and absolute equity coverage gap (AEG) between the top and bottom quintiles, ranked by multiple disadvantages. The multivariate concentration index and AEG are then compared with traditional concentration index and AEG measures, which use household wealth as the sole criterion for ranking individuals and determining quintiles. RESULTS: We find significant differences between the two sets of measures in almost all settings. For fully-immunized for age status, the inequities captured using the multivariate metric are between 32% and 324% larger than what would be captured examining inequities using traditional metrics. This results in a missed coverage gap of between 1.1 and 46.4 percentage points between the most and least advantaged. CONCLUSIONS: The VERSE equity toolkit demonstrated that wealth-based inequity measures systematically underestimate the gap between the most and least advantaged in fully-immunized for age coverage, correlated with maternal education, geography, and sex by 1.1-46.4 percentage points, globally. Closing the coverage gap between the bottom and top wealth quintiles is unlikely to eliminate persistent socio-demographic inequities in either coverage or access to vaccines. The results suggest that pro-poor interventions and programs utilizing needs-based targeting, which reflects poverty only, should expand their targeting criteria to include other dimensions to reduce systemic inequalities, holistically. Additionally, a multivariate metric should be considered when setting targets and measuring progress toward reducing inequities in healthcare coverage.

Financing And Funding Gap For 16 Vaccines Across 94 Low- And Middle-Income Countries, 2011-30.

We estimated immunization program costs, financing, and funding gaps for sixteen vaccines among ninety-four low- and middle-income countries during the period 2011-30. Inputs were obtained from the Institute for Health Metrics and Evaluation, the 2020 Decade of Vaccine Economics costing analysis, the World Health Organization, Gavi, and the United Nations Children's Fund. We found a total funding gap of $38.4 billion between 2011 and 2030, with the cost of immunization delivery being the main driver (86 percent) of the funding gap. On average, government financing of vaccination programs steadily rises throughout the period. However, the decline in both Gavi and development assistance for health (DAH) financing anticipated between 2011 and 2030 outpaces the forecasted increases in domestic government immunization spending. Probabilistic sensitivity analysis was applied to both the costing and the scenario analyses to address uncertainty in the financing of vaccines and vaccine delivery. The results highlight a narrowing gap for vaccine acquisition but a growing gap for vaccine delivery, which emphasizes the critical need for resource mobilization and sustainable financial strategies for immunization programs at national and global levels, as well as a need to address the COVID-19 pandemic's potential effects on government financing for vaccines between 2021 and 2030.

Achieving immunization agenda 2030 coverage targets for 14 pathogens: Projected product and immunization delivery costs for 194 Countries, 2021-2030.

Understanding the level of investment needed for the next decade is vital to achieve the goal of Immunization Agenda 2030 (IA2030). Through the immunization funder perspective, this study estimates both global and regional economic resources required to achieve IA2030 coverage among 194 WHO member countries from 2021 to 2030, against 14 pathogens: Hepatitis B (Hep B), Haemophilus influenzae type b (Hib), Human papillomavirus (HPV), Japanese encephalitis (JE), Measles, Meningitis A (Men A), Streptococcus pneumoniae, Rotavirus, Rubella, Yellow Fever (YF), Diphtheria, Tetanus, Pertussis, and Tuberculosis. The total cost of immunization program, routine vaccine, routine delivery, and non-routine costs (SIA and stockpile) were estimated using WHO coverage forecast for IA2030. Incremental costs of achieving IA2030 for all vaccines and cost per immunized child were also assessed. All costs were calculated for each income and regional level, as well as global level. Scenario analysis and sensitivity analysis were conducted to account for uncertainty in future vaccine pricing and delivery costs. The total cost of immunization programs is $269.8 billion (95% confidence interval: $247.1 - $311.8), of which $152.8 billion is considered as routine vaccine cost, $114.9 billion is routine delivery cost. Non- routine cost for LICs and LMICs totaled $2.1 billion. The incremental cost of achieving coverage goals after 2020 is $89.9 billion ($27.7-$110.1), with upper-middle income countries requiring the largest increase in investment (56.2% of incremental costs). The average immunization cost per child across all countries is $192.6. Scenario analysis using the minimum and maximum vaccines price for fully self-financing countries resulted in total costs ranging from $193.6 and $552.2 billion. The immunization program cost among 194 WHO member countries is expected to increase during this decade. The strategy for resource mobilization and increasing investment from country governments and donors are essential to achieving IA2030 coverage and ensuring sustainable immunization programs.

COVID-19 impact on index testing services and programmatic cost in 5 high HIV prevalence Indian districts.

BACKGROUND: Restrictions to curb the first wave of COVID-19 in India resulted in a decline in facility-based HIV testing rates, likely contributing to increased HIV transmission and disease progression. The programmatic and economic impact of COVID-19 on index testing, a standardized contact tracing strategy, remains unknown. METHODS: Retrospective programmatic and costing data were analyzed under a US government-supported program to assess the pandemic's impact on the programmatic outcomes and cost of index testing implemented in two Indian states (Maharashtra and Andhra Pradesh). We compared index testing continuum outcomes during lockdown (April-June 2020) and post-lockdown (July-Sept 2020) relative to pre-lockdown (January-March 2020) by estimating adjusted rate ratios (aRRs) using negative binomial regression. Startup and recurrent programmatic costs were estimated across geographies using a micro-costing approach. Per unit costs were calculated for each index testing continuum outcome. RESULTS: Pre-lockdown, 2431 index clients were offered services, 3858 contacts were elicited, 3191 contacts completed HIV testing, 858 contacts tested positive, and 695 contacts initiated ART. Compared to pre-lockdown, the number of contacts elicited decreased during lockdown (aRR = 0.13; 95% CI: 0.11-0.16) and post-lockdown (aRR = 0.49; 95% CI: 0.43-0.56); and the total contacts newly diagnosed with HIV also decreased during lockdown (aRR = 0.22; 95% CI: 0.18-0.26) and post-lockdown (aRR = 0.52; 95% CI: 0.45-0.59). HIV positivity increased from 27% pre-lockdown to 40% during lockdown and decreased to 26% post-lockdown. Further, ART initiation improved from 81% pre-lockdown to 88% during lockdown and post-lockdown. The overall cost to operate index testing was $193,457 pre-lockdown and decreased during lockdown to $132,177 (32%) and $126,155 (35%) post-lockdown. Post-lockdown unit cost of case identification rose in facility sites ($372) compared to pre-lockdown ($205), however it decreased in community-based sites from pre-lockdown ($277) to post-lockdown ($166). CONCLUSIONS: There was a dramatic decline in the number of index testing clients in the wake of COVID-19 restrictions that resulted in higher unit costs to deliver services; yet, improved linkage to ART suggests that decongesting centres could improve efficiency. Training index testing staff to provide support across services including non-facility-based HIV testing mechanisms (i.e., telemedicine, HIV self-testing, community-based approaches) may help optimize resources during public health emergencies.

Coverage and Equity of Childhood Vaccines in China.

Importance: Measuring vaccination coverage rates and equity is crucial for informing immunization policies in China. Objectives: To estimate coverage rates and multidimensional equity for childhood vaccination in China. Design, Setting, and Participants: This cross-sectional study was conducted via a survey in 10 Chinese provinces between August 5 and October 16, 2019, among children ages 6 months to 5 years and their primary caregivers. Children's vaccination records and their primary caregivers' demographics and socioeconomic status were collected. Data were analyzed from November 2019 to March 2022. Main Outcomes and Measures: Vaccine coverage rates were measured as a percentage of National Immunization Program (NIP) and non-NIP vaccines administered before the day on which the child was surveyed. A multidimensional equity model applied a standardized approach to ranking individuals from least to most unfairly disadvantaged by estimating differences between observed vaccination status and estimated vaccination status as function of fair and unfair variation. Fair sources of variation in coverage included whether the child was of age to receive the vaccine, and unfair sources of variation included sex of the child and sociodemographic characteristics of caregivers. Absolute equity gaps (AEGs), concentration index values, and decompositions of factors associated with vaccine equity were estimated in the model. Results: Vaccine records and sociodemographic information of 5294 children (2976 [52.8%] boys and 2498 [47.2%] girls; age range, 6-59 months; 1547 children aged 12-23 months) and their primary caregivers were collected from 10 provinces. Fully immunized coverage under the NIP was 83.1% (95% CI, 82.0%-84.1%) at the national level and more than 80% in 7 provinces (province coverage ranged from 77.8% [95% CI, 74.3% to 81.3%] in Jiangxi to 88.4% [95% CI, 85.7%-91.1%] in Beijing). For most non-NIP vaccines, however, coverage rates were less than 50%, ranging from 1.8% (95% CI, 1.3%-2.2%) for the third dose of rotavirus vaccine to 67.1% (65.4% to 68.8%) for the first dose of the varicella vaccine. The first dose of Haemophilus influenzae type b vaccine had the largest AEG, at 0.603 (95% CI, 0.570-0.636), and rotavirus vaccine dose 3 had the largest concentration index value, at 0.769 (95% CI, 0.709-0.829). The largest share of non-NIP vaccine inequity was contributed by monthly family income per capita, followed by education level, place of residence, and province for caregivers. For example, the proportion of explained inequity for pneumococcal conjugate vaccine dose 3 was 40.94% (95% CI, 39.49%-42.39%), 22.67% (95% CI, 21.43%-23.9%), 27.15% (95% CI, 25.84%-28.46%), and 0.68% (95% CI, 0.44%-0.92%) for these factors, respectively. Conclusions and Relevance: This cross-sectional study found that NIP vaccination coverage in China was high but there was inequity for non-NIP vaccines. These findings suggest that improvements in equitable coverage of non-NIP vaccination may be urgently needed to meet national immunization goals.

Return on Investment of 10-Valent Pneumococcal Conjugate Vaccine in Ecuador From 2010 to 2030.

OBJECTIVES: Ecuador introduced the pneumococcal conjugate vaccine in 2010. A recent time series analysis has demonstrated the impact of 10-valent pneumococcal conjugate vaccine (PCV10) on hospitalized pneumococcal disease in children. We leveraged these estimates to calculate the return on investment (ROI) of PCV10 in Ecuador from 2010 to 2030 at the national and regional levels. METHODS: We used 2 approaches to estimate the economic benefits: (1) cost of illness, which includes treatment, transportation, and productivity loss averted, (2) and the value of statistical life, which reflects society's average willingness to pay to save one life. Costs of the immunization program include vaccine costs (doses, syringes, injection supplies) and immunization delivery costs (personnel, cold chain equipment and maintenance, transportation, distribution services, and other recurrent costs). We estimated the ROI by dividing the net benefits by costs. RESULTS: The ROI using the cost-of-illness approach was slightly negative in the introduction year. From 2011 to 2020, we estimated the ROI to be 0.45 (0.15-0.73). For the future decade, the ROI is estimated at 0.37 (-0.03 to 1.03). Using the value-of-statistical-life approach, the ROI was 1.46 (0.82-2.17) in the introduction year. In the first decade, the ROI was 1.01 (0.49-1.60); in the second decade, the ROI fell to 0.83 (0.23-1.78). CONCLUSIONS: The results of this study demonstrate the total economic benefits of PCV10 in Ecuador exceed immunization program costs after the introduction year. Estimates from this study will inform country policy makers and will contribute to efforts to mobilize resources for immunization.

A standardized approach for measuring multivariate equity in vaccination coverage, cost-of-illness, and health outcomes: Evidence from the Vaccine Economics Research for Sustainability & Equity (VERSE) project.

Following a call from the World Health Organization in 2017 for a methodology to monitor immunization coverage equity in line with the 2030 Agenda for Sustainable Development, this study outlines a standardized approach for measuring multivariate equity in vaccine coverage, economic impact, and health outcomes. The Vaccine Economics Research for Sustainability & Equity (VERSE) composite vaccination equity measurement approach is derived from literature on the measurement of socioeconomic inequality combined with measures of direct unfairness in healthcare access. The final metrics take the form of a concentration index for vaccination coverage where individuals are ranked by multivariate unfairness in access and an absolute equity gap representing the difference in coverage between the top and bottom quintiles of individuals ranked by multivariate unfairness in access. Regression decomposition is applied to the concentration index to determine each factor's relative influence on observed inequity. These methods are applied to India's National Family Health Survey (NFHS) from 2015 to 2016 to assess the equity in being fully-immunized for age vaccination coverage and zero-dose status. The multivariate absolute equity gap is 0.120 (SE: 003) and 0.371 (SE: 0.008) for zero-dose status and fully-immunized for age, respectively. Therefore, the most disadvantaged quintile is 12 percentage points more likely to be zero-dose than the most advantaged quintile and 37.1 percentage points less likely to be fully immunized. The primary correlate of unfair disadvantage for both outcomes is maternal education accounting for 27.4% and 19.1% of observed inequality. The VERSE model provides a standardized approach for measuring multivariate vaccine coverage equity. It also allows policymakers to determine the relative magnitude of factors influencing multivariate equity rather than only the correlates of socioeconomic or bivariate equity. This framework could be adapted to track equitable progress toward Universal Health Coverage (UHC) or outcomes beyond the vaccine space.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review.

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

Economic Benefits of Immunization for 10 Pathogens in 94 Low- and Middle-Income Countries From 2011 to 2030 Using Cost-of-Illness and Value-of-Statistical-Life Approaches.

OBJECTIVES: Vaccination has prevented millions of deaths and cases of disease in low- and middle-income countries (LMICs). During the Decade of Vaccines (2011-2020), international organizations, including the World Health Organization and Gavi, the Vaccine Alliance, focused on new vaccine introduction and expanded coverage of existing vaccines. As Gavi, other organizations, and country governments look to the future, we aimed to estimate the economic benefits of immunization programs made from 2011 to 2020 and potential gains in the future decade. METHODS: We used estimates of cases and deaths averted by vaccines against 10 pathogens in 94 LMICs to estimate the economic value of immunization. We applied 3 approaches-cost of illness averted (COI), value of statistical life (VSL), and value of statistical life-year (VSLY)-to estimate observable and unobservable economic benefits between 2011 and 2030. RESULTS: From 2011 to 2030, immunization would avert $1510.4 billion ($674.3-$2643.2 billion) (2018 USD) in costs of illness in the 94 modeled countries, compared with the counterfactual of no vaccination. Using the VSL approach, immunization would generate $3436.7 billion ($1615.8-$5657.2 billion) in benefits. Applying the VSLY approach, $5662.7 billion ($2547.2-$9719.4) in benefits would be generated. CONCLUSION: Vaccination has generated significant economic benefits in LMICs in the past decade. To reach predicted levels of economic benefits, countries and international donor organizations need to meet coverage projections outlined in the Gavi Operational Forecast. Estimates generated using the COI, VSL, or VSLY approach may be strategically used by donor agencies, decision makers, and advocates to inform investment cases and advocacy campaigns.