India’s Universal Immunization Programme (UIP) is one of the largest in the world in terms of quantities of vaccines used, number of beneficiaries, number of immunization sessions organized and the geographical spread and diversity of areas covered. However, even with an annual budget of $500 million, the UIP has not been able to reach all children in India. When the District Level Household Survey 3 was carried out in 2007-2008, only 54 percent of Indian children were fully immunized. Additionally, there is a large geographical disparity : only 13 percent of children in Arunachal Pradesh were fully immunized, as compared with over 90 percent in Goa.
Strategic planning for immunization requires credible information about the cost to achieve program objectives, estimate available funding, allocate funds within the program, avoid funding shortfalls and ensure sustainable financial resources at national, state and district levels. For this reason, analysing the costing and financing of a comprehensive multi-year plan for immunization (cMYP) is a key step in the planning process. The second cMYP (2013-2017) in India gives the detailed costing and financing pattern for UIP. However, as this is based on national estimates, variations in the expected costs at sub-national levels are not addressed. The results of the cMYPs provide limited information on the delivery cost per dose or per infant by type of vaccine (traditional or specific new vaccine). It is challenging to raise resources to support ongoing routine program delivery costs without this information. In addition, the ability to estimate the costs associated with introduction of new vaccines is limited, as the cMYP tool does not set aside a specific analysis of vaccine introduction costs.
Understanding the variability of costs will help government and funding agencies to better comprehend which parameters vary within and between settings and how much variation in the parameters influences the resultant variation in the cost. This is particularly important in the Indian context as the immunization coverage differs significantly across the states in India. Therefore, a detailed cost analysis of delivering immunization services in different states will be helpful for understanding the reasons of variability in facility unit costs and productivity.
The purpose of this exercise will be to provide detailed cost estimates of the Routine Immunization Programme (RIP) in India. The specific questions that would be addressed by this exercise are:
- What is the total cost of the Routine Immunization Programme in different states and at various levels of the health system in India?
- What is the cost structure (cost by line item) of total facility costs, particularly cold chain recurrent and capital costs?
- What are the delivery costs associated with the RIP (delivery costs per dose, per infant) in different states and at various levels of the health system?
- At the facility level, how does productivity of the RIP vary, and what is the relationship between costs and levels of output?
- What are the facility total and unit costs, and what are the factors that drive this variation?
- What is the incremental cost to the government for new vaccine introduction (Pentavalent) in a few states?
The study will cover 255 facilities in seven states of India -- Bihar, Gujarat, Kerala, Meghalaya, Punjab, Uttar Pradesh and West Bengal. The states were selected on the basis of the levels of development and geographic location. To select the districts within each selected state, four variables were considered ̶ children in the age group (0-6 years); proportion of children (0-6 years) who have received full immunization; number of health facilities per 1000 children; and proportion of households living in rural areas.
Costs will be estimated using government health service perspective and retrospectively for the financial year 2013-2014. Both economic and financial costs will be considered though the focus will be on economic costing.
As of February 2015, data collection was completed for Bihar and Uttar Pradesh, and is ongoing in West Bengal.