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Technical Report Costing and Financing Analyses of Routine Do Not Circulate or Quote Without Permission Technical Report Costing and Financing Analyses of Routine Immunization in Zambia Carl Schütte, Anthony Kinghorn, Collins Chansa, Edmore Marinda, Teresa Guthrie, Stanley Banda, Kerrin Humphreys, Zipozihle Chuma Nombewu, Katlego Motlogelwa 30 November 2014 Mott MacDonald House 25 Scott St Waverley Johannesburg South Africa T: +27-87-310-5000 F: +27-87-310-5198 Contact Person: Dr. Anthony Kinghorn [email protected] (+27) 83 273 4276 1 Do Not Circulate or Quote Without Permission Contents Index of Figures and Tables .................................................................... iii Acknowledgements ............................................................................... v Acronyms ......................................................................................... vi Executive Summary ............................................................................. vii 1 Purpose and Scope of the Study ......................................................... 1 Rationale for and purpose of the study ........................................... 1 Scope of the study ................................................................... 2 2 Background ................................................................................. 4 Country overview ..................................................................... 4 Facility types and catchment populations ........................................ 5 Stewardship framework ............................................................. 6 2.3.1 Strategic Plans and Decision Making Process ................................ 6 2.3.2 Implementation structures ..................................................... 6 2.3.3 Joint coordination structures .................................................. 8 2.3.4 Annual planning and immunization schedule ................................ 8 2.3.5 EPI Program performance ...................................................... 8 Introduction of new vaccines in Zambia .......................................... 9 Current knowledge of costs and financing of immunization in Zambia ...... 10 2.5.1 Funding flows ................................................................... 10 2.5.2 Existing cost estimates of routine immunization .......................... 11 2.5.3 Resource requirements and sustainability .................................. 11 3 Cost Analysis of Routine Immunization ................................................ 12 Methods ............................................................................... 12 3.1.1 Perspective and key assumptions ............................................ 12 3.1.2 Sampling ......................................................................... 18 3.1.3 Data collection .................................................................. 22 3.1.4 Data quality and verification process ........................................ 23 3.1.5 Data entry and analysis ........................................................ 23 3.1.6 Aggregation of costs from facility to national level estimates ........... 24 3.1.7 Limitations of the approach .................................................. 24 3.1.8 Ethical issues .................................................................... 25 Results - total and unit costs ...................................................... 26 3.2.1 Facility level .................................................................... 26 3.2.2 Comparison of Financial and economic costs at facility level ........... 37 3.2.3 District, provincial and national level costs ................................ 39 3.2.4 Total national immunization program economic and unit costs ......... 45 3.2.5 Impact of changed wastage rates ............................................ 47 3.2.6 Impact of reduced outreach time ............................................ 48 Discussion ............................................................................. 49 3.3.1 Generalisability of results ..................................................... 49 3.3.2 Profile of EPI costs in Zambia ................................................. 49 3.3.3 Unit costs ........................................................................ 50 3.3.4 Comparison with the cMYP .................................................... 51 3.3.5 Comparison with health expenditure and national budget for EPI ...... 54 Summary and Conclusions .......................................................... 55 4 Cost Analysis of New Vaccine Introduction ........................................... 58 Introduction .......................................................................... 58 Methods ............................................................................... 58 4.2.1 Perspective and key assumptions ............................................ 58 4.2.2 Data collection, entry and analysis .......................................... 62 4.2.3 Data quality and verification process ........................................ 63 4.2.4 Limitations of the approach .................................................. 63 Incremental cost estimates ........................................................ 64 i Do Not Circulate or Quote Without Permission 4.3.1 Total incremental NUVI costs ................................................. 64 4.3.2 NUVI costs by activity .......................................................... 67 4.3.3 Start-up and Ongoing costs of NUVI .......................................... 67 4.3.4 NUVI unit costs .................................................................. 68 4.3.5 Costs at various levels of the health system ................................ 69 Comparison with NUVI introduction grant ....................................... 70 Conclusions ........................................................................... 72 5 Productivity Analysis ..................................................................... 75 Background: assessing productivity of immunization and health services .. 75 5.1 Methods ............................................................................... 77 5.2.1 Approach to productivity analysis ............................................ 77 5.2 Results ................................................................................ 79 5.2.1 Quadrant analysis ............................................................... 79 5.2.2 Statistical analysis .............................................................. 82 5.1 Discussion ............................................................................. 84 5.3 Conclusions ........................................................................... 84 6 Analysis of the Determinants of Routine Immunization Costs ...................... 86 6.1 Background: cost function analysis of immunization and primary health care86 6.2 Methods ............................................................................... 87 6.2.1 Dependent and Independent variables: selection and description ...... 87 6.2.2 Functional form for evaluating the cost function & estimation techniques 90 6.3 Results ................................................................................ 91 6.3.1 Quadrant analysis ............................................................... 91 6.3.2 Regression results .............................................................. 92 6.4 Discussion ............................................................................. 95 6.5 Conclusions ........................................................................... 96 7 Analysis of Financial and Commodity Flows for Routine Immunization ........... 98 7.1 Background: health care financing, immunization planning and budgeting 98 7.2 Methods for the quantitative analysis of financial and commodity flows ... 98 7.2.1 Data collection and key assumptions ........................................ 98 7.2.2 Coding and analysis ............................................................ 99 7.2.3 Limitations of the approach ................................................. 100 7.3 Mapping of financial flows ........................................................ 100 7.4 Results of the quantitative analysis ............................................. 101 7.4.1 Sources of finance and funding agents ..................................... 101 7.4.2 Transfers from funding agents to service providers ...................... 103 7.4.3 Allocation of funding to expenditure categories and line items ........ 104 7.5 Results of the qualitative assessment ........................................... 105 7.5.1 Comparison with cMYP estimates of financing and aggregated costs .. 105 7.5.2 Other observations ............................................................ 106 7.6 Discussion ............................................................................ 107 7.7 Conclusions .......................................................................... 108 8 Conclusions and recommendations .................................................. 110 8.1 Main conclusions .................................................................... 110 8.2 Recommendations .................................................................. 115 Annex 1 – References ......................................................................... 118 Annex 2 - Sampling Frame ................................................................... 122 Annex 3 - Codes for mapping financial flows .............................................. 125 Annex 4 – List
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