RESEARCH

Estimating the costs of achieving the WHO–UNICEF Global Immunization Vision and Strategy, 2006–2015

Estimation des coûts pour réaliser l'objectif de l'initiative OMS-UNICEF « La Vaccination dans le monde : vision et stratégie » pour la période 2006-2015

Estimación de los costos de llevar a término la Visión y Estrategia Mundial de Inmunización OMS-UNICEF, 2006-2015

Lara J Wolfson^{I, 1}; François Gasse^II; Shook-Pui Lee-Martin^III; Patrick Lydon^IV; Ahmed Magan^II; Abdelmajid Tibouti^II; Benjamin Johns^V; Raymond Hutubessy^I; Peter Salama^II; Jean-Marie Okwo-Bele^IV

^IInitiative for Vaccine Research, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
^IIUnited Nations Children's Fund (UNICEF), New York, NY, United States of America
^IIIDepartment of Equity, Poverty and Social Determinants of Health, World Health Organization, Geneva, Switzerland
^IVDepartment of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
^VDepartment of Health Systems Financing, World Health Organization, Jakarta, Indonesia

ABSTRACT

OBJECTIVE: To estimate the cost of scaling up childhood immunization services required to reach the WHO–UNICEF Global Immunization Vision and Strategy (GIVS) goal of reducing mortality due to vaccine-preventable diseases by two-thirds by 2015.
METHODS: A model was developed to estimate the total cost of reaching GIVS goals by 2015 in 117 low- and lower-middle- income countries. Current spending was estimated by analysing data from country planning documents, and scale-up costs were estimated using a bottom-up, ingredients-based approach. Financial costs were estimated by country and year for reaching 90% coverage with all existing vaccines; introducing a discrete set of new vaccines (rotavirus, conjugate pneumococcal, conjugate meningococcal A and Japanese encephalitis); and conducting immunization campaigns to protect at-risk populations against polio, tetanus, measles, yellow fever and meningococcal meningitis.
FINDINGS: The 72 poorest countries of the world spent US$ 2.5 (range: US$ 1.8–4.2) billion on immunization in 2005, an increase from US$ 1.1 (range: US$ 0.9–1.6) billion in 2000. By 2015 annual immunization costs will on average increase to about US$ 4.0 (range US$ 2.9–6.7) billion. Total immunization costs for 2006–2015 are estimated at US$ 35 (range US$ 13–40) billion; of this, US$ 16.2 billion are incremental costs, comprised of US$ 5.6 billion for system scale-up and US$ 8.7 billion for vaccines; US$ 19.3 billion is required to maintain immunization programmes at 2005 levels.
In all 117 low- and lower-middle-income countries, total costs for 2006–2015 are estimated at US$ 76 (range: US$ 23–110) billion, with US$ 49 billion for maintaining current systems and $27 billion for scaling-up.
CONCLUSION: In the 72 poorest countries, US$ 11–15 billion (30%–40%) of the overall resource needs are unmet if the GIVS goals are to be reached. The methods developed in this paper are approximate estimates with limitations, but provide a roadmap of financing gaps that need to be filled to scale up immunization by 2015.

RÉSUMÉ

OBJECTIF: Estimer le coût du développement à plus grande échelle des services de vaccination infantile nécessaires à la réalisation de l'objectif de l'initiative OMS-UNICEF « La vaccination dans le monde : vision et stratégie (GIVS) », consistant à réduire des deux-tiers d'ici 2015 la mortalité due aux maladies évitables par la vaccination.
MÉTHODES: Un modèle a été élaboré pour estimer le coût total de la réalisation de l'objectif de cette initiative d'ici 2015 dans 117 pays à revenu faible ou faible à moyen. Les dépenses actuelles ont été estimées par une analyse des documents de planification nationale et les coûts du passage à l'échelle supérieure en utilisant une démarche partant de la base et des intrants. Les coûts financiers pour atteindre une couverture vaccinale de 90 % ont été estimés par pays et par année pour tous les vaccins existants, dans le cas où l'on introduirait une série discrète de nouveaux vaccins (vaccins antirotavirus, antipneumococcique conjugué, contre le méningocoque de type A et contre l'encéphalite japonaise) et dans celui où l'on mènerait des campagnes de vaccination pour protéger les populations à haut risque contre la polio, le tétanos, la rougeole, la fièvre jaune et la méningite à méningocoque.
RÉSULTATS: Les 72 pays les plus pauvres du monde ont consacré US$ 2,5 milliards (plage de variation : US$ 1,8-4,2) à la vaccination en 2005, soit une augmentation de US$ 1,1 milliard (plage de variation : US$ 0,9-1,6) par rapport à l'année 2000. D'ici 2015, les coûts annuels de la vaccination augmenteront en moyenne d'environ US$ 4,0 milliards (plage de variation : US$ 2,9-6,7). Les coûts totaux de la vaccination pour la période 2006-2015 sont estimés à US$ 35 milliards (plage de variation : US$ 13-40), dont US$ 16,2 milliards de surcoûts, se répartissant en US$ 5,6 milliards pour le passage à l'échelle supérieure du système et US$ 8,7 milliards pour les vaccins. US$ 19,3 milliards seront nécessaires pour maintenir les programmes de vaccination aux niveaux de 2005.
Pour l'ensemble des 117 pays à revenu faible ou faible à moyen, les coûts totaux pour la période 2006-2015 sont estimés à US$ 76 milliards (plage de variation : US$ 23-110), dont US$ 49 milliards pour maintenir les systèmes actuels et US$ 27 milliards pour passer à l'échelle supérieure.
CONCLUSION: Pour les 72 pays les plus pauvres, 30 à 40 % (soit US$ 11 à 15 milliards) des besoins en ressources ne sont pas couverts s'il on veut atteindre l'objectif de la GIVS. Les méthodes présentées dans cet article donnent des estimations approximatives et comportent des limites, mais elles permettent d'identifier les lacunes à combler sur le plan financier pour le passage à l'échelle supérieure des programmes de vaccination d'ici 2015.

RESUMEN

OBJETIVO: Estimar el costo de extender masivamente los servicios de inmunización infantil requeridos para alcanzar la meta de la Visión y Estrategia Mundial de Inmunización (GIVS) OMS-UNICEF de reducir la mortalidad por enfermedades prevenibles mediante vacunación en dos tercios para 2015.
MÉTODOS: Se elaboró un modelo para estimar el costo total del logro de las metas de GIVS para 2015 en 117 países de ingresos bajos o medios bajos. El gasto actual se estimó a partir de datos extraídos de los documentos de planificación de los países, y los costos de la extensión masiva se estimaron mediante un método ascendente basado en componentes. Se calcularon los costos financieros requeridos por país y año para alcanzar una cobertura del 90% con todas las vacunas existentes; introducir un conjunto de vacunas nuevas (contra rotavirus, antineumocócica conjugada, conjugada contra el meningococo A y contra la encefalitis japonesa); y realizar campañas de inmunización para proteger a las poblaciones de riesgo contra la poliomielitis, el tétanos, el sarampión, la fiebre amarilla y la meningitis meningocócica.
RESULTADOS: Los 72 países más pobres del mundo invirtieron US$ 2500 millones (intervalo: US$ 1800 - 4200 millones) en actividades de inmunización en 2005, lo que supone un aumento respecto a los US$ 1100 millones (intervalo: US$ 900 - 1600 millones) de 2000. Para 2015, los costos anuales de la inmunización aumentarán por término medio a unos US$ 4000 millones (intervalo: US$ 2900 - 6700 millones). Los costos totales de la inmunización para 2006-2015 se estiman en US$ 35 000 millones (intervalo: US$ 13 000 - 40 000 millones); de esa cantidad, US$ 16 200 millones son costos adicionales, de los que US$ 5600 millones corresponden a la expansión del sistema y US$ 8700 millones a las vacunas; se necesitan US$ 19 300 millones para mantener los programas de inmunizacion a los niveles de 2005.
En el conjunto de los 117 países de ingresos bajos y medios bajos, se estima que los costos totales para 2006 - 2015 ascenderán a US$ 76 000 millones (intervalo: US$ 23 000 - 110 000 millones): US$ 49 000 millones para mantener los sistemas actuales y US$ 27 000 millones para expandirlos.
CONCLUSIÓN: Considerando los 72 países más pobres, se necesitan aún US$ 11 000 - 15 000 millones (30% - 40% de los recursos globales necesarios) para poder alcanzar las metas de la GIVS. Los métodos desarrollados en este artículo arrojan estimaciones aproximadas que presentan limitaciones, pero proporcionan una hoja de ruta para financiar los déficits que hay que cubrir a fin de expandir la inmunización para 2015.

Introduction

In 2005, the World Health Assembly approved, and the United Nations Children's Fund (UNICEF) Executive Board endorsed, the Global Immunization Vision and Strategy (GIVS).^1,2 The primary objective of GIVS is to reduce vaccine-preventable disease mortality and morbidity by two-thirds by 2015 compared to 2000, a contribution towards achieving the Millennium Development Goals, especially Goal 4, which calls for a two-thirds reduction of under-5 mortality by 2015.³

GIVS identifies four strategic areas: immunizing more people against more diseases; introducing newly available vaccines and technologies; linking immunization to other critical health interventions; and managing vaccination programmes and activities within the context of global interdependence. GIVS articulates more than 25 new ideas and innovative approaches, and it is anticipated that countries will adopt the strategies most suited to their needs.

GIVS was developed in the context of increasing resources for immunization; in 1999 a public–private partnership, The Global Alliance for Vaccines and Immunization (GAVI Alliance) was initiated to provide financial support for immunization in the world's poorest countries.^4–6 By the end of 2005, government and private sources had pledged a total of US$ 3.3 billion to the GAVI Alliance, enabling it to provide support to 73 of 75 eligible countries. Between 2000 and 2005, total GAVI Alliance disbursements were US$ 760.5 million.⁷ GAVI Alliance's resource outlook over the next decade has improved with the launch of two innovative funding mechanisms: the International Finance Facility for Immunisation (IFFIm),⁸ which could provide up to US$ 4 billion over the next 10 years, and the Pneumo Advance Market Commitment (AMC),⁹ which will provide US$ 1.5 billion to support low-income countries for the purchase of new vaccines against Streptococcus pneumoniae, a leading cause of childhood meningitis and pneumonia mortality.

In 2005, WHO and UNICEF undertook, as a companion to the GIVS document, to estimate the costs to reach immunization goals;¹⁰ this paper reports on the methods and results of that initial exercise.

Methods

Countries included

Estimates were done for all low- and lower-middle-income countries (as of 2003)¹¹ focusing on the subset of GAVI Alliance-eligible countries¹² (for 2005–2010, countries with 2003 gross national income (GNI) per capita <US$ 1000), whose characteristics^11,13,34 are highlighted in Table 1.

Cost components included

The costing has two main components: the first estimates current spending for immunization as of 2005 and how much will be needed to maintain the current immunization system. The second component estimates the incremental costs needed to scale up immunization coverage, including routine delivery and campaigns, and to introduce all available and safe vaccines according to WHO recommendations, including a finite set of new vaccines expected to become widely available (see Fig. 1).

For vaccine-specific costs, we define "traditional" vaccines as those in widespread use in the Expanded Programme on Immunization (EPI): Baccillus Calmette–Guérin (BCG), three doses each of diphtheria-tetanus-pertussis (DTP) and oral polio vaccine (OPV); (we assume use of this ceases in 2010 following polio eradication), a single dose of measles vaccine (MCV1) for children under one year of age, and two doses of tetanus toxoid (TT2+) vaccine for pregnant women. "Underused" vaccines include a second dose of measles (MCV2); three doses of hepatitis B (HepB) and Haemophilus influenzae type b (Hib) vaccines; yellow fever (YF); and rubella. "New" vaccines include three doses of rotavirus and conjugate pneumococcal vaccines; and single doses of Japanese encephalitis (JE) and conjugate meningococcal A (MenA) vaccine, for populations at risk.

Deriving country-specific projections

Costs are projected using the following assumptions: (a) routine coverage of existing vaccines based on actual 2005 country-specific immunization schedules in use reaching 90% by 2015; (b) mortality reduction campaigns; and (c) introduction of underused and new vaccines as rapidly as feasible. We developed a Microsoft Excel-based framework to generate country-specific coverage estimates and projections, the WHO Immunization Coverage Estimates and Trajectories (WHO ICE-T)¹⁴ (Annex 1, available at: http://www.who.int/immunization_financing/analyses/givs_costing_annex1.pdf).

Four types of vaccination campaigns are included: for rapid mortality reduction (tetanus, measles); and in conjunction with the introduction of new or underused vaccines (yellow fever and meningococcal A). The schedule of campaigns occur in each country based on expected coverage levels, the joint UNICEF and WHO strategic plans for Measles Mortality Reduction¹⁵ and Maternal and Neonatal Tetanus elimination,^16,17 and the assumed year of introduction of new or underused vaccines. If the expected routine coverage levels are achieved by 2015, we assume no further immunization campaigns are needed, except occasionally in isolated areas with very low routine coverage.

We assume measles campaigns are needed until adequate routine two-dose coverage is reached; and schedule the occurrence of such campaigns every three years when routine first-dose coverage is under 75% and then every four years until first-dose routine coverage reaches 95% and routine second dose coverage reaches 90%. We assume that measles second-dose routine is introduced when a country reaches 80% routine first-dose coverage, and rubella vaccine is introduced after the first campaign following the introduction of routine second dose. Including a second dose of measles vaccine to the routine schedule adds a new visit to the schedule, another opportunity for children to contact the health-care system and receive other complementary interventions. Because of the complexity of adding a new visit to the schedule, we (conservatively) assume a five-year roll out to introduce a second dose.

For the introduction of underused (where not already used) and new vaccines, we assume phase-in over several years, based on grouping of countries by current immunization coverage and economic status (Annex 1, available at: http://www.who.int/immunization_financing/analyses/givs_costing_annex1. pdf). The dates of introduction of the pneumococcal, rotavirus, Hib, and HepB vaccines are country-specific, based on expert opinion, and it was assumed that in countries at risk, the YF vaccine would be introduced in 2006–2007, and that introduction of the meningococcal and JE vaccines would begin in 2009 and 2008 respectively.

Estimating country-specific costs

Estimating baseline costs (costing block A).

We developed an econometric model based on country-level data from the GAVI Alliance Financial Sustainability Planning (FSP)^18,19 process to estimate current investments in immunization and how much will be needed to maintain immunization systems at the status quo, assuming no change in vaccination schedules and constant immunization coverage levels.

These baseline data from 40 countries (country groupings and characteristics are listed in Table 1), use a common methodology comparable across the subset of countries and are relatively recent (2002–2004). However, they are biased towards low-income countries (82%) because of GAVI Alliance- eligibility requirements and because the African Region is over-represented (57%).

All routine immunization-specific costs (see costing block C for a description of what is included in these costs), excluding spending on vaccines and campaigns, which we estimate separately in costing blocks B and D respectively, are included.²⁰ To these were added shared health systems costs (mainly personnel and transportation costs). Inflationary adjustments²¹ are made to bring all costs to year 2000 US dollars for analysis, although all cost results are reported in 2005 dollars.

Various regressions using different linear combinations of Box-Cox^22,23 transformed variables were tested, with size-effect variables (either population or surviving infants), coverage,³⁴ rural population,²⁴ a dummy variable indicating the use of the hepatitis B vaccine, and GNI per capita representing the independent variables significantly correlated with costs. Standard model selection techniques of backward and forwards stepwise selection were used to find the optimal combinations of variables to include in the regression model.²⁵ We used nonparametric graphical modelling techniques^26,27 to find the optimal transformations of both independent and dependent variables, and the "leaps and bounds" regression technique²⁸ to determine which effects should be included in the model built from the transformed variables. Of over 270 models considered, the final model which simultaneously yielded good explanatory power (R²=81%), had no violation of regression assumptions and had relative parsimony, and did not appear to systematically underestimate the total costs across the 40 data points used in estimating the model. Further details on this model can be found in Annex 2 (available at: http://www.who.int/immunization_financing/analyses/givs_costing_annex1.pdf).

The fitted regression equation is used to estimate total non-vaccine costs (inflation adjusted) for the 72 poorest countries for the years 2000–2015. We applied the same model to estimate the costs in the 45 lower-middle-income countries (see Table 1), acknowledging the limitation that this is extrapolating outside the support of the fitted regression.

Uncertainty bounds are based on applying standard formulae²⁹ for predicting new observations from a fitted regression equation. The relative width of the uncertainty intervals for the baseline costing estimates was applied to estimates from other cost categories (B, C and D) to obtain overall uncertainty bounds.

Vaccine costs (costing block B)

We estimate the costs of traditional, underused and new vaccines for both campaign and routine use. For traditional and underused vaccines, UNICEF cost sheets, adjusted for inflation, provide price estimates, although this may be an underestimate of price for countries that are not using UNICEF or pooled procurement mechanisms.³⁰ For new vaccines, prices are based on assumptions derived from available data and expert opinion, together with an assumption that prices will drop towards a "mature" price as demand rises. Vaccines are estimated as "bundled" costs, including safe injection supplies (syringes and safety boxes), and adjusted for wastage (based on vial sizes) and buffer stocks needed. Shipping and freight are also included as a percentage of the price per dose. Table 2 gives the assumed prices and assumptions used for wastage and freight charges applied to all countries. Costs for disposable items (e.g. syringes, safety boxes) are based on 2005 international prices and adjusted for inflation (3%) assuming wastage of 10% of the auto- disposable syringes (US$ 0.074), reconstitution syringes (US$ 0.03) and safety boxes (100-syringe capacity, US$ 0.59).

The number of doses is based on the appropriate target population (births, surviving infants, women of childbearing age or as specified for a campaign) combined with expected coverage levels.^14,24

Systems costs (costing block C)

To estimate the costs of scaling-up coverage, we use country-specific variables to define likely production function rules for each component. The main assumptions and variables used for each component (both capital and recurrent costs) include a country classification used by the McKinsey³¹ consulting firm in a report to the GAVI Alliance on barriers to immunization systems performance, the Commission on Macroeconomics in Health infrastructure index,³² a transportation index based on types of available transport and communication,³³ district-level vaccine coverage and country-reported immunization-specific indicators.³⁴ The McKinsey classification groups countries into three types: TU or "turn around" countries, low performers where major system strengthening is required; SI, "strategic intervention" countries, middle performers in need of targeted interventions; and SA, "stand alone" countries, higher performers with good infrastructure. The classification is based on an assessment of political and financial commitment, physical infrastructure and equipment availability, monitoring and information systems, human resource availability and social mobilization strategies.³¹

Table 3 presents a summary of these assumptions. For example, the percentage of districts with less than 50% DTP3 vaccine coverage is used as an indicator as to whether additional supervisory visits at the district level are required. Media and information, education and communication costs are based on whether the country has reported an existing budget for social mobilization (and, hence, these costs were included in the baseline systems costs, rather than being new costs). Transportation costs related to the cold chain are linked to estimates of the average distance between facilities at the national, provincial, district and health service delivery levels, with the transport quartile³³ determining the type of vehicle to be used and the average distance that can be travelled daily.

The analysis builds on a large database of parameters developed for the WHO-CHOICE³⁵ project, e.g. country-specific prices for factor inputs such as stationery, fuel and other macro- and microeconomic parameters needed. Prices for immunization-specific items are obtained from Product Information Sheets.³⁶ Additional quantities are determined for items such as outreach personnel based on analysis of country financial sustainability planning documents.¹⁹

Campaign costs (costing block D)

Delivery costs per person vaccinated, exclusive of cost of vaccines and vaccine supplies, in the different types of campaigns are based on data collected from several different country-level costing studies^37–42 as well as those reported in the FSPs.¹⁹ The unit costs per person targeted include training, cold chain equipment, social mobilization, waste management, salaries and per diem and transport costs.

Where a cost per person targeted, by campaign, is available for a country, we used that estimate; where it was unavailable, we estimated the costs by using averages across WHO subregions and regions, or by extrapolating the ratio between costs of other types of campaigns in another country and applying that to a single campaign cost estimate from the country. Measles catch-up (nine months to 14 years) and follow-up campaigns (nine months to four years) were estimated to cost between US$ 0.19–1.68 per person targeted. Campaigns associated with the introduction of yellow fever (nine months and up) and meningococcal vaccines (nine months to 29 years) ranged between US$ 0.17–1.53 per person targeted; and campaigns to reduce the burden of maternal and neonatal tetanus (targeted towards women of childbearing age, 15–49), were estimated to cost US$ 0.19–1.51 per person targeted.

Findings

The total cost for immunization from 2006 to 2015, including the costs to maintain the existing immunization system, is estimated to be US$ 35.5 billion in the 72 GAVI Alliance-eligible countries (range: US$ 13–40 billion), of which 54% maintains current immunization efforts and the remaining 46% is for scaling-up (5% campaigns, 16% systems, 25% vaccines). This shows a considerable shift in the distribution of spending from systems to vaccines as more expensive vaccines are introduced: of the costs to maintain current routine immunization, 25% are for vaccines; in scaling up, 60% of the costs are for vaccines.

Applying the same methods (despite the potential limitations) to the remaining 45 lower-middle-income countries, we estimate an overall cost of US$ 76.1 billion (range: US$ 23–110 billion). Among the 45 lower-middle-income countries that are not GAVI Alliance-eligible, where baseline systems costs are estimated to be higher, 71% of the projected costs for 2006–2015 are for maintaining the current programmes, of which 13% goes towards vaccines; of the scaling-up costs, 69% will be for vaccines (Table 4).

In GAVI Alliance-eligible countries, on average US$ 0.54 per capita (range: US$ 0.21–3.11 across countries), or US$ 24 (range: US$ 7–105) per child born, needs to be spent to maintain current immunization levels, varying with population size, DTP3 coverage and economic status. This needs to be nearly doubled to achieve the GIVS goals, resulting in a cost per capita of US$ 1.18 (range: US$ 0.78–4.01), or cost per child of US$ 46 (range: US$ 27–167). This is comparable to the estimated spending level of the 45 lower-middle-income countries to maintain their current immunization levels.

Estimated spending on immunization in the 72 poorest countries has risen between 2000 and 2005, from an average of US$ 1.1 billion (range: US$ 0.9–1.6) in 2000 to US$ 2.5 billion (range: US$ 1.8–4.2) in 2005.¹⁰ Despite using a different methodology, the year 2000 results are remarkably consistent with estimates from other approaches of US$ 1.1 billion in low-income countries in 2000,⁴³ and US$ 1.17 billion (range: US$ 0.717–1.48 billion)⁴⁴ in 2001.

The composition of immunization activities relative to baseline costs will differ depending on the timing of vaccine introduction. The highest- performing countries, which introduce new vaccines earlier, will need relatively more cold-chain training and supervision investment compared (34% and 22%, respectively, of systems costs) to the late introducers of new vaccines, whose current immunization systems are not as strong (18% and 4%, respectively) and who need to make more substantial investments in core areas such as personnel and outreach (2% and 5% for high performers/early introducers; 21% and 23% for low performers/late introducers). In addition, the average incremental systems costs of scaling-up per child is more in the latter group (US$ 9) than the former (US$ 8), while the average incremental vaccine costs are lower (US$ 13) for late introducers than for early introducers (US$ 23). Our findings that US$ 16.2 billion is required to scale up immunization in the 72 poorest countries over the next 10 years are sensitive to underlying assumptions. As an example, we have assumed that the cold chain volume of a rotavirus vaccine will be 11.5 ml per dose, but the currently available presentation is nearly 112 ml per dose. If the larger vial size had been used in the costing, then an additional US $1.9 billion would be required, doubling the costs of scaling-up the cold chain, and increasing associated vehicle and transportation costs by 60%.

For the subset of GAVI Alliance-eligible countries, Table 5 shows the breakdown of projected costs for each immunization activity by WHO region. The largest proportions are in the African (34%) and South-East Asian (46%) Regions. This reflects the size of the birth cohorts, as these regions have 35% and 47% of the 2005 GAVI Alliance-eligible birth cohorts, respectively.

A primary use of these costing figures is to provide a better understanding of where financing gaps will occur, to start mobilizing the necessary resources to achieve the GIVS. We assume an optimistic funding scenario based on available data^18,19,45–47 from national programmes, the GAVI Secretariat and the WHO Polio Team, and the funding gaps are shown in Table 5.

For the 72 GAVI Alliance-eligible countries, about US$ 25 billion is estimated to be available for the 2006–2015 period, of which 16% is projected to come from national governments, 15% from the GAVI Alliance and 40% from external donors. Between 30% and 40% of need is unmet, an annual shortfall of more than US$ 1 billion.

The main unfunded area during the 2006–2015 period is vaccines. However, this becomes the case only when new vaccines become available in the longer term. In the medium term, the main unfunded elements will be for reaching more children, through strengthening systems and campaigns (Table 5). Regionally, the largest funding gaps in absolute terms are in the South-East Asia and African Regions; by percentage, the largest gap is in the Eastern Mediterranean Region.

Discussion

Putting a cost estimate to an immunization vision, 2006–2015 is no doubt subject to uncertainty around the data and methods used, individual strategies chosen by each country to reach its visions, price uncertainties around vaccines and other inputs to national immunization programmes, and the availability of funds to finance continuous expansions and improvements of immunization. The uncertainty bounds around the cost estimates reflect these limitations. These costing figures should be taken as indicative approximations of what it may take to scale up immunization to reach GIVS goals over the next decade. The estimates for lower–middle-income countries have additional limitations due to much of the input data for predicting baseline costs, and price data for vaccines, being specific to poorer countries.

A further limitation of this analysis is that only a finite set of potential immunization interventions is included. The newly licensed human papillomavirus vaccine is not included, nor are vaccines against seasonal influenza, nor are global public goods, including research and development, global capacity to assist countries in crisis situations with stockpiles of vaccines (e.g. for cholera). All of these are possible strategies identified in the GIVS² and many of them will be pursued. There is a need to periodically update this costing exercise to reflect the strategies being pursued at the country level, and our improved understanding of the dynamics of immunization costing and financing. Nonetheless, the present analysis is based on realistic and rigorous assumptions, the best available data (as of 2005), and fills an important gap in knowledge.

Recognizing these limitations, we estimate that reaching immunization goals is achievable at a cost of US$ 35 billion during 2006–2015. By 2015, more than 70 million children in the world's 72 poorest countries can be protected annually against 14 major childhood diseases if an additional US$ 1 billion per year can be invested towards immunization.¹⁰ This equates to an additional US$ 0.5 per capita per year above current levels (<US$ 1 per capita) of investment in immunization.

At such modest costs and high benefits, immunization continues to be one of the best values for public health investment today.⁴⁴ Not only do immunizations save lives, but in impoverished countries they boost economies, potentially yielding a rate of return of up to 18%.⁴⁸ In addition, immunization can serve as a platform to strengthen health systems and deliver other life-saving interventions such as those against malnutrition, malaria and intestinal worms.

Despite being a good buy for the health sector, financing for immunization remains a significant challenge. A funding gap of between US$ 11 billion and US$ 15 billion is estimated to remain if the goal of saving 10 million more lives is to be achieved by 2015. This financing challenge exists despite the favourable context of significant additional new resources for immunization that are available through the GAVI Alliance, IFFIm,⁸ the AMC⁹ and other global efforts. There are growing concerns about the financial sustainability of future immunization efforts, and for many of the poorest countries, shared financial responsibility between national governments and international donors will be required.⁴⁹

In late 2005, WHO and UNICEF, together with GAVI Alliance partners launched the comprehensive Multi-Year Plan (cMYP) process for immunization with tools to estimate the financial requirements and gaps for reaching national goals in line with the GIVS.⁵⁰ The cMYP process is a first step in translating the global into the local: a national immunization plan to implement appropriate strategies at country level. With the implementation of these plans, countries are paving the way towards sustainability of their current programmes and preparing themselves for the later generations of vaccines and technologies where financing requirements will grow.

The real challenge will hinge on how national governments, WHO, UNICEF and the international community at large, manage their roles and responsibilities in reaching and financing the goals of the GIVS until 2015.

Acknowledgements

The staff of the Department of Immunization, Vaccines and Biologicals at WHO and in Immunization Plus at UNICEF have all contributed to the development of this paper. In particular, we thank Marta Gacic-Dobo and Sandra Garnier for providing underlying immunization data, UNICEF Supply Division for providing data on vaccine and equipment costs, GAVI Secretariat for providing details on expected current and future commitments and resources as of December 2005, and the GAVI Accelerated Introduction and Development Projects (ADIPS) for providing guidance on assumptions regarding the timing of introduction and pricing of new vaccines, and Taghreed Adam, Tracey Goodman, Logan Brenzel and Tessa Tan-Torres Edejer for intensive review of the work and their contributions. Early versions of this work were used as the basis for the GAVI/Vaccine Fund International Financing Facility for Immunization (IFFIm) proposal in October 2004.

Competing interests: None declared.

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(Submitted: 18 June 2007 – Revised version received: 9 October 2007 – Accepted: 12 October 2007 – Published online: 6 December 2007)

1 Correspondence to Lara J Wolfson (e-mail: wolfsonl@who.int)