Costing and financing analyses of routine immunization in Zambia

Zambia had a population of just over 13 million in 2010 of which 60.5% lived in rural areas. The total fertility rate is high at 5.9 per woman and higher in rural areas. Zambia is classified as a lower-middle income country (per capita gross national income (GNI) US$1350 in 2012, with 61% of the population living in poverty. Zambia’s geographic location, climate, socioeconomic profile and demographic characteristics put its population at risk of preventable childhood diseases. Managing efficiency and costs of health care is important to ensure increasing coverage and sustainability. In 2011 (the year of the costing study) there were 9 provinces1 and 72 districts. Immunization is predominantly delivered through 409 urban health centres (UHC) and 1 131 rural health centres (RHC). Of these approximately 81% are owned by government and 6% by faith-based organizations, which are largely funded by government and tend to have public sector salary and other inputs. Zambian government EPI reports indicate national full immunization coverage rates above 90% between 2009 and 2011, although WHO-UNICEF estimates based on national surveys, suggest lower immunization, with DTP3 coverage of 83% in 2010 and 81% in 2011. Sustaining high immunization coverage and resolving uneven performance across districts has been difficult due to shortage of human resources, cold chain challenges and inadequate attention to routine activities. In 2012, Zambia introduced three new vaccines: PCV, rotavirus and measles second dose in a phased manner. An up-to-date and detailed understanding of routine program costs is important for planning and management of EPI (and other primary health care) services. This study is part of a multi-country EPI costing project to tackle that challenge. The overall purpose of the multicountry project is to generate accurate costing and financing information for the EPI in each country, including consideration of cost implications of new vaccines. This particular study sought to develop an updated, detailed evidence-base around routine immunization program costs to inform planning, management and funding in Zambia. Specific objectives were to assist the Government of Zambia (GRZ) and other stakeholders to:

1) Replace dated estimates of costs of providing immunization and introducing new vaccines with more accurate estimates of EPI costs. 2) Generate costing estimates, which are methodologically consistent with estimates generated in other countries. 3) Relate delivery costs to output or coverage indicators, and identify cost determinants and factors affecting productivity. 4) Obtain information on patterns of financing by government and other EPI funders. 5) Generate cost and financing data to inform assumptions which underpin estimates of budgets and resource requirements in the cMYP, to enhance resource mobilization. The findings from the study can also potentially inform the refinement of standard methodologies to estimate immunization costs such as the cMYP, and the tracking of resource flows for immunization.