Analyses of Costs and Financing of the Routine Immunization Program and New Vaccine Introduction in the Republic of Moldova George Gotsadze, MD., Ph.D; Ketevan Goguadze, MD.; Ivdity Chikovani, MD.; Daniel Maceira, Ph.D Curatio International Foundation 2013 This study was conducted as part of a multi-country analysis of the costing and financing of routine immunization and new vaccines (EPIC) supported by the Bill & Melinda Gates Foundation. The methods were derived from a Common Approach developed for this exercise 2013 Table of Content ACRONYMS 1 ACKNOWLEDGEMENTS 2 EXECUTIVE SUMMARY 3 Introduction and Methodology 3 Unit Cost of the Routine Immunization Program and for New Vaccines 4 Production and Cost Determinants on a Facility Level 5 Cost of New Vaccine Introduction 6 Financial Needs of the Immunization Program and with New Vaccines 7 Major Conclusions 9 Increasing Immunization Program Efficiency 9 Increasing Immunization Coverage 9 Introducing New Vaccines 10 GAVI Graduation and Possible Policy Implications 10 PURPOSE OF THE STUDY 12 BACKGROUND 12 Routine immunization in Moldova 13 Introduction of new vaccines in Moldova 14 Current knowledge on costs and financing of immunization globally 15 Current knowledge on costs and financing of immunization in Moldova 15 IMMUNIZATION COSTING 17 The Study Methodology 17 Sampling 17 The survey tool and data collection 18 Data Quality Assurance 18 Data weighting 19 Approaches used for cost estimation 19 Approach to estimating routine immunization costs 19 Approach to estimating a new vaccine introduction cost 22 Data analysis 23 The Study Limitations 23 Ethical Issues 23 Results of routine immunization costs 24 Total Costs and Cost Variation on a facility level 24 Unit Costs and Cost Variation on a facility level 26 Unit Costs and Immunization Program Performance on a Facility Level 30 Unit Cost Structure on a Facility Level 31 Total Cost and Cost Structure of the National Immunization Program 34 Discussion 38 Comparison of Financial Flows with updated cMYP 39 Conclusions 41 ANALYSIS OF FINANCIAL FLOWS FOR THE ROUTINE IMMUNIZATION 43 Background 43 Methods 43 Results 43 Funds Flow for Immunization Services 43 Funds flow on a provider level 44 Financing of Immunization Functions 45 Funding inputs for immunization services 46 Conclusions 47 COST ANALYSIS OF NEW VACCINE INTRODUCTION 50 Incremental Costs for NUVI on a Facility Level 50 Funding NUVI 53 Discussion of Results 54 Comparison with NUVI introduction plan 56 Conclusions 57 IMMUNIZATION COST DETERMINANTS AND PRODUCTIVITY 58 Introduction 58 Methodology and Major Research Questions 59 Results 61 Productivity 61 First Step: Production Determinants 62 Second Step: Cost Determinants 64 Conclusions and Discussions 71 Acronyms BMGF Bill and Melinda Gates Foundation CNAM National Health Insurance Company cMYP Comprehensive Multi-Year Plan CPH Centre of Public Health DTP Diphtheria-Tetanus-Pertusis EVM Effective Vaccine Management EPI Expanded Program for Immunization FA Funding Agent Fully Immunized Child, which for this report equals to child that received FIC DPT3 dose FMC Family Medicine Centre FS Funding Source HC Health Centre HF Financing Scheme Code HMIS Health Management Information System HO Health Office HP Healthcare Provider IRB Institutional Review Board MDL Moldovan Lei MoH Ministry of Health OFD Office of a Family Doctor PHC Primary Health Care ULY Useful Life Year WHO World Health Organization GAVI Global Alliance for Vaccines and Immunization 1 | P a g e Acknowledgements This study would have not been possible without continuous support of the Ministry of Health of the Republic of Moldova, EPI manager, directors of District Public Health Centres and health care providers who gave their time as well as allowed access to facilities and facility records. Therefore, study team would like to acknowledge their invaluable support in carrying out this work. Authors like to thank Bill & Melinda Gates Foundation for providing financial support. And in particular we would like to acknowledge the support of Logan Brenzel and Damian Walker, steering committee members and other country teams that commented on an earlier draft of this paper and provided valuable inputs and guidance to the study team. 2 | P a g e Executive Summary Introduction and Methodology The costs and financing of the national immunization programs have been evaluated since 1980s, particularly as part of Universal Childhood Immunization Initiative. However, available information is out-dated and up-to-date knowledge on full economic costs and financing of routine immunization programs, as well as the financial cost and financing of a new vaccine introduction is lacking. For going forward and increasing vaccine coverage rates as well as for introduction of new vaccines in national immunization programs, requires better knowledge of costs as well as cost determinants. Therefore, the purpose of this study is to evaluate routine immunization program costs and financing as well as incremental costs and financing of a new vaccine introduction in the Republic of Moldova. Our study is part of a larger effort to evaluate costs and financing of routine immunization in six countries (Moldova, Benin, Uganda, Zambia, Ghana, Honduras) supported by the Bill & Melinda Gates Foundation. In this study we focus on: a) Evaluating overall and detailed economic and financial costs (and cost elements) of the routine immunization program in Moldova and describing observed variation in costs and its elements; b) Evaluating incremental costs for a new vaccine introduction for Rotavirus vaccine; c) Analyzing the main sources of financing and funds flow for the routine immunization program and for the new vaccine introduction; d) Evaluating factors determining productivity of the facilities involved in immunization and trying explaining major cost drivers for the immunization program. Moldova delivers immunization services primarily from 1,318 primary health care facilities1 using fixed strategy and therefore all costs presented throughout this paper are relevant to this approach. Being part of a multi-country study supported by Gates foundation, we have employed standardized facility based costing approach using similar tools while adjusting to the country context. Consequently this is a cross-sectional facility-based costing study, which looked at total costs of the routine immunization program and estimated incremental costs of a new vaccine introduction, arising at different levels of the health care system (i.e. facility, district and the national level). The study employed multi-stage random sampling to select fifty providers, which included: 8 urban/peri-urban facilities and 42 rural facilities represented by 5 family medicine centres, 10 health centres, 23 offices of family doctors and 12 health offices2. Therefore, the findings of this study are representative on a national level. The data was collected with the help of experienced data collectors, who received extensive training. The data collection took place during October 3rd 2012 to January 14th 2013 and included face-to-face interviews with the facility staff and managers, facility observation and record review. Excel™ based database specifically designed for this study was used to transfer the data from questionnaires. The research team validated the data using basic logical links and descriptive statistics, which helped detect odd results and outliers that were followed on and corrected, if necessary. 1 The only vaccine, which is administered in hospitals, are BCG and first dose of Hep B. Due to low number of doses of BCGs and Hep B administered at the hospital facilities, the study team decided to concentrate most resources on sampling the facilities where vaccination is one of the critical function. 2 Detailed description and explanation of facility types listed here is provided on page 23 – Routine Immunization in Moldova 3 | P a g e This study used retrospective costing for the routine EPI and evaluated both financial and economic costs of the routine EPI program for 2011. All local costs were converted into 2011 $US using average exchange rate of 11.73 MDL per dollar. Calculations were based on Common Approach developed for this exercise, cMYP Costing Guideline and WHO Guideline for Estimating Costs of New Vaccine Introduction. The study questionnaire helped capture the costs of all inputs using an ingredients approach and listing all inputs by activity, quantities and prices. Information was collected for all resources used in delivery of EPI services, including value of donated goods and services. The cost data included a comprehensive list of capital as well as recurrent expenditure items. Items with a useful life of more than one year were treated as capital cost elements and EPI related resources consumed or replaced within a period of up to one year were treated as a recurrent cost item. Considering that Moldova introduced Rotavirus vaccine in July 2012 the cost of Rotavirus vaccine introduction was estimated prospectively. The data collection captured all costs incurred six-month prior and six month following the date of vaccine introduction. Obtained costs in local currency were converted to 2011 $ US using current exchange rate, annualized and used in the analysis. We looked at all costs for capital equipment, trainings of health care providers, social mobilization and etc. Due to the fact that staff does not work exclusively on the Rotavirus vaccine; incremental personnel costs were assessed on the bases