Estimating the cost of vaccination in southeastern Iran

ABSTRACT

Background: Specification of vaccination cost of children would help policymakers in determining the nation-wide budget needed for the maintenance of the vaccination program. The budget came these days under scrutiny due to the imposed sanctions tightening the public funds. This study aims at estimating the cost of vaccination in southeastern Iran for obtaining more accurate budget projections.

Methods: Fifty-two healthcare centers from 10 cities in south-east Iran participated in using a quota sampling method for their selection. A bottom-up method determined the human resource use, the consumption, and the overhead costs to estimate the cost of vaccination. Data collection used a standard tool that was adjusted to local conditions. Sensitivity analyses were performed.

Results: The overall vaccination cost for the region was estimated at around 5,984,000 USD for the year 2015. Salaries took the largest part of the cost estimate (64%), while vaccine cost and its equipment were much lower (22%). The average cost per vaccine dose administrated was 40.94 USD. Sensitivity analysis of the population and inflation rate indicates that the vaccination cost may fluctuate between 37% and 53% over 6 years (2021) from the data of 2015.

Conclusion: Maintaining vaccination has a substantial cost. The results of the study will support the budget planning and decision making and will define more precisely the resource allocation needed for maintaining the vaccination at a high level across the country. It may also help to facilitate the assessment of cost-benefit and cost-effectiveness analysis when new vaccines should be introduced.

Introduction

Suppressing contagious diseases in childhood through an Expanded Program of Immunization (EPI) is one of the most cost-efficient interventions in public health.^1,2 The first EPI-program in Iran was initiated in 1974. It recommended vaccines against six diseases including tuberculosis, poliomyelitis, diphtheria, tetanus, measles, and whooping cough. In 1998, the vaccination against hepatitis B was added following the recommendations of the World Health Organization (WHO). The program should approximately avoid 2 to 3 million deaths of children per year in Iran.³

This achievement was only possible having an extended primary health-care organization in place across the country by which vaccination is implemented in Iran. The organization has a network of health houses in small villages, rural health centers in larger villages, urban-rural health centers for mixed city-villages, and urban health centers serving only the urban populations.^4–6 The national vaccination program has been quite successful for the country, achieving important goals of disease control, elimination, and eradication of infections such as measles, rubella, and neonatal tetanus. It provides stable free situations of poliomyelitis, and it controls the spread of diphtheria and hepatitis B. The Ministry of Health and Medical Education (MoHME) was able to obtain very high vaccine coverage rates of 99%, putting also in place a permanent monitoring system of vaccine-preventable diseases and guaranteeing a suitable cold chain program for transporting the vaccines throughout the country.⁷

Because Iran is under international sanctions for several years, public funds are getting tight and experiences from the past about vaccination expenses cannot be utilized anymore for projecting the vaccination cost of the next decade for the country. Therefore, new determination of those expenditures is urgently needed. Since the country is a vast territory, trying to include in the study all the different parts of the country were not feasible. The region where vaccination activities were best operational was therefore selected and that region is the southeastern territories of Iran.

Cost estimate of vaccination can be very different across countries. It highly depends on several parameters such as facilities available, volume of vaccines consumed and wasted, logistics for transporting the vaccines to the centers where they will be administrated, and the vaccine prices, to name a few ones.⁸ With the introduction of the new vaccines, it is also expected that the overall cost will dramatically increase.^8,9 Reported by the WHO is the expense of immunizing children in low-income countries that have significantly increased from 1.1 billion USD in 2000 to 2.5 billion USD in 2005.¹⁰ For our study here we followed a method of evaluation done by a group of experts who recently assessed the vaccination cost in low and middle-income countries focusing their evaluation on routine and supplemental immunization activities.¹¹ Our approach has evaluated the former type of vaccination cost only.

Methods

The study is descriptive and retrospective in its design measuring the cost of vaccination over 1 year, namely for the year 2015. The population includes the children attending the different types of the participating health centers in the region. The first selection of 100 health centers of the 490 available was made in 10 cities through quota sampling. Since vaccines were not administrated in all of the rural centers, along with a lack of cooperation of some centers, only 52 centers participated in the study. Four were urban centers, 5 urban-rural, 4 rural, and 39 were health houses.^9,12

The seven vaccines considered in this evaluation include Bacillus Calmette-Guerin (BCG) against tuberculosis, the hepatitis B vaccine at birth, the oral polio vaccine (OPV), the inactivated polio vaccine (IPV), the pentavalent combination vaccine against diphtheria, tetanus, pertussis, Haemophilus influenza type B, and hepatitis B (DTP-HepB-Hib) at month 2, 4, and 6, the triple combination vaccine DTP at month 18 and 6 years and the combination vaccine against measles, mumps, and rubella (MMR).

A bottom-up approach was used for measuring the cost. Its advantage is the possibility to allocate for each activity in the organization a shared cost related to vaccination within each health-care unit under study.¹¹ The following six steps were applied using interviews and observational methods to collect the information: identifying and defining all the activities at each center; type of activity and operation related to vaccination; output of those latter activities through the vaccines given; direct cost estimates of these activities; attributing cost of shared activities in each center (overhead costs); cost estimate per output using cost per activity + shared activities.

Data on personnel salary, equipment, and number of vaccine doses were collected in each participating center.¹³ Data on cost of consumer goods (e.g. vaccines, syringes, and safety boxes), of human resources (e.g. vaccine administration, headquarter supervision, and ambulance units), and shared cost at the unit (e.g. transportation and fuel, repair and maintenance of vehicles and buildings, energy, depreciation of the equipment employed for the cold chain, vehicles, buildings, and other equipment) were all considered (see Table 1). Costs were converted in USD according to the currency exchange rate at the time of doing the study.¹⁴

Table 1.

Type of centers, cost variables, and units for sharing activities to estimate cost of the different activities in a health center

Type of centers	Cost variables	Units for sharing activities	Formula
Urban, Urban-rural, Rural, Health houses	Vaccine types	Registered doses per vaccine type	(Vaccine price/Number of each dose) × Number of each dose for child
	Vaccine administrations & safety supplies	Numbers	Number of vaccine administrations & safety supplies × Price
	Personnel salary	Annual paid hours	Duration of each service (in hours) × Cost per hour
	Transportation and fuel	Distance traveled	Monthly fuel consumed by the center (in liters) × Price of a liter of fuel
	Building maintenance	Square meters	Building maintenance contract/Area of building
	Energy	Square meters	(Area of room/Total area of Health Unit) × Total cost of energy
	Depreciation of cold chain equipment	Hours using equipment	Number of equipment used × (Price of cold chain equipment/Useful life)
	Depreciation of vehicles	Distance traveled	(Price – Residual value)/Useful life)
	Depreciation of buildings	Square meters	(Price- Residual value)/Useful life)
	Rent	Square meters	12 × Cost of one month rent of the building × (Area of room/Total area of Health Unit)

Data collection and analysis

Data collection used a standard, pre-tested tool developed by the Bill and Melinda Gates Foundation,¹⁵ that was adjusted to the local conditions. The modifications added to the tool were first approved by the Ministry of Health before its general use. The data were collected studying local documents and performing local interviews and observations. The researchers determined the duration of vaccination activities via in-person studies using the technique of time and motion observation. Using an expert-panel approach, the participants were asked to state their opinion regarding the times obtained. They were accordingly adjusted if large discrepancies were noted. The proportion of time dedicated to vaccination was determined from the working hours split by the time devoted to the different vaccination activities. If in 1 h work time, 3 activities were devoted to vaccination related to 3 min, 7 min and 15 min, that working hour was assigned for 25 min to the vaccination program. Overall income of the personnel who participated in the vaccination process was divided by the vaccination activities according to the annual paid hours. Again, if the 25 min assigned to the 3 activities of vaccination were performed by 3 different people with a different salary, each activity was adjusted in cost, related to the salary of the person doing the job. All the data were stored into one database and analyzed using the statistical software package, STATA 14.

The output selected for the study is the cost measured per vaccine dose given that is vaccine type-specific and context-specific per health center type. The cost of vaccination is reported per child up to the age of 6 years (cost per capita) as this is the period during which he/she will receive all the different vaccines. The overall cost of vaccination per year for the region is the sum of all the children at the age of 6 years in the region who received the full vaccination schedule at that age, multiplied by the cost of vaccination that includes all the cost of administration and handling with the cost of the vaccines. We report the overall cost for the region with the relative split of the cost items in different categories including personnel cost, vaccines, and equipment, building, transportation, and fuel, cold chain infrastructure and overhead cost. Cost will also be reported by the age-group in the children and by health center type.

Estimating the future cost of vaccination

Predictions for the vaccination cost of children <6 years old for the year 2021 was carried out in two steps. First, estimates of the birth cohort for the year 2021 were calculated using time-series data of the birth cohort in 2015. In a second step the estimated child population of the year 2021 is multiplied by the cost of vaccination one child (0 to 6 year) using the following formula:

$$A_n=A_O\ast {\left(1+i\right)}^n$$

$A_0:$ sum of the cost of vaccination one child from birth to age 6 years old in 2015,

i: inflation rate, 11.9% for 2015¹⁶

n: number of years

To generalize the results across the country, sensitivity analysis was performed on the variables of inflation rate and under-6 years old population. In sensitivity analysis, parameters were tested of the population growth rate of children <6 years old along with a range of change of ±20% and of the inflation rate at 20% and 25% instead of 11.9% now.

Results

Table 2 and Figure 1 summarize the share of the different cost items from the overall cost in the health centers assessed. The share of salary cost, vaccine, and equipment cost, and other costs were 64%, 22%, and 14% of the overall cost, respectively. The overall cost of vaccination for the region was estimated at 5,984,191.59 USD. Surprisingly, the cost of the cold chain infrastructure was only 1%.

Table 2.

Cost-sharing of each cost items for different vaccine

Cost items	Cost USD (%)
	BCG	Hepatitis B	Oral polio	Injection polio	Triple	Pentavalent	MMR
Personnel Salary	22.81 (69.9)	19.78 (66.9)	166.05 (66.6)	23.50 (66.8)	52.71 (61.8)	85.04 (62.7)	51.52 (58.9)
Vaccines and Equipment	7.98 (24.5)	7.80 (26.4)	49.55 (19.9)	7.59 (21.6)	18.64 (21.9)	28.15 (20.8)	21.68 (24.8)
Houses	0.71 (2.2)	0.77 (2.6)	13.61 (5.5)	1.59 (4.5)	5.93 (7)	10.08 (7.4)	5 (5.7)
Overhead	0.27 (0.8)	0.32 (1.1)	11.43 (4.6)	1.40 (4)	4.95 (5.8)	7.66 (5.6)	5.53 (6.3)
Transportation and Fuel	0.74 (2.2)	0.75 (2.5)	6.49 (2.6)	0.91 (2.6)	2.26 (2.6)	3.33 (2.5)	2.09 (2.4)
Cold Chain Equipment	0.13 (0.5)	0.14 (0.5)	2.29 (0.9)	0.20 (0.6)	0.75 (0.9)	1.36 (1)	1.61 (1.8)

Figure 1.

The share of the different cost items as part of the overall cost of vaccination

Table 3 specifies the vaccine cost per dose and per vaccine type for different age groups. Vaccines for children at 18 months old had the highest cost, due to the high number of vaccines to be given and the high price for combination vaccines. The lowest cost was for the age-group at 12 months old. The overall cost of vaccination from birth to 1-year-old was 443.02 USD. Finally, the overall cost per child under the age of 6 years old is 655.11 USD. The average cost per dose is given 40.94 USD (Table 3).

Table 3.

Cost of vaccination per dose per vaccine type and for different age groups (USD)

Age group	BCG	Hepatitis B	Oral polio	Injection polio	Triple	Pentavalent	MMR	Total sum
Less than one month	32.63	29.56	41.57					103.76
2 months			41.57			45.21		86.78
4 months			41.57	35.18		45.21		121.96
6 months			41.57			45.21		86.78
12 months							43.72	43.72
18 months			41.57		42.60		43.72	127.89
6 years			41.57		42.60			84.17
Number	1	1	6	1	2	3	2	16
Cost per child								655.11
Average cost/dose								40,94

Table 4 reports the cost per vaccine dose and per vaccine type for the different health center types, urban, urban-rural, rural, and health houses. The highest overall vaccination costs are for urban centers (923,982 USD). The cost of vaccination per child is the highest in health houses (884.88 USD). The cost per dose and per vaccine type (except for BCG and Hepatitis B, which were not administrated in all centers) were the same in urban, urban-rural, and rural centers.

Table 4.

Cost per vaccine dose and per vaccine type for the different health centers (USD)

Type of center	Average total cost for vaccination per center per year	% of vaccination cost of the total cost per center per yar	BCG	Hepatitis B	Oral polio	Injection polio	Triple	Pentavalent	MMR	Cost per child	Per capita cost
Urban	923,982	1.8	2.71	2.81	3.73	6.87	4.08	6.77	5.25	73.81	19.31
Urban-rural	46,994.9	20	2.73	2.84	3.35	6.82	3.68	6.39	4.86	68.68	17.05
Rural	89,843.5	13	0.48	0.54	2.74	7.45	3.07	5.76	4.25	56.81	10.31
Health houses	43,433.7	14	44.51	40.23	56.48	46.37	57.78	60.49	58.94	884.88	122.04

Table 5 reports the total cost estimates for vaccination of the region 6 years from 2015. The population sensitivity analysis indicates that in comparison to the base case (n = 12,806,622 children), the cost may vary between −25% and +17% if we expect −20 to +20 growth rate. The sensitivity results for the inflation rate indicate that the costs may vary between 37% and 52%. We combined the results in the two-way sensitivity analysis Figure 2.

Table 5.

One-way sensitivity analysis on uncertain parameters of the projection cost

	Cost
	Population		Inflation rate
	Down	Up	Scenario 20%	Scenario 25%
Per capita cost of vaccination in 2021	524	786	1,039	1,364
Percent of cost change	−0.25	0.17	0.37	0.52

Base case value: Population (N)= 12,806,622, Cost of Vaccination = $ 655, Inflation rate = 11.9%.

Figure 2.

Two-way sensitivity analysis changing the child population size and the inflation rate on cost (hypothetical numbers)

Discussion

Seven different vaccines are administrated today in the national vaccination program in Iran. The results indicated that in the studied region with high vaccine coverage, the total vaccination cost of children up to the age of 6 years old is 5,984,191.6 USD. The average cost per dose is estimated at 40.94 USD. The question raises whether this cost is high or not? Can we do a comparison with other countries that are equivalent to Iran? Several studies have investigated the costs of routine vaccination including studies in Rwanda, Moldova, Honduras, Ghana, Gambia, Benin, and Zambia.^{1,9,12,17–20} Table 6 summarizes the cost results and we included the cost of Iran from our study here (last row).

Table 6.

Results of the vaccination cost of different countries (USD)

Country	Year	Cost per dose	Cost per infant	Cost per infant(PPP)	Cost per FIC
Ghana8,19	2011	5	36	78	51
Honduras8,18	2011	8	113	217	128
Moldova1,8	2011	18	317	672	332
Uganda8	2011	5	20	61	44
Benin8	2011	2	19	42	25
Zambia8,9	2011	7	60	123	66
Iran	2015	40.9	443	1,605	655

FIC: full-immunized child.

As indicated in Table 6, the cost per vaccine dose in Iran is much higher than in other countries. Even though the difference was decreased by adjusting the vaccination cost in the other countries to that of the year 2015, in Iran it is still much higher. One explanation for that big difference is the provision of services to the many health houses in the country. While the number of people visiting those places is low, the price to pay for getting and maintaining the vaccination program in those places could be very high which increases the overall cost of service provision. Other reasons are high geographical distribution of the study area and the long distance between health houses. The problem becomes more serious when considering that the vaccine is used for children in different doses and ages, which need more travel by health houses’ personnel. However, all vaccine-related costs have been taken from the Iranian Ministry of Health and Medical Education, which is the only available source in Iran for this information.

As indicated in the study, 64% of the total vaccination cost is related to the salary, while only 22% to vaccine cost and equipment. These percent costs are in accordance with other studies. A study in Ghana confirmed that the proportion of salary cost and vaccine and equipment cost to the overall vaccination cost were 61% and 19%, respectively.¹⁹ Another study in Honduras also revealed that salaries (54%) and vaccines and equipment (25%) had the highest share of the total vaccination cost.¹⁸ A study in Zambia indicated that salaries and vaccines and equipment cost were responsible for 49% and 17% of the total vaccination costs, respectively.⁹ Variations in the % across the different countries are possibly due to differences in payment methods, in unit costs and in differences of the health-care systems of the countries studied.

Meanwhile, the average vaccination cost per capita in Iran was 443 USD for a child less than 1y old. That absolute number is not in accordance with the other studies. It could be that the search for getting a 100% coverage rate of vaccination in Iran, may also explain the big difference in cost as it increases the service providers’ costs.

In urban-rural health centers and in health houses, the share of vaccination cost to the overall cost of the center was the highest, because the focus of those centers is on prevention and control of diseases in their catchment area. These centers do not provide other clinical services. Therefore, the fact that the vaccination cost is high in those centers, shouldn’t be such a surprise.

The analysis of the future financial cost of vaccination suggests that the per capita cost of vaccination could be estimated between 1040 and 1370 USD in 2021. However, due to the high inflation rate in Iran, a different variation range was considered.

Though the vaccination cost seems high, another recent study about vaccination in Iran indicated that the cost imposed on society by having no vaccination in place could approximate $31 million, which is at least twice the cost measured for implementing vaccination.²¹

Our estimations can provide great support for political decision-makers in health care to finance and plan the vaccination cost that maintains a high coverage rate.

The current study has limitations. First and foremost, the region under study may not be the best representative one for all of Iran. Since the area of study is vast, with scattered cities and villages, the costs of service providers could be very high. Another limitation was using timing to determine vaccination activities only for some, not all centers, and therefore using this timing for other centers. Another issue is that the oral polio vaccine was the only form of vaccine prescribed to children at the time of the study, but now according to WHO and national policies to eradicate poliomyelitis cases, both oral and injectable forms of the vaccine are used for vaccinating children.

Conclusion

This study provides reference information about the current cost of vaccination in Iran. Those estimates are possibly impacted by what is happening at the international level of getting imposed sanctions for the country that reduce the availability of enough public funds. However, having those data now available, it could help the planning for optimum utilization of the limited resources. It may also help in assessing the cost-benefit and cost-effectiveness evaluation of new vaccines to be introduced.

The estimated cost of vaccination is substantial for maintaining the vaccination status at a high level as it is now in the country. For the better planning, it was, therefore, necessary to get a proper evaluation of all the different aspects related to the correct implementation of vaccination.

Appendix.

Table A1.

Cost item of employees salary

Center code	Total cost	Vaccination share of the total cost	MMR	Pentavalent	Triple	Injection polio	Oral polio	Hepatitis B	BCG	Cost per capita
964	18499	2085	344.18	526.39	249.70	87.73	823.32	47.24	6.75	27.44
962	22892	2148	385.52	495.67	367.16	36.72	862.83	0.00	0.00	37.03
961	22606	2161	449.10	484.19	336.83	63.15	828.03	0.00	0.00	22.05
963	22678	2239	394.17	700.75	184.92	72.99	885.67	0.00	0.00	11.14
564	31309	2247	85.31	445.52	265.42	0.00	957.40	246.46	246.46	16.05
363	21613	2322	313.25	460.66	239.54	110.56	847.62	165.84	165.84	52.77
563	26154	2340	389.97	536.21	259.98	113.74	877.43	81.24	81.24	55.71
932	17686	2351	435.64	645.74	268.80	83.42	917.63	0.00	0.00	7.81
561	26273	2368	427.18	547.90	362.17	120.72	910.07	0.00	0.00	16.33
442	18333	2387	378.26	478.68	291.22	100.42	883.72	127.20	127.20	16.93
1062	20630	2414	349.42	456.94	327.92	75.26	924.63	139.77	139.77	29.08
365	25360	2431	331.02	467.99	365.26	79.90	958.80	114.14	114.14	21.56
366	23719	2432	418.95	531.35	326.98	61.31	929.86	81.75	81.75	31.58
965	19844	2466	518.62	560.96	349.27	21.17	1016.07	0.00	0.00	28.02
362	27029	2540	455.81	499.22	314.73	75.97	1020.15	86.82	86.82	28.22
165	26075	2628	345.77	276.62	276.62	138.31	968.16	414.92	207.46	18.99
164	26085	2631	526.12	736.56	210.45	210.45	947.01	0.00	0.00	87.69
163	29947	2647	460.43	594.72	431.65	115.11	1035.96	9.59	0.00	46.45
161	26218	2693	423.45	389.57	389.57	84.69	999.34	169.38	152.44	35.91
562	24773	2719	361.94	794.51	308.98	150.07	1103.49	0.00	0.00	18.62
467	27574	2724	371.44	742.88	371.44	0.00	1114.32	0.00	123.81	09.53
166	26589	2815	383.24	475.75	475.75	52.86	1110.09	158.58	158.58	26.81
364	31948	2851	510.27	676.67	443.72	99.84	1120.39	0.00	0.00	33.54
162	26623	2865	238.73	636.61	159.15	198.94	1074.27	278.52	278.52	68.51
462	27997	2887	577.40	519.66	375.31	86.61	1039.32	144.35	144.35	67.14
167	27163	2940	615.36	820.48	273.49	0.00	1093.98	68.37	68.37	33.64
862	27414	2979	262.89	942.01	328.61	175.26	1270.62	0.00	0.00	60.80
463	28569	3001	187.56	750.24	375.12	0.00	1312.92	187.56	187.56	00.16
861	32758	3062	551.00	787.15	409.32	118.07	1196.46	0.00	0.00	18.79
864	28037	3116	620.23	708.84	428.26	191.98	1166.63	0.00	0.00	34.62
1061	32136	3151	434.59	618.46	451.31	100.29	1211.84	167.15	167.15	29.72
866	32790	3183	565.64	782.69	460.40	131.54	1243.09	0.00	0.00	17.30
468	36440	3225	356.40	744.87	253.04	99.79	1329.36	220.97	220.97	12.22
867	33171	3227	391.13	880.05	391.13	228.16	1336.37	0.00	0.00	89.81
441	24198	3232	427.83	688.42	346.15	151.69	1229.04	194.47	194.47	10.99
865	26440	3235	551.28	884.95	435.22	123.31	1240.38	0.00	0.00	18.81
461	10120	3361	423.54	611.01	465.20	118.04	1298.39	222.18	222.18	32.01
863	33059	3372	597.95	827.40	493.66	139.06	1314.11	0.00	0.00	21.90
942	28106	3675	581.24	933.07	527.75	175.94	1460.82	0.00	0.00	5.65
464	30312	3754	435.95	775.03	403.66	137.24	1453.18	274.49	274.49	22.21
911	33381	3755	644.16	926.11	558.34	141.54	1484.45	0.00	0.00	7.82
943	23606	3918	473.16	842.90	268.28	149.26	1645.80	269.26	269.26	2.56
465	30597	3939	549.09	763.95	495.37	119.37	1533.87	238.73	238.73	20.30
931	19511	4275	676.00	1100.87	614.08	169.43	1714.95	0.00	0.00	1.32
466	30597	4387	618.95	843.44	500.29	153.94	1674.05	298.25	298.25	9.28
912	11333	4552	793.22	1055.13	632.33	173.98	1777.26	65.48	54.25	3.98
913	36559	4572	679.12	1217.44	728.81	0.00	1946.25	0.00	0.00	4.60
933	40542	4760	992.27	814.93	945.11	131.21	1798.99	38.95	38.95	4.21
411	38286	5031	676.62	924.38	535.32	148.26	1888.56	428.86	428.86	5.17
941	20152	5184	864.47	1362.87	796.89	0.00	2159.76	0.00	0.00	3.19
831	45467	6533	1036.54	1635.11	969.39	287.60	2604.50	0.00	0.00	3.54
361	81092	18977	3530.54	3971.86	1323.95	882.64	6619.76	1323.95	1323.95	63.56
Total	1460288	180785

Funding Statement

No funding was received towards this work.

Abbreviations

EPI

Expanded program of immunization

WHO

World Health Organization

CRS

Congenital rubella syndrome

RI

Routine immunization

BCG

Bacillus Calmette-Guerin

OPV

Oral Polio Vaccine\

IPV

Inactivated Polio Vaccine

DTP

Diphtheria–Tetanus–Pertussis

MMR

Measles–Mumps–Rubella

Authors’ contributions

RG, MTG, SA, and MN contributed to the conception and design of the CRCT. RG and MTG contributed to the acquisition of the data. RG and MTG performed the analysis. All authors contributed to the interpretation of the results. MTG drafted the manuscript. All authors revisited the manuscript critically. All authors read and approved the final manuscript.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Availability of data and materials

The datasets used and analyzed are available from the corresponding author on reasonable request.