Cost of Delivering Child Immunization Services in Urban Bangladesh: A Study Based on Facility-Level Surveys
Khan, M. Mahmud, Khan, Suhaila H., Walker, Damian, Fox-Rushby, Julia, Cutts, Felicity, Akramuzzaman, S. M., Journal of Health Population and Nutrition
The Expanded Programme on Immunization (EPI) aims to reduce morbidity and mortality from six vaccine-preventable diseases: tuberculosis, diphtheria, pertussis, tetanus, measles, and poliomyelitis. A fully-immunized child (FIC) receives six standard EPI antigens through eight vaccinations given in the first year of life. The recommended schedule is: one shot of Bacille Calmette Guerin (BCG) at birth, three doses of oral polio vaccine (OPV) together with three shots of diphtheriapertussis-tetanus (DPT) at age 6, 10, and 14 weeks, and one shot of measles vaccine at age 9 months. Along with these six antigens, the routine EPI also included two doses of tetanus toxoid (TT) for pregnant women and one dose of vitamin A for children at the time of the study. The main EPI programme (the routine EPI) is supplemented by other interventions, such as National Immunization Day (NID), mop-up after NID, acute flaccid paralysis (AFP) surveillance, and maternal and neonatal tetanus (MNT) surveillance.
EPI has reduced morbidity and mortality from vaccine-preventable diseases in Bangladesh, but little is known about costs and effectiveness of urban EPI. A comprehensive review in 1998 and two studies on the cost-effectiveness of the Bangladesh EPI have pointed out the need for collecting cost information from urban areas (1-4). Unlike rural Bangladesh, urban EPI is delivered through a partnership between the public sector and the private sector. In fact, the private service providers, especially NGOs, play such an important role in urban EPI that estimates based on national-level expenditure or cost data will be a significant underestimate of total costs if the contribution of NGOs is not included. However, the exact level of involvement of NGOs in EPI delivery was not known at the time of the study. The national-level data do not include all the costs incurred by NGOs and, therefore, an attempt to estimate the costs of urban EPI will be extremely useful for calculating the actual cost of immunization in Bangladesh.
MATERIALS AND METHODS
Study design and sampling
This facility-based study estimated the costs of providing routine EPI services from the perspective of EPI service providers. A comprehensive list of all the facilities involved in the delivery of EPI services in Dhaka city was used as the sampling frame to select a random sample of facilities. The then Urban Health Programme of ICDDR, B prepared the list to better understand the supply environment of primary healthcare services in Dhaka city (5). Information contained in the list was used for stratifying the EPI delivery sites by type (static and outreach) and location (zone within Dhaka city). For the classification of the EPI sites by type, health centres operating one day or less per week were defined as outreach sites, while all others were categorized as static sites. From each of the strata defined, 25% of the facilities, chosen at random, generated a sample of 132 EPI delivery sites. The classification of health facilities by ownership (government/NGO) could not be carried out prior to drawing of the sample due to lack of information. Since the study selected a large proportion (25%) of all EPI sites, the results of the survey should indicate the relative importance of the Government of Bangladesh (GoB) and NGO service providers in urban Dhaka.
Facility-based data were collected from the EPI delivery sites for 1999. Two approaches were followed for collecting data on the use of resources, costs, and number of immunizations delivered. The first approach obtained information on the use of resources and the number of vaccinations administered from the record-keeping and accounting books of the facility. The second approach interviewed facility staff to obtain relevant additional information. In most cases, the manager or the vaccinator of the facility was interviewed. To ensure that the enumerators collect all the relevant data from the health facilities, a structured questionnaire was designed. …