Vaccine xxx (xxxx) xxx Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine A cost-effectiveness analysis of traditional and geographic information system-supported microplanning approaches for routine immunization program management in northern Nigeria Disha Ali a, Ann Levin b, Masduq Abdulkarim c, Usman Tijjani d, Bakoji Ahmed e, Faruk Namalam f, ⇑ Femi Oyewole g, Leanne Dougherty h, a Maternal and Child Survival Program (MCSP), John Snow, Inc. (JSI), 2733 Crystal Dr 4th Floor, Arlington, VA 22202, USA b Independent Consultant to MCSP, 6414 Hollins Dr., Bethesda, MD 20817, USA c MCSP, JSI, New G.R.A., Adjacent River Edge Resort, Bauchi, Nigeria d MCSP, JSI, Block 14 Shehu Kangiwa Secretariat Ahmad Daku Road, Sokoto, Nigeria e Disease Control and Immunization Unit, Primary Health Care Development Agency, Bello Kirfi Road, Off Murtala Muhammed Road, Bauchi State, Nigeria f Planning Research and Statistics, Sokoto State Primary Health Care Development Agency, Block 14 Shehu Kangiwa Secretariat, Ahmad Daku Road, Sokoto State, Nigeria g MCSP, JSI, Plot 448 Reuben Okoya Street, Wuye, Abuja, Nigeria h MCSP, JSI, 2733 Crystal Dr 4th Floor, Arlington, VA 22202, USA article info abstract Article history: Effective RI microplanning requires accurate population estimates and maps showing health facilities and Received 11 August 2019 locations of villages and target populations. Traditional microplanning relies on census figures to project Received in revised form 28 November 2019 target populations and on community estimates of distances, while GIS microplanning uses satellite ima- Accepted 2 December 2019 gery to estimate target populations and spatial analyses to estimate distances. This paper estimates the Available online xxxx cost-effectiveness of geographical information systems (GIS)-based microplanning for routine immuniza- tion (RI) programming in two states in northern Nigeria. Keywords: For our cost-effectiveness analysis, we captured the cost of all inputs for both approaches to capture the Immunization incremental cost of GIS over traditional microplanning and present the incremental cost-effectiveness Microplanning GIS ratios for each vaccine-preventable illness, death, and disability-adjusted life year (DALY) averted. Mapping We considered two scenarios for estimating vaccine requirements for each microplanning approach, Costing one based on administrative vaccination coverage rates and one based on National Nutrition and Nigeria Health Survey rates. With the administrative rates, GIS microplanning projected approximately Sub-Saharan Africa 194,000 and 157,000 more required vaccinations than traditional microplanning in Bauchi and Sokoto States; with the survey rates, the additional number of vaccinations required was nearly 113,000 in Bauchi and about 47,000 in Sokoto. For each state under each scenario, we present numbers of and costs per measles and pertussis cases, deaths, and DALYs averted by the additional vaccinations, as well as annual costs. As expected, GIS-based microplanning incurs higher costs than traditional microplanning, due mainly to the additional vaccinations required for populations previously unreached. Our estimates of cost per DALY averted suggest, however, that GIS microplanning is more cost-effective than traditional microplanning in both states under both coverage scenarios and that the higher costs incurred by GIS microplanning are worth adopting. Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction Routine immunization (RI) program performance in Africa, as measured by coverage with the third dose of diphtheria- pertussis-tetanus (DPT3) vaccine, increased from 57% in 2000 to ⇑ Corresponding author. 72% in 2017 but has lagged behind the global level and expected E-mail addresses: [email protected] (D. Ali), [email protected] (A. Levin), [email protected] (L. Dougherty). target of 85% [1–3]. Current performance is far below the https://doi.org/10.1016/j.vaccine.2019.12.002 0264-410X/Ó 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: D. Ali, A. Levin, M. Abdulkarim et al., A cost-effectiveness analysis of traditional and geographic information system-supported microplanning approaches for routine immunization program management in northern Nigeria, Vaccine, https://doi.org/10.1016/j.vaccine.2019.12.002 2 D. Ali et al. / Vaccine xxx (xxxx) xxx Global Vaccine Action Plan 2011–2020 stated goal of reaching [21]. However, there is a dearth of information on economic cost greater than 90% for all vaccines in the RI schedule by 2020 [4]. and cost-effectiveness related to operationalizing specific RI sys- In 2002, the World Health Organization, the United Nations Chil- tems approaches, such as the microplanning process [22]. For pol- dren’s Fund, and other partner organizations such as Gavi, the Vac- icymakers to adopt a new approach at scale, the cost of executing cine Alliance, developed the Reaching Every District (RED) guide to the interventions, the long-term financial implications, and the improve immunization program performance and reduce inequi- potential return on investment are critical to make an informed ties in countries with low immunization coverage [2,3]. Since its decision. To address these gaps in the literature, we determined development, the RED strategies have been implemented in several the cost-effectiveness of a GIS-supported microplanning approach African and Asian countries to a varying degree, resulting in compared with the traditional microplanning approach in Bauchi increased immunization coverage [3,4]. The RED strategies encour- and Sokoto States of Nigeria. age and guide countries to develop microplans at the district and health facility level in order to estimate resource needs and formu- 2. Methods late action plans based on available data [5] to increase immuniza- tion coverage. The effectiveness and efficiency of RED microplans 2.1. Study design largely depend on detailed knowledge of the local situation; accu- rate population estimates; and maps showing the location of We conducted a cost-effectiveness analysis from the program- health facilities, villages, and other points of interest. The matic perspective (state government as the provider of RI) in line microplanning approach helps the district with determining the with the annual RI budgeting and planning cycle. We focused on resources needed, including vaccine requirements, human costs associated with government implementation of the approach resource allocation, service delivery strategies, and supervision and did not include costs associated with technical assistance pro- [6,7]. However, outdated population estimates and limited infor- vided by MCSP or societal costs such as a client’s transportation to mation on the distances between health facilities and communities services. We captured the incremental cost of the GIS-based make it difficult to make evidence based decisions. microplanning approach over traditional microplanning and pre- In recent years, program managers have introduced digital sented the cost-effectiveness ratios for each vaccine-preventable technologies to accelerate improvements in the health and vacci- case, death and disability-adjusted life year (DALY) averted in an nation status of the poor and underserved [8,9]. Mobile phones annual RI microplanning cycle. are now increasingly being used to facilitate communication through messaging services [10–12] and to support data collection, 2.2. Data management, and use in real-time during supervision and moni- toring [13]. There is a growing interest in applying geographical We developed tools to capture the cost of all inputs for both tra- information systems (GIS) to the immunization field [14–16]. ditional and GIS based approaches of microplanning, as shown in Recent applications of GIS to support immunization programs Table 1. We derived cost categories and inputs from program include identifying and reaching previously unreached populations records and activity documents. We collected cost data from two with vaccinations, remotely monitoring the performance of vacci- states and six LGAs (Bauchi, Darazo, Itas Gadau, Bodinga, Gada nation teams in the field and exploring the effects of vaccine strat- and Wamakko), three in each state. We extracted salary informa- egy delivery mechanisms on coverage rates [13–17]. tion from the state consolidated health salary structure. The Bauchi In line with the growing interest in applying GIS data and and Sokoto SPHCDAs each have a fully costed and harmonized RI technology for strengthening immunization systems [14] in low- work plan that outlines all activities assigned to the state and part- resource settings, the state primary health care development agen- ners each year. These harmonized RI work plans provided cost data cies (SPHCDAs) in the northern Nigeria states of Bauchi and Sokoto, for microplanning, vaccination services, and RI logistics. with support from the Maternal and Child Survival Program We determined the resources needed to deliver RI services (MCSP) of the United States Agency for International Development, based on the health facility microplans in the selected LGAs. implemented GIS-based microplanning as an alternative to the tra- ditional process of hand drawing