The costs of delivering vaccines in low- and middle-income countries: Findings from a systematic review.

Information on immunization delivery costs (IDCs) is essential for better planning and budgeting for the sustainability and performance of national programs. However, delivery cost evidence is fragmented and of variable quality, making it difficult for policymakers, planners, and other stakeholders to understand and use. This study aimed to consolidate and summarize the evidence on delivery costs, answering the question: What are the unit costs of vaccine delivery across low- and middle-income countries (LMICs) and through a variety of delivery strategies? We conducted a systematic review of over 15,000 published and unpublished resources from 2005 to 2018 that included IDCs in LMICs. We quality-rated and extracted data from 61 resources that contained 410 immunization delivery unit costs (e.g., cost per dose, cost per fully immunized child). We converted cost findings to a common year (2016) and currency (U.S. dollars) to ensure comparability across studies and settings. We performed a descriptive and gap analysis and developed immunization delivery cost ranges using comparable unit costs for single vaccines and schedules of vaccines. The majority of IDC evidence comes from low-income countries and Sub-Saharan Africa. Most unit costs are presented as cost per dose and represent health facility-based delivery. The cost ranges may be higher than current estimates used in many LMICs for budgeting: $0.16-$2.54 incremental cost per dose (including economic, financial, and fiscal costs) for single, newly introduced vaccines, and $0.75-$9.45 full cost per dose (economic costs) for schedules of four to eight vaccines delivered to children under one. Despite increased attention on improving coverage and strengthening immunization delivery, evidence on the cost of delivery is nascent but growing. The cost ranges can inform planning and policymaking, but should be used with caution given their width and the few unit costs used in their development.