Vaccine 33S (2015) A93–A98

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Vaccine
journal homepage: www.elsevier.com/locate/vaccine

What have we learned on costs and financing of routine immunization

from the comprehensive multi-year plans in GAVI eligible countries?
Logan Brenzel ∗
Bill & Melinda Gates Foundation, Seattle, Washington, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Background: Immunization is one of the most cost-effective health interventions, but as countries intro-
Costs duce new vaccines and scale-up immunization coverage, costs will likely increase. This paper updates
Routine immunization estimates of immunization costs and financing based on information from comprehensive multi-year
Financing
plans (cMYPs) from GAVI-eligible countries during a period when countries planned to introduce a range
Sustainability
of new vaccines (2008–2016).
Low-income
Methods: The analysis database included information from baseline and 5-year projection years for
each country cMYP, resulting in a total sample size of 243 observations. Two-thirds were from African
countries. Cost data included personnel, vaccine, injection, transport, training, maintenance, cold chain
and other capital investments. Financing from government and external sources was evaluated. All esti-
mates were converted to 2010 US Dollars. Statistical analysis was performed using STATA, and results
were population-weighted.
Results: Results pertain to country planning estimates. Average annual routine immunization cost was
$62 million. Vaccines continued to be the major cost driver (51%) followed by immunization-specific
personnel costs (22%). Non-vaccine delivery costs accounted for almost half of routine program costs
(44%). Routine delivery cost per dose averaged $0.61 and the delivery cost per infant was $10. The cost
per DTP3 vaccinated child was $27. Routine program costs increased with each new vaccine introduced.
Costs accounted for 5% of government health expenditures. Governments accounted for 67% of financing.
Conclusion: Total and average costs of routine immunization programs are rising as coverage rates
increase and new vaccines are introduced. The cost of delivering vaccines is nearly equivalent to the
cost of vaccines. Governments are financing greater proportions of the immunization program but there
may be limits in resource scarce countries. Price reductions for new vaccines will help reduce costs and
the burden of financing. Strategies to improve efficiency in service delivery should be pursued.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction
Immunization is one of the most cost-effective health interven-
tions for achieving the Millennium Development Goal of reducing
deaths among children less than 5 years of age (MDG4) by two-
thirds [1,2]. Vaccines provide health benefits not only for the
immunized child, but also for the community as a whole through
herd immunity. In addition, studies have shown that immunization
extends life expectancy and contributes to economic growth [3,4].
Studies show it costs between $17 and $25 to fully vaccinate a
child with traditional vaccines. Variation in estimates is related to
level of scale, type of delivery strategy, and prices [5–7].1 Costs
of immunization have increased with the addition of new and
more expensive vaccines [8]. As of March 2014, almost all low-
and middle-income GAVI-eligible countries have introduced pen-
tavalent vaccine; 40 included pneumococcal vaccine; 34 launched
rotavirus vaccine [9]. This paper evaluates total and unit cost
and financing, of routine immunization based on country-level
information from comprehensive multi-year plans (cMYPs) in
GAVI-eligible countries.

1
The traditional vaccine schedule includes three doses each of oral polio vac-
∗ Tel.: +1 202 662 8186. cine, and combined diphtheria–pertussis–tetanus vaccine, and a single dose each of
E-mail address: logan.brenzel@gatesfoundation.org measles and Bacillus-Calmette Guerin (BCG) vaccine against tuberculosis.

http://dx.doi.org/10.1016/j.vaccine.2014.12.076
0264-410X/© 2015 Elsevier Ltd. All rights reserved.
A94 L. Brenzel / Vaccine 33S (2015) A93–A98
2. Methods
The cMYP is a planning tool for estimating current and future
costs and financing of the national immunization program using
a standard method [10]. Baseline year estimates are retrospective.
Countries also estimate 5 years of future resource requirements and
financing to achieve national immunization program goals, such
as introducing new vaccines and ramping up coverage rates. The
present analysis is based on 40 cMYPs from GAVI-eligible countries
with a baseline year between 2008 and 2011 and projection years
until 2016.2 This timeframe more fully captures plans to introduce
Hib-containing, pneumococcal and rotavirus vaccines as compared
to earlier estimates [8].3 These vaccines prevent the majority of
preventable child deaths and the global community has coalesced
around their widespread introduction through the GAVI Alliance.
The database was structured to evaluate baseline and pro-
jection year data, resulting in 6 years of data for each country.
Costs included both immunization-specific and health system costs
categorized into line items: shared and immunization-specific
personnel and per diem; traditional and new vaccines; injection
supplies; transport for fixed sites and outreach services; training;
social mobilization and advocacy activities; disease surveillance;
program management; operational costs (cold chain and other
equipment maintenance, building operating costs and utilities);
other recurrent costs; cold chain equipment; vehicles; other equip-
ment, including construction of buildings. Delivery costs excluded
vaccine and safe injection costs. Information on sources and uses
of financing was incorporated. Data on doses utilized, DTP3 cov-
erage rates, and total and target populations were derived from
the cMYPs, and used to estimate unit costs.4 The number of chil-
dren receiving the third dose of DTP vaccine served as a proxy to
estimate the cost per fully immunized child, or FIC [5,6,11,12].
The database contained categorical information on vacci-
nation schedule for each country year: Hepatitis B vaccine
(including tetravalent vaccine); Hib-containing vaccine (mostly
pentavalent vaccine); Hib-containing and pneumococcal vaccine;
or, Hib-containing vaccine, pneumococcal, rotavirus vaccines. No
distinction was made for vaccine formulation. A novel approach
to assessing the impact of different vaccine schedules on program
costs was developed.
Macroeconomic data on gross domestic product, GNI per capita,
and government health expenditures also were incorporated into
the database [13,14]. Projections of GHE were based on real GDP
growth rates. Regional affiliation and GAVI Alliance co-financing
groupings were included [9]. As the median baseline year was 2010,
all costs and financing was converted into 2010 USD equivalents
using the consumer price index [15].
The database of 40 baseline country years and 203 projection
country years, for a total of 243 total country years was statistically
2
The sample included the following countries: Afghanistan, Angola, Armenia,
Azerbaijan, Bangladesh, Benin, Cameroon, Central African Republic, Republic of
Congo, Djibouti, Democratic People’s Republic of Korea, Eritrea, Gambia, Ghana,
Georgia, Guinea, Guinea Bissau, India, Kenya, Lesotho, Liberia, Mali, Moldova,
Mozambique, Niger, Pakistan, Rwanda, Senegal, Sudan (north), Tanzania, Timor
L’Este, Togo, Uganda, Yemen, and Zambia. Data from Ethiopia were excluded because
of missing information on routine doses.
3
Most sample countries have or will introduce pentavalent vaccine.
4
Estimates of doses, coverage and population in the cMYP were used in the analy-
sis to ensure internal consistency in the analysis, as costs reflected the coverage and
program goals of the country. Utilizing other estimates, such as WHO–UNICEF Best
Estimates would have introduced bias into the analysis and created inconsistencies
between inputs and outputs. For the projection years, there are some differences
between the cMYP projected coverage rates and those determined retrospectively
by WHO and UNICEF.
Table 1
Comparison of regional RI programs in sample cMYPs (baseline year, weighted
average).
Region % DTP3 Target infants Doses (million)
AFRO (n = 27) 84.9% 899,588 12.2
EMRO (n = 4) 75.6% 4.7 million 88
EURO (n = 4) 86.4% 93,273 1.6
SEARO/WPRO (n = 5) 94.3% 3.8 million 107.2
Total (n = 40) 86.5% 2.9 million 92.7
Source: author’s calculations.
analyzed using STATA [16].5 All estimates are population-weighted.
This approach represents a small methodological advance over pre-
vious analyses of cMYPs.
Financing sources reflect the last source from which financing is
allocated. For example, if a bilateral donor channels funds through
a multi-lateral agency, the cMYP method attributes financing to
the multi-lateral agency and not the bilateral donor. As a result,
the cMYP estimate may under-represent some funding sources.
In addition, sources of financing are not mutually exclusive, as
pooled financing includes funds from the government, bilateral
donor agencies, development banks, and other sources.
3. Results
3.1. Sample data
The cMYP sample represents a population of 1.02 billion and
30.6 million surviving infants. Most countries are from the Africa
region (66%), and 56% have a GNI/capita less than $975. Eighty-five
percent of sample countries utilize Hib-containing vaccine in the
baseline year. In the projection years, 82% of countries plan to intro-
duce pneumococcal vaccine, and 58% expect to include rotavirus
vaccines.
Table 1 summarizes routine immunization program outputs
from the sample cMYPs by region for the baseline year. DTP3 cover-
age varies from 76% in AFRO countries to 94% in SEARO and WPRO
countries, with an average of 86.5%. The average number of target
infants is highest in EMRO countries, though the number of doses
utilized per year is largest for countries in the SEARO and WPRO
regions.
3.2. Costs of routine immunization programs
The population-weighted average annual RI cost was $62 mil-
lion for the baseline year, increasing 86% to $114 million on average
for the projection period. Countries in the EMRO Region had the
highest average annual RI cost in the baseline year ($86 million),
compared to countries in the AFRO region ($22 million). Regional
RI cost variation may be related to differences in goals, size of
the target population, coverage rates, health system configuration,
delivery strategies, and prices.
Fig. 1 illustrates the distribution of RI costs by line item for the
baseline year compared to the projection years for the sample. Vac-
cines are the main cost driver, accounting for more than half of RI
cost, rising to 61% of RI cost in projection years. Personnel time rep-
resents 22% of RI cost, declining to 15% of RI cost in future years.
Cold chain cost, maintenance, and safe injection supplies have rel-
ative shares of total cost at 3%, 6%, and 5%, respectively, which are
maintained in the projection period.
5
One outlier observation from Djibouti, Haiti, and Mali (n = 3) were removed from
the dataset on the basis that total immunization cost was more than two-times the
standard deviation.
 L. Brenzel / Vaccine 33S (2015) A93–A98 A95

Fig. 1. Comparison of RI cost line items in sample cMYPs.

Source: author’s calculations.

Table 2
RI total and delivery unit costs in sample CMYPs (baseline and projection years).

Region Cost/capita Cost/dose‘ Cost/child Cost/FIC

Baseline results
AFRO (n = 27) $0.92 $2.01 $23.60 $28.00
EMRO (n = 4) $0.64 $1.29 $18.78 $24.83
EURO (n = 4) $0.80 $3.00 $56.62 $65.43
SEARO/WPRO (n = 5) $0.46 $0.68 $22.35 $23.72
Total baseline (n = 40) $0.67 $1.34 $22.68 $26.72
Non-vaccine delivery costs (n = 40) $0.31 $0.61 $10.36 $12.06

Projection years results

Total (n = 203) $1.30 $2.00 $41.80 $45.16

Source: author’s calculations.

Table 3
Financing per infant by source and region in sample cMYPs.

Indicator/region Total government financing Government vaccine financing Government non-vaccine

per infant per infant financing per infant

Total baseline (n = 40) $14 $6 $8

AFRO (n = 27) $11 $4 $8
EMRO (n = 4) $8 $3 $6
EURO (n = 4) $47 $28 $19
SEARO/WPRO (n = 5) $19 $10 $9
GAVI poorest (n = 22) $12 $5 $7
GAVI intermediate (n = 9) $10 $4 $6
GAVI graduating (n = 9) $23 $12 $11

Total projection years (n = 203) $18 $9 $10

Source: author’s calculations. Results rounded.

3.3. Unit costs of RI
RI unit costs are higher, on average, than what has been previ-
ously reported in the literature [1,5–8,12]. Baseline year estimates
reveal a cost per dose of $1.34; cost per infant of $23; a cost per fully
immunized child (FIC) of $27. Unit costs for the projection period
are double baseline values, with a cost per dose of $2, cost per child
of $42, and cost per FIC at $45 (Table 2).
There is significant regional variation in these estimates, with
unit costs greatest for EURO countries, and least for SEARO
and WPRO countries. The analysis reveals a strong inverse rela-
tionship between population size and unit cost, but a weaker
relationship between costs and country income. Countries clas-
sified as ‘intermediate’ under the GAVI co-financing classification
(GNI per capita between $975 and $1500) have lower costs per
child and per FIC than either poorer or graduating countries
(Table 3).
3.4. Non-vaccine delivery costs
Non-vaccine delivery costs represent 44% of total RI costs in the
baseline year, ranging from 37% in EURO countries to 46% for AFRO
countries. The importance of delivery costs is also reflected in unit
costs: delivery cost per dose of $0.60; delivery cost per child of
$10; and, delivery cost per FIC of $12 (Table 2). Countries in the
EURO region have the highest delivery costs per infant and per dose,
probably related to higher wages of health workers. While vaccines
are an important cost element, these results suggest that health
systems delivery costs are an equally important factor for under-
standing cost requirements for immunization programs. Recent
A96 L. Brenzel / Vaccine 33S (2015) A93–A98
Fig. 2. Effect of new vaccines on cost per infant (baseline and projection year,
n = 243).
Source: author’s calculations.
studies confirm the growing importance of non-vaccine delivery
costs and need for strong systems [18,19].
3.5. Unit costs and new vaccines
This study compares total and unit costs of different immuniza-
tion schedules and finds increasing costs per dose with each new
vaccine incorporated. For the baseline year, the average cost per
dose in countries with Hepatitis B vaccine is $1. This figure rises
to $1.40 for countries with Hib-containing vaccine and to $1.50 for
countries with both Hib-containing and pneumococcal vaccines.
Adding rotavirus vaccine increases the cost per dose further to
$2.70.
Fig. 2 shows the effects of new vaccines on the cost per infant.
Vaccine schedules with Hib-containing and pneumococcal vaccines
cost $15 more per infant than those with Hib-containing vaccine.
Rotavirus vaccine introduction appears to increase cost per child
by an additional $12, and this schedule with three new vaccines
is 141% higher than a program with HepB vaccine alone. Increases
appear to be driven primarily by the cost of the vaccines, as the
share of delivery costs to total unit costs steadily declines with
each new vaccine in the schedule from 54% (HepB alone) to 22%
(schedule with three new vaccines).
3.6. Affordability of the routine program
Total RI costs represent a fraction of gross domestic product
(0.1%), but nearly 5% of government health expenditures (GHE) in
the baseline year, rising to 8% in projection years. Vaccine costs
account for 2.8% of GHE in the baseline year, which is more than
double a previously reported benchmark of 1% [20]. The share of
GHE appears to increase with the number of new vaccines, from 2%
Hepatitis B for schedules, to 13% for schedules with Hib-containing
and pneumococcal vaccines.
3.7. Financing of routine immunization
Sources of RI financing for the sample of cMYPs include the gov-
ernment and pooled funds, bilateral and multilateral assistance,
the GAVI Alliance, non-governmental organizations (NGOs), pri-
vate organizations and foundations, and other sources. Countries
co-finance a portion of the cost of new vaccine costs supported by
the GAVI Alliance, which also provides health systems support to
countries.
The study found that government sources account for the largest
share of total RI financing (67%) in the baseline year (Fig. 3). GAVI
support represents 22% of total RI financing, and financing from
multilateral organizations, such as WHO and UNICEF, account for
Fig. 3. Share of RI financing by source in 40 cMYPs (population-weighted).
Source: author’s calculations.
11% of the total. Higher income countries appear to finance a greater
share of their RI program from government sources. The share of
government and pooled financing of RI programs is largest for
countries in the EURO Region (84%) and smallest for the AFRO
Region (43%), for which GAVI support accounts for 38% of financing,
and multilateral agencies account for 19% of financing. Govern-
ments also finance the lion’s share (76%) of delivery costs. The GAVI
Alliance finances a small proportion (4%) of delivery costs, most
probably through Immunization Services Support (ISS) and Health
Systems Strengthening (HSS) support. In projection years, govern-
ment financing drops somewhat to 59% of total RI financing, and
GAVI financing increases to 33%. Both appear related to growth in
new vaccine introduction.
Government financing is $14 per infant for the baseline year,
rising to $18 per infant in the projection years. Countries in
the EURO region have the highest government financing of RI
per infant ($47), and EMRO countries the lowest ($8). For AFRO
and EMRO countries, government vaccine financing per infant
is lower than that for non-vaccine financing. In SEARO/WPRO
countries, governments finance roughly equal amounts of vac-
cine and non-vaccine costs; while, in EURO countries, government
financing for vaccines per infant is higher than that of delivery
costs.
4. Discussion
This analysis of cMYP data shows that total and unit costs
of RI are higher than previously estimated for the baseline year,
with projected increases to $45 per FIC related to new vaccine
introduction and coverage increases [1,5,8,12]. The analysis also
reveals regional variations. Unit costs are lower in countries with
larger populations and higher immunization coverage, relating to
scale effects. Unit and marginal costs may increase with higher
coverage levels (as predicted by economic theory) because of
additional efforts required to reach remaining pockets of low
coverage. On the other hand, changes in technology or delivery
strategy may reduce average costs as greater efficiencies are gained.
Additional country-level studies on these relationships will be
important.
Non-vaccine delivery costs were found to be an important com-
ponent (44%) of total RI costs, at $10 per child and $12 per FIC, on
average with some regional variation. While the share of delivery
costs declined with addition of each new vaccine because of ris-
ing share of vaccine costs, the absolute amount increased slightly
from $12 to $14 per child indicating that new vaccines have a pos-
itive effect on delivery costs. Delivery costs play an important role
and should be fully considered during planning and budgeting and
reflected in the cMYP [18,19].
 L. Brenzel / Vaccine 33S (2015) A93–A98
In this study, RI and vaccine costs account for much higher
shares of GHE than previously estimated, but these ratios also
should be evaluated with in-country studies. EMRO countries in
the sample have the highest shares and may have particular chal-
lenges with program affordability and sustainability. Fiscal space
can be expanded through health sector allocation as well as more
efficient service delivery.
Governments are committing more, both in absolute terms and
as a percent of total financing (67%) to the routine program, up
from estimates of 42–56% [8,12]. Government financing of RI has
increased from $5.60 per infant to $14 per infant, representing a
150% increase within the past 10 years.
The cMYP provides a wealth of country-level information on
immunization program costs and financing for both GAVI-eligible
and other countries. The cMYP tool is designed to guide planners on
future resource mobilization needs and not for reporting or cross-
country evaluation. As such, application of the guidelines and drive
for accuracy will vary by country. Conditions over the cMYP period
may change and there is uncertainty in projecting costs and finan-
cing. Estimates are evaluated for internal consistency by WHO but
are not routinely externally validated. For these reasons, the qual-
ity and reliability of cMYP data have been called into question.
Baseline-year figures are thought to be a more reliable reflection of
actual costs and financing [17]. Focus should be on baseline results,
with those for the projection years viewed as indicative rather than
conclusive.
In 2015, approximately 40 country cMYPs will need to be
updated which represents an opportunity to strengthen the quality
of cMYP estimates. Additional consistency and plausibility checks
could be employed to ensure that all inputs required to support
new vaccine introduction, particularly for delivery costs, are fac-
tored into the estimates. Distinguishing new vaccine introduction
start-up costs with recurrent costs in the tool may be useful.
Comparing cMYP cost estimates with GHE could provide useful
benchmark for determining whether specific policy objectives are
affordable and feasible. RI programs that account for more than
5% of GHE may have substantial challenges in mobilizing needed
resources where there are competing priorities for scarce health
resources.
Further, information from detailed costing and financing stud-
ies, such as the EPI Costing and Financing Studies of RI and New
Vaccines (EPIC) studies could serve as benchmarks for cMYP cal-
culations, including those related to labor time, maintenance and
supply chain costs, and transport costs per dose of vaccine, among
others. Finally, a database of immunization unit costs from pub-
lished and unpublished literature may serve as a useful reference
point for cMYP estimations.
5. Conclusion
This study employed statistical methods to evaluate cost and
financing estimates from cMYPs covering a planning period of sig-
nificant new vaccine introduction. The study found a cost per FIC of
$27 and cost per child of $23 on average for the baseline year, with
regional variation. Vaccines continue to be the main cost driver, but
the role of delivery costs was found to be important. Unit costs are
projected to double.
The study showed evidence that total and unit costs increase
with additional new vaccines using a new approach that com-
pares vaccine schedules. Country-level, retrospective studies are
needed to measure the actual incremental cost (both start-up and
ongoing) of new vaccines, and there is a growing literature in this
area.
Planning and budgeting for national immunization programs
cannot be made in isolation from the rest of the health system.
This analysis highlighted potential issues related to affordability
A97
and sustainability [21]. Although total government financing levels
are expected to increase, government contribution as a share
will decline as new vaccines are introduced. There is need to
maintain government commitment to financing the RI program
as a whole, including traditional vaccines. Ensuring adequate
financing for the poorest countries, not only in Africa, but also
in the EMRO region should continue to be a priority. Further
price reductions for new vaccines will help reduce costs and
burden of financing, but focus on efficiency gains will be important
[18,19].
Acknowledgements
The author would like to thank the members of the GAVI
Alliance Immunization Financing & Sustainability Task Team who
provided feedback and advice on earlier versions of the analysis.
Special mention goes to Claudio Politi, WHO Immunization, Vac-
cines, and Biologicals Unit, who provided access to the initial cMYP
database.
Conflict of interest: The author declares no conflict of interest.
The views expressed in this paper represent those of the author
only. Some financial support in preparation of this manuscript and
conduct of the analysis was provided the Bill & Melinda Gates Foun-
dation. However, the views expressed represent those of the author
only.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.vaccine.
2014.12.076.
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