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THE PAKISTAN EXPANDED PROGRAM on IMMUNIZATION and the NATIONAL IMMUNIZATION SUPPORT PROJECT: Public Disclosure Authorized an ECONOMIC ANALYSIS

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THE PAKISTAN EXPANDED PROGRAM on IMMUNIZATION and the NATIONAL IMMUNIZATION SUPPORT PROJECT: Public Disclosure Authorized an ECONOMIC ANALYSIS THE PAKISTAN EXPANDED PROGRAM ON IMMUNIZATION AND THE NATIONAL IMMUNIZATION SUPPORT PROJECT: Public Disclosure Authorized AN ECONOMIC ANALYSIS DISCUSSION PAPER NOVEMBER 2016 Public Disclosure Authorized Minhaj ul Haque Muhammad Waheed Tayyeb Masud Wasim Shahid Malick Hammad Yunus Rahul Rekhi Robert Oelrichs Oleg Kucheryavenko Public Disclosure Authorized Public Disclosure Authorized THE PAKISTAN EXPANDED PROGRAM ON IMMUNIZATION AND THE NATIONAL IMMUNIZATION SUPPORT PROJECT An Economic Analysis Minhaj ul Haque, Muhammad Waheed, Tayyeb Masud, Wasim Shahid Malick, Hammad Yunus, Rahul Rekhi, Robert Oelrichs, and Oleg Kucheryavenko November 2016 1 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Martin Lutalo at [email protected] or Erika Yanick at [email protected]. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected]. © 2016 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper The Pakistan Expanded Program on Immunization and the National Immunization Support Project An Economic Analysis Minhaj ul Haque,a Muhammad Waheed,b Tayyeb Masud,c Wasim Shahid Malick,d Hammad Yunus,e Rahul Rekhi,f Robert Oelrichsg, and Oleg Kucheryavenkoh a Health Specialist, Independent Consultant b Senior Economist, World Bank, Islamabad, Pakistan c Senior Health Specialist, World Bank, Islamabad, Pakistan d Health Specialist, Independent Consultant e Health Specialist, Independent Consultant f Health Specialist, Independent Consultant g Senior Health Specialist, World Bank, Washington DC, USA h Health Specialist, Consultant, World Bank, Washington DC, USA This paper was prepared by the World Bank as part of preparation for the Pakistan National Immunization Support Project (P132308) and financed in part by Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation Abstract: Pakistan faces a formidable challenge in eliminating the polio virus from the country. With transmission of the polio virus substantially slowing in the Africa region, the only two countries worldwide with ongoing endemic polio transmission may soon be Pakistan and Afghanistan. A substantial number of the polio cases or infant paralysis occurring in Afghanistan is linked to cross-border transmission from Pakistan. The ongoing cycle of polio infection is not just a tragedy for the children of Pakistan, it is a global public health emergency constituting one of the final barriers to permanently eradicating polio. The outbreaks of vaccine-preventable diseases in Pakistan result in significant costs to individuals and to society. These include costs associated with visits to health care providers, hospitalizations, disability, and premature deaths. Despite a slow decline over the past 10 years, the under-five mortality rate in Pakistan remains high, with more than 400,000 deaths annually in this demographic over the past twenty years. Pakistan is lagging behind other South Asian countries in improving this indicator. This paper demonstrates clear economic benefits and efficacy of the National Immunization Support Project (NISP), which is financing interventions in terms of DALYs saved, and establishes that this approach is affordable and economically effective with a high rate of return. In addition to increased investment, the effectiveness of the Expanded Program on Immunization can be enhanced by improving the capacity building of health professionals, as well as by improving logistics of program interventions to reach marginalized populations, remote areas, and pockets of resistance. An increased financial investment alone will be insufficient to address the root causes of persistent under- coverage of immunization in Pakistan. It is imperative that ample attention and resources iii be diverted to strengthen the procurement systems, local and provincial management capacity, and reporting mechanisms, among other capacity improvements. Keywords: EPI, financing, immunization, Pakistan Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Robert Oelrichs, World Bank, 1818 H St NW, Washington DC, USA, email [email protected] iv Table of Contents LIST OF ACRONYMS .................................................................................................. VI ACKNOWLEDGMENTS ........................................................................................... VIII EXECUTIVE SUMMARY ............................................................................................ IX INTRODUCTION........................................................................................................... 13 BACKGROUND ............................................................................................................. 15 PERFORMANCE OF THE EPI ............................................................................................ 16 CAUSES OF LOW IMMUNIZATION .................................................................................... 18 EXPENDITURES ON IMMUNIZATION ................................................................................ 19 PROPOSED MITIGATION THROUGH CMYP AND NISP .................................................... 21 INVESTIGATION INTO UNIT COST ANALYSIS .................................................. 23 METHODOLOGY AND APPROACH TO ESTIMATE UNIT COSTS ......................................... 23 UNIT COST OF VACCINE DELIVERY PER IMMUNIZATION ................................................ 26 PROGRAM COST AND ECONOMIC RETURNS ANALYSIS ............................... 27 METHODOLOGY AND DATA USED .................................................................................. 27 COST OF FULLY IMMUNIZED CHILDREN FOR DIFFERENT COVERAGE SCENARIOS .......... 29 EFFICIENCY GAINS THROUGH COVERAGE IMPROVEMENTS ............................................ 32 ECONOMIC BENEFITS OF INTERVENTION ........................................................................ 35 RETURNS ON INVESTMENT UNDER NISP ........................................................................ 35 COST-SAVING AND EFFICIENCY GAINS .......................................................................... 38 CONCLUSIONS ............................................................................................................. 40 REFERENCES ................................................................................................................ 42 ANNEX ............................................................................................................................ 45 UNIT COST OF FULLY IMMUNIZED CHILD ...................................................................... 45 PROJECTION OF ANNUAL BIRTHS IN PAKISTAN .............................................................. 45 COVERAGE RATIO AND THE TARGET POPULATION ........................................................ 47 COST OF IMMUNIZING CHILDREN ................................................................................... 49 BENEFITS OF IMMUNIZATION.......................................................................................... 50 ANNEX II ........................................................................................................................ 55 UNIT COST ESTIMATION ......................................................................................... 55 v LIST OF ACRONYMS ADP Annual Development Program AEFI Adverse Effects Following Immunization AGPR Accountant General Pakistan Revenues AHP Accelerated Health Program ASFR Age-Specific Fertility Rates BCG Bacillus Calmette–Guérin BMGF Bill & Melinda Gates Foundation CEA Cost-effectiveness Analyses CER Cost-effectiveness Ratio CMR Child Mortality Rate CMYP Comprehensive Multi-Year Plan DALY Disability-Adjusted Life Year DDO Drawing and Disbursement Officer Department for International Development, United
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