An evaluation of the cost of human papilloma virus (HPV) vaccine delivery in Zambia.

BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted infection and the leading cause of cervical cancer. The HPV vaccine is a safe and effective way to prevent HPV infection. In Zambia, the vaccine is given during Child Health Week to girls aged 14 years who are in and out of school in two doses over two years. The focus of this evaluation was to establish the cost to administer a single dose of the vaccine as well as for full immunisation of two doses. METHODS: This work was part of a broader study on assessing HPV programme implementation in Zambia. For HPV costing aspect of the study, with a healthcare provider perspective and reference year of 2020, both top-down and micro-costing approaches were used for financial costing, depending on the cost data source, and economic costs were gathered as secondary data from Expanded Programme for Immunisation Costing and Financing Project (EPIC), except human resource costs which were gathered as primary data using existing Ministry of Health salary scales and reported time spent by different health cadres on activities related to HPV vaccination. Data was collected from eight districts in four provinces, mainly using a structured questionnaire, document reviews and key informant interviews with staff at national, provincial, district and health facility levels. Administrative coverage rates were obtained for each district. RESULTS: Findings show that schools made up 53.3% of vaccination sites, community outreach sites 30.9% and finally health facilities 15.8%. In terms of coverage for 2020, for the eight districts sampled, schools had the highest coverage at 96.0%. Community outreach sites were at 6.0% of the coverage and health facilities accounted for only 1.0% of the coverage. School based delivery had the lowest economic cost at USD13.2 per dose and USD 28.1 per fully immunised child (FIC). Overall financial costs for school based delivery were US$6.0 per dose and US$12.4 per FIC. Overall economic costs taking all delivery models into account were US$23.0 per dose and US$47.6 per FIC. The main financial cost drivers were microplanning, supplies, service delivery/outreach and vaccine co-financing; while the main economic cost drivers were human resources, building overhead and vehicles. Nurses, environmental health technicians and community-based volunteers spent the most time on HPV related vaccination activities compared to other cadres and represented the greatest human resource costs. CONCLUSIONS: The financial cost of HPV vaccination in Zambia aligns favourably with similar studies conducted in other countries. However, the economic costs appear significantly higher than those observed in most international studies. This discrepancy underscores the substantial strain placed on healthcare resources by the program, a burden that often remains obscured. While the vaccine costs are currently subsidized through the generous support of Gavi, the Vaccine Alliance, it's crucial to recognize that these expenses pose a considerable threat to long-term sustainability. Consequently, countries such as Zambia must proactively devise strategies to address this challenge.

Small area estimation of under-5 mortality in Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia using spatially misaligned data.

BACKGROUND: The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes). METHODS: We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh. RESULTS: We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not. CONCLUSIONS: Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.

Fiscal space for the immunisation program in Zambia- an efficiency analysis approach.

OBJECTIVE: The immunisation programme in Zambia remains one of the most effective public health programmes. Its financial sustainability is, however, uncertain. Using administrative data on immunisation coverage rate, vaccine utilisation, the number of health facilities and human resources, expenditure on health promotion, and the provision of outreach services from 24 districts, we used Data Envelopment Analysis to determine the level of technical efficiency in the provision of immunisation services. Based on our calculated levels of technical efficiency, we determined the available fiscal space for immunisation. RESULTS: Out of the 24 districts in our sample, 9 (38%) were technically inefficient in the provision of immunisation services. The average efficiency score, however, was quite high, at 0.92 (CRS technology) and 0.95 (VRS technology). Based on the calculated level of technical efficiency, we estimated that an improvement in technical efficiency can save enough vaccine doses to supply between 5 and 14 additional districts. The challenge, however, lies in identifying and correcting for the sources of technical inefficiency.

Evaluating the functionality and effectiveness of ZITAG and related expanded programme on immunisation technical committees in Zambia.

The Zambia Immunisation Technical Advisory Group (ZITAG) was established in 2016 as an advisory body to provide evidence-based recommendations on vaccine policy. As part of the Gave Full Country Evaluation, we evaluated the functionality and effectiveness of ZITAG and related EPI committees through an online stakeholder survey of Interagnecy Coordinating Committee (ICC), ZITAG and Extended programme on Immunisation Technical Working Group (EPI-TWG) members, document review and key informant interviews. The survey was sent out via SurveyMonkey between May and July 2020 to 69 members of ZITAG, ICC or the EPI TWG. A total of 52 individuals responded (75%). Eight key informant interviews were also carried out at the national and global level in September 2020 to elaborate further on some of the quantitative findings and for triangulation. Findingsrevealed that the EPI committees were reasonably functional and effective entities, each with its unique role, though some overlaps occurred. Functionality was shown by having a broad membership with wide expertise and long-serving members; sub-committees existed and meetings were occurring regularly. Leadership and coordination structures also existed and were largely felt to be working well. Funding challenges however persisted, in particular for ZITAG operations and functionality of its subcommittees. Effectiveness and value addition fo the committees to the EPI was illustrated through decision-making processes and evidence use as well as relatively good country ownership in terms of commitment, legitimacy, capacity and accountability. Full independence and ownership may however be compromised by funding challenges. Recent changes to ICC terms of reference and focus beyond immunisation side-lined the EPI and weakened the linkage between ICC and ZITAG with many ZITAG recommendations not having been followed through by ICC as the ultimate endorsing entity.