For a bit of context, the cost of the pneumococcus vaccine is $2-$3.50 per dose. It can only be that cheap because the AMC (Advance Market Commitment) agreed to pay top-up prices for the first 200 million doses (to incentivise development). Least-developed, GAVI-eligible countries can effectively get them for free. Iâm still sceptical about the low estimates, as there are surely many other costs to getting them into arms, especially in neglected areas/â conflict zones, and Iâd assume that all the âlow-hanging fruitâ (very poor, very easy-to-access) kids are already being vaccinated.
I couldnât find the study supporting this, but Iâd assume that the low-end estimates were simply talking about how many lives could be saved by adding free (to the recipient country) pneumococcus vaccines to an existing vaccine schedule.
As for the actual pneumococcus vaccine cost-effectiveness estimates, according to Kremer: âAt initial program prices, the pneumococcal vaccine rollout avoided the loss of a disability adjusted life year (DALY) at cost of only $83.â
Thank you for pointing this out! It also seemed a bit low to me .. but I assumed that subsidies are never taken into account , although can be discussed as an opportunity (for example, for HPV âGavi-subsidized [HPV] vaccine costs only US$0.20 to US$0.40 per dose, while program costs range between US$4 and US$13 per fully immunized girl (Denny and others 2015; Gavi 2013)â (vol. 3, p. 10).
But you are rightâfor pneumococcus GAVI seems to be using something like a sliding price scheme: âRotavirus and pneumococcus vaccine costs to LICs are a fraction (for example, 5 percent) of the price paid by Gavi, the Vaccine Alliance to procure the vaccines; Gavi, in turn, receives prices that are more favorable than what upper-middle-income countries pay as a result of volume discounts and other factorsâ vol. 2, p. 15).
The cost in conflict zones or post-conflict areas does not need to be so highâfor example, a high pay for a primary healthcare NGO employee in communities in Ambazonia controlled by armed groups can be $450/âmonth. Another example is paying local community members in this region below the minimum wage ($0.25/âhour) to share healthcare messages on COVID prevention (trekking to communities). Considering that vaccination requires little specialized training then the distribution cost could be low. Also, according to the primary healthcare NGO, the government clinics are closed due to the conflict, so after the organization stopped operating the mobile clinics, there was no primary healthcare for the communities. So, I hypothesize that some not easy, but cost-effective to reach patients are uncovered due to neglectedness. The majority of the internally displaced persons that the NGO served were extremely poor.
According to this study, a dose averts 0.059-0.067 DALYs (p. 12). So, for the cost to be $1/âDALY, the provision of 1,000 vaccines would have to cost $59-$67, which requires low or no cost of the vaccine.
The argument for considering the subsidized price rather than the production cost is that philanthropes use marginal cost to othersâ donations (that is done for deworming for which drugs are 100% donated). If the donation recommendation is for drug donors, such as pharmaceutical companies, then production cost (alongside with distribution and other expenses) should be taken into account to maximize cost-effectiveness.
In especially neglected settings (such as conflict zones) since elsewhere could be covered, or increased uptake (such as community leaders endorsement)
Itâs not clear to me if the cost-effectiveness assessment is just for the vaccine itself or for a program implementing its provision. I assume distributing vaccines in conflict zones is hard work (meaning costs more), and same for increasing uptake in other areas. Iâm not sure about the scalability of either.
Thank you. See my response to Jack_S on the hypothesized cost-effectiveness in conflict settings. Based on the scale and neglectedness of this particular conflict in Ambazoniaâaccording to the Norwegian Refugee Council â4.4 million people [are] in need of humanitarian supportâ and 1.9 million have been reached. Thus, there seem to be, broadly, coverage opportunities. Pneumococcus vaccination rates are not specified.
This reasoning is based on these anecdotes so can be biased by overestimating the neglectedness of conflict areas and underestimating the coverage in non-conflict settings.
The community leaders endorsement is another hypothesis, based on the relative cost and effectiveness of incentives and community leaders endorsement: vaccine incentive can be of the cost of a bag of lentils while a radio show recorded with community leaders can be much lower per person and could change behavior comparably. For the COVID example in Ambazonia, maybe >10% of people knew about COVID before the program, so informing extremely poor people could be cost-effective, if that is the bottleneck.
Very impressive work. I havenât heard of DCP3 before and if I had I wouldnât have read 4000 pages of it. Thank you for making this summary.
Iâm skeptical of these impact estimates ($1-20 per life saved with pneumococcal vaccines!!) but I hope theyâre right
Yeah, itâs misleading.
For a bit of context, the cost of the pneumococcus vaccine is $2-$3.50 per dose. It can only be that cheap because the AMC (Advance Market Commitment) agreed to pay top-up prices for the first 200 million doses (to incentivise development). Least-developed, GAVI-eligible countries can effectively get them for free. Iâm still sceptical about the low estimates, as there are surely many other costs to getting them into arms, especially in neglected areas/â conflict zones, and Iâd assume that all the âlow-hanging fruitâ (very poor, very easy-to-access) kids are already being vaccinated.
I couldnât find the study supporting this, but Iâd assume that the low-end estimates were simply talking about how many lives could be saved by adding free (to the recipient country) pneumococcus vaccines to an existing vaccine schedule.
As for the actual pneumococcus vaccine cost-effectiveness estimates, according to Kremer: âAt initial program prices, the pneumococcal vaccine rollout avoided the loss of a disability adjusted life year (DALY) at cost of only $83.â
Thank you for pointing this out! It also seemed a bit low to me .. but I assumed that subsidies are never taken into account , although can be discussed as an opportunity (for example, for HPV âGavi-subsidized [HPV] vaccine costs only US$0.20 to US$0.40 per dose, while program costs range between US$4 and US$13 per fully immunized girl (Denny and others 2015; Gavi 2013)â (vol. 3, p. 10).
But you are rightâfor pneumococcus GAVI seems to be using something like a sliding price scheme: âRotavirus and pneumococcus vaccine costs to LICs are a fraction (for example, 5 percent) of the price paid by Gavi, the Vaccine Alliance to procure the vaccines; Gavi, in turn, receives prices that are more favorable than what upper-middle-income countries pay as a result of volume discounts and other factorsâ vol. 2, p. 15).
The cost in conflict zones or post-conflict areas does not need to be so highâfor example, a high pay for a primary healthcare NGO employee in communities in Ambazonia controlled by armed groups can be $450/âmonth. Another example is paying local community members in this region below the minimum wage ($0.25/âhour) to share healthcare messages on COVID prevention (trekking to communities). Considering that vaccination requires little specialized training then the distribution cost could be low. Also, according to the primary healthcare NGO, the government clinics are closed due to the conflict, so after the organization stopped operating the mobile clinics, there was no primary healthcare for the communities. So, I hypothesize that some not easy, but cost-effective to reach patients are uncovered due to neglectedness. The majority of the internally displaced persons that the NGO served were extremely poor.
According to this study, a dose averts 0.059-0.067 DALYs (p. 12). So, for the cost to be $1/âDALY, the provision of 1,000 vaccines would have to cost $59-$67, which requires low or no cost of the vaccine.
The argument for considering the subsidized price rather than the production cost is that philanthropes use marginal cost to othersâ donations (that is done for deworming for which drugs are 100% donated). If the donation recommendation is for drug donors, such as pharmaceutical companies, then production cost (alongside with distribution and other expenses) should be taken into account to maximize cost-effectiveness.
Itâs not clear to me if the cost-effectiveness assessment is just for the vaccine itself or for a program implementing its provision. I assume distributing vaccines in conflict zones is hard work (meaning costs more), and same for increasing uptake in other areas. Iâm not sure about the scalability of either.
Thank you. See my response to Jack_S on the hypothesized cost-effectiveness in conflict settings. Based on the scale and neglectedness of this particular conflict in Ambazoniaâaccording to the Norwegian Refugee Council â4.4 million people [are] in need of humanitarian supportâ and 1.9 million have been reached. Thus, there seem to be, broadly, coverage opportunities. Pneumococcus vaccination rates are not specified.
This reasoning is based on these anecdotes so can be biased by overestimating the neglectedness of conflict areas and underestimating the coverage in non-conflict settings.
The community leaders endorsement is another hypothesis, based on the relative cost and effectiveness of incentives and community leaders endorsement: vaccine incentive can be of the cost of a bag of lentils while a radio show recorded with community leaders can be much lower per person and could change behavior comparably. For the COVID example in Ambazonia, maybe >10% of people knew about COVID before the program, so informing extremely poor people could be cost-effective, if that is the bottleneck.