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Variation in the Costs of Delivering Routine Immunization Services in Peru D

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Variation in the Costs of Delivering Routine Immunization Services in Peru D Variation in the costs of delivering routine immunization services in Peru D. Walker,1 N.R. Mosqueira,2 M.E. Penny,3 C.F. Lanata,3 A.D. Clark,4 C.F.B. Sanderson,5 & J.A. Fox-Rushby6 Objective Estimates of vaccination costs usually provide only point estimates at national level with no information on cost variation. In practice, however, such information is necessary for programme managers. This paper presents information on the variations in costs of delivering routine immunization services in three diverse districts of Peru: Ayacucho (a mountainous area), San Martin (a jungle area) and Lima (a coastal area). Methods We consider the impact of variability on predictions of cost and reflect on the likely impact on expected cost–effectiveness ratios, policy decisions and future research practice. All costs are in 2002 prices in US$ and include the costs of providing vaccination services incurred by 19 government health facilities during the January–December 2002 financial year. Vaccine wastage rates have been estimated using stock records. Findings The cost per fully vaccinated child ranged from US$ 16.63–24.52 in Ayacucho, US$ 21.79–36.69 in San Martin and US$ 9.58–20.31 in Lima. The volume of vaccines administered and wastage rates are determinants of the variation in costs of delivering routine immunization services. Conclusion This study shows there is considerable variation in the costs of providing vaccines across geographical regions and different types of facilities. Information on how costs vary can be used as a basis from which to generalize to other settings and provide more accurate estimates for decision-makers who do not have disaggregated data on local costs. Future studies should include sufficiently large sample sizes and ensure that regions are carefully selected in order to maximize the interpretation of cost variation. Keywords Immunization/economics; Immunization programs/economics; Vaccines/supply and distribution/administration and dosage; Child; Costs and cost analysis; Analysis of variance; Comparative study; Peru (source: MeSH, NLM). Mots clés Immunisation/économie; Programmes de vaccination/économie; Vaccins/ressources et distribution/administration et posologie; Enfant; Coût et analyse coût; Analyse variance; Etude comparative; Pérou (source: MeSH, INSERM). Palabras clave Inmunización/economía; Programas de inmunización/economía; Vacunas/provisión y distribución/administración y dosificación; Niño; Costos y análisis de costo; Análisis de varianza; Estudio comparativo; Perú (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2004;82:676-682. Voir page 681 le résumé en français. En la página 681 figura un resumen en español. Introduction the intra-country variation in these costs. Indeed, in applying In 1974, when the Expanded Programme on Immunization cost-effectiveness analyses to health services, it is rare to see (EPI) was launched by WHO less than 5% of the world’s chil- detailed cost analyses across facilities. Cost data can provide dren had been immunized during their first year of life against valuable information for national decision-makers and develop- the six initial target diseases: diphtheria, tetanus, pertussis (whoop- ment partners. It can help EPI programme managers improve ing cough), poliomyelitis, measles and tuberculosis. However, national budgeting and planning, identify cost inefficiencies vaccines were soon judged to be one of the most cost-effective (e.g. high wastage rates), and identify priorities by acting as ways of improving and maintaining children’s health (1, 2). The an input to cost-effectiveness analyses. However, the represen- extensive promotion of vaccines resulted in a global coverage tativeness of reported costs is frequently questionable because of fully vaccinated children of 80% by the mid-1990s (3). Yet they are often based on national estimates of total expenditure this rate disguises considerable variation between and within or estimates from only a few facilities. Hence, variation in the countries. expected costs (and benefits) at subnational levels is often not While there has been some reporting of the cost of addressed. Therefore, as noted by the Immunization Financing providing vaccination services (4), few studies have detailed Database team, “Further work is needed to better understand 1 Lecturer, Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, England (email: [email protected]). Correspondence should be sent to this author. 2 Researcher, Instituto de Investigación Nutricional, Lima, Peru. 3 Senior Researcher, Instituto de Investigación Nutricional, Lima, Peru. 4 Research Fellow, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, England. 5 Reader, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London, England. 6 Senior Lecturer, Health Policy Unit, London School of Hygiene and Tropical Medicine, London, England. Ref. No. 04-011643 (Submitted: 16 January 2004 – Final revised version received: 6 July 2004 – Accepted: 7 July 2004) 676 Bulletin of the World Health Organization | September 2004, 82 (9) Special Theme – Economics of Immunization D. Walker et al. Cost of vaccines in Peru the sources of variation we find in the cost of immunization • personnel, other goods, third party services, capital items programmes. Understanding this variability will be extremely (except the cold chain), infrastructure and overhead costs useful for future analyses” (5). In particular, it will be useful in were distributed on the basis of the number of visits; helping governments and funding agencies to better understand • the costs of the cold chain were distributed according to which parameters vary within and between settings, how much the number of vaccine doses administered. variation in the parameters influences the resultant variation in the cost, and which parameters can, in general, be taken as The calculation of the number of visits took the following constant across settings. The overall aim of this paper is to report into account: and describe variations in the cost of delivering routine immuni- • for each dose of bacille Calmette–Guérin (BCG) given, we zation services, by specific antigens, in three districts of Peru and assumed that a dose of oral polio vaccine (OPV) was given to consider the implications for cost-effectiveness analyses. to a newborn and that hepatitis B vaccine where applicable had also been given (Table 1); Methods • at the second, third and fourth visits we assumed that OPV, diphtheria–pertussis–tetanus (DPT) and Selection of sites Haemophilus influenzae type b vaccine (Hib), or the pentavalent vaccine We selected three districts from the 33 health regions in Peru to where applicable, had also been given; reflect the geographical diversity of the country (coast, jungle • the rest of the vaccines, such as yellow fever and measles, are and mountains), differences in immunization schedules (the administered in separate visits. general schedule and specific for endemic hepatitis B and low- income zones), the availability of hospital cost-information sys- The weighted mean cost of vaccine delivery per dose was calcu- tems, spread of disease (for example, the incidence of hepatitis B lated using the number of vaccines administered as the weights. is greatest in the jungle area, in certain parts of the mountainous Also estimated and reported is the wastage rate, in which vaccine area, and in the coastal region, particularly in Lima, where the wastage is the proportion of vaccine supplied but not adminis- incidence depends on migration patterns to the capital) and tered to children. This is calculated as: finally, the interest and willingness of local authorities to collabo- vaccine wastage rate = ([doses supplied - doses administered]/ rate. The three areas selected were Ayacucho (a mountainous doses supplied) x 100. area), Lima (a coastal area) and San Martin (a jungle area). Table 1 shows the current immunization schedules in Peru and the We have also estimated the cost per fully vaccinated child new national schedule, which is being introduced during 2004 (FVC) as defined by the schedule — for example, a child in and will harmonize schedules across the country. Within each Lima who has received one dose of BCG, four doses of OPV, of the selected districts we chose a stratified sample of health three doses of DPT, one dose of yellow fever vaccine and one facilities to reflect the range of facilities delivering vaccines. The dose of measles vaccine by his or her first birthday. Tests for selection of these facilities was undertaken with the coopera- statistical differences in the mean cost of vaccine delivery per tion of officials from the Ministry of Health in each district; dose and per FVC within and between facility types and districts this was an attempt to identify facilities from which we could were not performed because there was often only one facility draw general conclusions. The number and type of facilities in costed per facility type in each selected district. which the costs were measured are given in Table 2. Cost analysis Results The costs borne by the government in providing routine im- Table 3 presents the mean number of doses administered, munization services were gathered for the January–December vaccine wastage rates, weighted mean cost per antigen and the 2002 financial year. All costs are in 2002 prices in US$ and cost per FVC by district and type of facility (web version only, reflect those incurred by government providers. (The exchange available at: http://www.who.int/bulletin). We found that on rate used was US$ 1.00 = 3.66 soles.) In Peru, routine vac- average OPV is the most common type of vaccine provided cination services are delivered via fixed sites at each level of by all facilities in all districts; this is followed by DPT. Doses care (Table 2). In seven facilities a cost-and-revenue information of BCG and Hepatitis B vaccine are provided least regularly. system was in place (the Sistema de Informacion de Costos y Across the three districts, the health posts administer the lowest Ingresos).
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