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Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage?
Vaccine 36 (2018) 7542–7548
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Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage? Hnin Nwe Ni Aye a,b, Yu Mon Saw b,c,⇑, Aye Mya Chan Thar d, Nwe Oo e, Zaw Zaw Aung f, Htun Tin g, Thet Mon Than h, Tetsuyoshi Kariya b, Eiko Yamamoto b, Nobuyuki Hamajima b a
Expanded Programme on Immunization/Communicable Diseases Unit, Mandalay Regional Public Health Department, Ministry of Health and Sports, Mandalay, Myanmar Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan c Nagoya University Asian Satellite Campuses Institute, Nagoya, Japan d Central Expanded Programme on Immunization, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar e Department of Food and Drug Administration, Ministry of Health and Sports, Nay Pyi Taw, Myanmar f Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar g Central Epidemiological Unit, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar h Department of Medical Services, Ministry of Health and Sports, Myanmar b
a r t i c l e
i n f o
Article history: Received 10 July 2018 Received in revised form 13 October 2018 Accepted 15 October 2018 Available online 28 October 2018 Keywords: Routine immunization Operational cost Sub-center Myanmar
a b s t r a c t Background: Myanmar’s national immunization program was launched in 1978. Routine immunization is mainly provided at sub-center level with midwives assigned as main vaccinators. The vaccinators at the sub-centers have to obtain vaccines from their designated township health department’s cold room for immunization services. This study aimed to calculate the operational costs of routine immunization at sub-centers in Myanmar. Methods: A cross-sectional study was conducted among 160 sub-centers throughout the country. Faceto-face interviews were conducted with the main vaccinator at each sub-center using a pre-tested questionnaire. The study analyzed the operational costs per facility and the associations between sub-center characteristics and operational costs. Results: In Myanmar, the average operational costs of routine immunization per sub-center ranged from 434,700–990,125 MMK for rural areas and 235,875–674,250 MMK for urban areas. The operational costs increased by 8,749.50 MMK (95% CI: 6,805.79–10,693.21; p < 0.001) per mile and 5,752.50 MMK (95% CI: 914.22–10,590.79; p < 0.05) per working day. Conclusion: This study indicated that the operational costs at sub-centers were high and varied significantly among the different geographical areas. The operational costs could be reduced by additional support for the resources, for example, installing cold chain facilities at sub-centers and opening new sub-centers throughout the country. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction Myanmar’s national immunization program was launched in 1978 to combat vaccine-preventable diseases [1]. Since then, the immunization program for Myanmar children has been expanded to improve their access to new and underused vaccines. In 2012, the Myanmar government committed to co-financing new ⇑ Corresponding author at: Department of Healthcare Administration, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya 4668550, Japan. E-mail address: [email protected] (Y.M. Saw). https://doi.org/10.1016/j.vaccine.2018.10.051 0264-410X/Ó 2018 Elsevier Ltd. All rights reserved.
vaccines with Gavi, the Global Vaccine Alliance for Vaccine and Immunization [1]. Currently, Myanmar is in the preparatory phase of the transition process of Gavi’s co-financing plan [2]. During the transition process, Myanmar needs to gradually increase the share its government pays for the vaccines [3]. At the end of the process, the Myanmar government will completely self-finance the national immunization program [4,5]. Myanmar comprises 330 townships, and every township health department includes three types of health facilities: maternal and child health centers (MCH), rural health centers (RHC), and urban health centers (UHC) [6–8]. MCH and UHC provide health services to the urban population, while RHC target the rural population [9].
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These health facilities are subdivided into sub-urban health centers and sub-rural health centers (hereafter sub-centers) to provide health services to the community. As the smallest health care units, sub-centers are the front line of public health services, which includes providing routine immunizations to the communities [8]. In Myanmar, the primary vaccinators are midwives, who also have other roles in as maternal and child health services and school health services [10]. Vaccinators perform immunizations through a combination of strategies categorized as fixed immunization sessions, outreach immunization sessions, mobile immunization sessions, and crash immunization sessions [1,11]. A good cold chain system plays a vital role in delivering immunization services. Every township’s health department has a cold room for vaccine storage. Generally, there are no cold chain facilities below the township level, so vaccinators at the sub-centers have to pick up vaccines from their corresponding cold rooms. In order to procure the vaccines from cold rooms while maintaining the cold chain, vaccinators need vaccine carriers with ice packs. However, ice packs are not adequately distributed by township health departments’ cold rooms. Accordingly, vaccinators have to make their own arrangements to maintain the cold chain with wet ice. These arrangements increase the workload of vaccinators and reduce their willingness to perform routine immunization activities [1]. The catchment areas of sub-centers are determined by population density; there is generally one sub-center for every 3000 people [12]. The rule for claiming travel allowances is based only on the distance, without taking geographical conditions into account [13]. Therefore, the current rule for travel allowances does not cover the actual transportation and delivery costs of immunization services. National immunization coverage in Myanmar has declined slightly in recent years [14]. This downward trend in immunization coverage may be due to low immunization coverage in self-administered regions and conflict areas, an increased number of mobile people who are not properly registered, inadequate resources for the sub-centers, and limited funding for vaccinators’ operational costs [1]. The comprehensive multiyear immunization plan for 2017– 2021 was developed based on the routine immunization expenditures in 2015. However, the sub-center level operational costs for routine immunization activities were not included in the plan due to a lack of data regarding the operational costs [1]. Consequently, sub-center level operational costs for routine immunizations were underestimated. This study aims to calculate the operational costs for routine immunizations at the sub-center level in Myanmar, with details for each line item of the operational cost.
2. Methods A cross-sectional study was conducted in 160 sub-centers in both urban and rural areas, as defined by the General Administration Department (GAD) of Myanmar’s Ministry of Home Affairs [6,15]. This study followed the common approach of multicountry studies to determine the cost and financing for routine immunizations [16], adapted to reflect the context of Myanmar. Myanmar is composed of 14 states/regions and one Union Territory [6] and data collection from each states/regions is not possible. The study utilized a two-stage sampling procedure. In the first stage, five states/regions were selected: one state/region each from the hilly plateau, delta, central plain, mountain range, and coastal areas. In the second stage, two townships were chosen from each selected state/region through a sampling procedure, stratified by transportation accessibility. In total, 160 sub-centers from 10 townships were selected (80 sub-centers from urban areas and 80 sub-centers from rural areas). One vaccinator from each
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sub-center was interviewed during the period from June to August 2017. The questionnaire was developed by reviewing the literature and consulting with technical experts from the Ministry of Health and Sports. It was designed to collect information on the characteristics of the sub-centers, working days for immunization activities, and the operational costs related to immunization services. The interviews were conducted face-to-face, at the health facilities, using the pre-tested questionnaire. 2.1. Cost categories Operational costs were estimated based on the operating cost line items. The costs were subdivided into vaccine transport, vaccinator’s travel, labor, cold chain energy, social mobilization, waste management, meals, and accommodation costs. Vaccine transport costs were defined as the transportation charges for vaccines, syringes, and other items related to immunization services. Travel costs were the transportation charges vaccinators incurred when they delivered immunization services. Vaccine transport and travel costs included bus fare, fuel, and boat rental costs. Labor costs included the cost of labor to carry heavy cold boxes, especially for vaccine collection, and to provide mobile sessions when motor vehicles were unavailable. Cold chain energy costs represented the cost of wet ice. Social mobilization costs included the rental costs for microphones, speakers, and sound boxes used to advertise immunization services, as well as the phone charges related to recruiting and/or reminding parents to avail immunization services. Waste management costs were defined as the cost of the fuel to run an incinerator. Meal costs were the vaccinators’ meal costs incurred while they delivered immunization services. Accommodation costs were defined as the room rental charges during vaccine collection and mobile sessions. Operational costs excluded crash immunization session costs and the operating costs of supplemental immunization activities. All operational costs were calculated in the local currency, the Myanmar Kyat (MMK). The costs were shown in US dollars for reference, with the exchange rate being 1 USD to 1,362 MMK at the end of 2016 [17]. 2.2. Data analysis This study applied the outline method of a common approach to analyze the costs and financing of routine immunizations [16]. This study calculated only the operational costs of routine immunization activities at the sub-center level; therefore, the costs of the vaccines, syringes, salaries, and other suppliers were not included. The operational costs were analyzed using the Statistical Package for the Social Sciences version 24 (IBM SPSS Inc.). This study examined sub-center level operational costs and analyzed the variation in operational costs by geographic area. Furthermore, the relationship between sub-center characteristics and operational costs were examined using the percentage frequency, minimum, maximum, mean, and standard deviation of the operational costs, and was calculated using linear regression analysis with a 95% confidence interval (CI). The variation of the operational costs by geographic area was analyzed using an ANOVA test. 3. Results Table 1 displays the characteristics of the urban and rural subcenters. Sixty-one sub-centers in both urban and rural areas each covered more than 3,000 people. The study found 10 sub-centers in rural areas that covered 11–25 villages/wards, while five subcenters in urban areas covered 11–25 villages or wards. Thirteen sub-centers in rural areas, and four sub-centers in urban areas,
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Table 1 Characteristics of sub-centers (N = 160). Characteristics
Urban (N = 80)
Rural (N = 80)
Total (N = 160)
N
%
N
%
N
%
Catchment population 712–3,000 3,001–6,000 6,001–18,171
28 35 17
35.0 43.8 21.2
33 30 17
41.3 37.5 21.2
61 65 34
38.1 40.6 21.3
Catchment infant population 12–60 61–120 121–454
26 36 18
32.5 45.0 22.5
29 32 19
36.3 40.0 23.7
55 68 37
34.4 42.5 23.1
Catchment area (wards/villages) 1–5 6–10 11–25
54 21 5
67.5 26.3 3.2
46 24 10
57.5 30.0 12.5
100 45 15
62.5 28.1 9.4
Working days for routine immunization 1–3 4–7
68 12
85.0 15.0
48 32
60.0 40.0
116 44
72.5 27.5
Working days for outreach sessions 1–3 4–6
76 4
95.0 5.0
67 13
83.8 16.2
143 17
89.4 10.6
Distance between sub-center and the health facility for vaccines collection 1–25 miles 55 68.8 26–50 miles 21 26.2 51–87 miles 4 5.0
46 21 13
57.5 26.3 16.2
101 42 17
63.1 26.3 10.6
Health facility of vaccines collection Rural health center Township health department
31 49
38.8 61.2
8 72
10.0 90.0
39 121
24.4 75.6
Mode of transportation to obtain vaccines Motorcycle Bus Boat
68 8 4
85.0 10.0 5.0
47 6 27
58.8 7.5 33.8
115 14 31
71.9 8.8 19.4
Mode of transportation to provide outreach sessions Motorcycle 77 Boat 3
96.3 3.8
55 25
68.8 31.3
132 28
82.5 17.5
Mobile sessions Yes No
15.0 85.0
16 64
20.0 80.0
28 132
17.5 82.5
12 68
N: number of sub-center.
were located 51–87 miles away from the designated health facilities where vaccines were stored. Most of the sub-centers (75.6%) picked up vaccines from the cold rooms of their designated township health departments, while 24.4% of sub-centers collected their vaccines from RHC. Vaccinators from 115 sub-centers used a motorcycle to obtain the vaccines (85.0% of sub-centers in urban areas and 58.8% of sub-centers in rural areas). Vaccinators from 28 sub-centers opened mobile sessions during the study year, which composed 15.0% of the sub-centers in urban areas and 20.0% of the sub-centers in rural areas.
Table 2 presents the line item operational costs by geographic area. For routine immunizations, travel costs were the highest (42.2%) of the overall operational cost. Among the different geographic areas, the delta area incurred the highest travel costs (39.6%), while the central plain area incurred the lowest (34.4%). Social mobilization was the second highest line item cost (13,842,000 MMK) for routine immunizations. Waste management was the lowest at 1.5% of the total operational cost. Operational costs were highest in the hilly plateau area (21,570,000 MMK), and lowest in the mountain range area (11,594,400 MMK).
Table 2 Differences between geographical areas of sub-center level operational costs by line items (in MMK). Line items
Vaccine transport cost Travel cost Labor cost Cold chain energy cost Social mobilization cost Waste management cost Othera Total operational cost a
Hilly plateaus area (N = 32)
Delta area (N = 32)
Central plain area (N = 32)
Coastal area (N = 32)
Cost
%
Cost
%
Cost
%
Cost
3,572,000 7,648,000 1,256,000 1,298,000 3,844,000 314,000 3,638,000 21,570,000
16.5 35.5 5.8 6.0 17.8 1.5 16.9 100.0
2,548,000 7,774,000 994,000 1,544,000 3,876,000 428,000 2,452,000 19,616,000
12.9 39.6 5.1 7.9 19.8 2.2 12.5 100.0
2,802,000 4,758,000 0 1,329,600 2,844,000 382,600 1,734,000 13,849,200
20.2 34.4 0.0 9.6 20.5 2.8 12.5 100.0
2,660,000 10,310,000 1,232,000 1,870,000 2,150,000 114,000 490,000 18,826,000
Mountain range area (N = 32)
Total cost (N = 160)
%
Cost
%
Cost
%
14.1 54.8 6.6 9.9 11.4 0.6 2.6 100.0
2,036,000 5,586,000 360,000 856,000 1,104,000 66,000 1,586,400 11,594,400
17.6 48.2 3.1 7.4 9.5 0.6 13.6 100.0
13,748,000 36,392,000 3,902,000 6,927,600 13,842,000 1,303,600 9,992,400 86,107,600
16.0 42.2 4.5 8.1 16.1 1.5 11.6 100.0
Meal/Accommodation cost, N: number of sub-center, MMK: Myanmar Kyat (1USD = 1362 MMK on 31st Dec 2016).
P value
0.144 0.003 0.910 0.018 <0.001 0.001 <0.001 0.006
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Table 3 exhibits the operational costs for routine immunizations at the sub-center level in urban and rural areas. Average rural operational costs were higher than urban costs in all geographic areas except the hilly plateaus. The difference between the average operational costs of rural and urban areas was highest in the delta area (754,250 MMK) and lowest in the hilly plateau area (375 MMK). The average rural operational cost per sub-center ranged from 434,700 to 990,125 MMK. For routine immunization in urban areas, the average operational cost per sub-center ranged from 235,875 to 674,250 MMK. Table 4 presents the variation in operational costs, stratified by geographic area. A statistically significant difference in the average operational cost by geographic area was found (p = 0.006). The highest average operational cost per sub-center was 674,062 MMK in the hilly plateau area, with a standard deviation of 440,041.2 MMK (95% CI: 515,410.7–832,714.3), and the lowest was 382,700 MMK in the mountain range area, with a standard deviation of 221,580.7 MMK (95% CI: 302,811.6–462,588.4). Table 5 presents the linear regression analysis of sub-center level operational costs. Geographical area (urban/rural) had a statistically significant positive association with operational costs in the univariate model (B: 304,335.0 MMK, with a 95% CI of 197,005.45–411,664.54; p < 0.001), although there was no significant association in the multivariate model. Each working day of outreach sessions increased the operational costs by 12,186.93 MMK (95% CI: 7,876.66–16,497.21; p < 0.001) in the univariate model, and 5752.50 MMK (95% CI: 914.22–10,590.79; p < 0.050) in the multivariate model. There was a positive association between the operational costs and the distance from the sub-center to the
health facility for vaccine collection. The operational costs increased by 11,437.10 MMK for each additional mile traveled in the univariate model (95% CI: 9,086.62–13,787.59; p < 0.001), and by 8749.50 MMK per mile in the multivariate model (95% CI: 6805.79 – 10,693.21; p < 0.001). In the univariate model, operational costs also varied according the type of health facility. The operational costs for vaccine collection at township health department cold rooms was 193,096.08 MMK (95% CI: 59,664.75 – 326,527.40; p < 0.010) greater than the operational costs of vaccine collection at RHC. The mode of transportation used to obtain the vaccines was also positively associated with operational costs. Traveling by bus or boat increased the operational costs by 239,029.65 MMK in the univariate model (95% CI: 171,456.44 – 306,602.86; p < 0.001) and 138,166.40 MMK in the multivariate model (95% CI: 68,771.11 – 207,561.68; p < 0.050). Fig. 1 shows the relationship between the operational cost per sub-center by its distance from the health facility and working days per outreach session. 4. Discussion This was the first study to calculate the operational costs of routine immunizations at sub-centers in Myanmar. The highest operational costs (21,570,000 MMK) were in the hilly plateau area, while the lowest were in the mountain range area (11,594,400 MMK). The average operational costs in rural areas were higher than urban areas in all geographic areas except the hilly plateau area. The distance between the sub-center and the cold room, the mode of transportation used to obtain the vaccines, the mode
Table 3 Operational costs at sub-center level by urban/rural (in MMK). Geographical area
N
Minimum
Maximum
Mean
Standard deviation
Difference means between urban and rural
P value
Hilly plateaus area Urban Rural
16 16
84,000 84,000
1,436,000 1,436,000
674,250 673,875
403,986.0 486,802.6
375
0.998
Delta area Urban Rural
16 16
102,000 504,000
390,000 1,896,000
235,875 990,125
79,831.3 428,540.1
754,250
<0.001
Central plain area Urban Rural
16 16
336,000 162,000
552,000 607,200
430,875 434,700
68,802.9 108,223.3
3,825
0.906
Coastal area Urban Rural
16 16
102,000 318,000
1,328,000 1,654,000
327,500 849,125
310,670.2 325,664.0
521,625
<0.001
Mountain range area Urban Rural
16 16
126,000 174,000
726,400 780,000
261,525 503,875
177,228.7 196,811.2
242,350
0.001
1USD = 1,362 MMK on 31st Dec 2016. N: number of sub-center. MMK: Myanmar Kyat.
Table 4 Geographical variation of operational costs at sub-center level (in MMK). Geographical area
Hilly plateaus area Delta area Central plain area Coastal area Mountain range area 1USD = 1,362 MMK on 31st Dec 2016. MMK: Myanmar Kyat.
Mean
674,062 613,000 613,000 588,312 382,700
Standard deviation
440,041.2 488,626.8 488,626.8 410,166.6 221,580.7
95% confidence interval
P value
Upper bound
Lower bound
515,410.7 436,831.3 436,831.3 440,431.7 302,811.6
832,714.3 789,168.7 789,168.7 736,193.3 462,588.4
0.006
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Table 5 Liner regression analysis on sub-center level operational costs (N = 160) (in MMK). Factors
Geographical areas (urban/rural) Catchment infant population Catchment area (wards/villages) Working days for routine immunization Working days for outreach sessions Distance between sub-center and the health facility for vaccines collection Number of vaccine collection times Health facility of vaccines collection Mode of transportation to obtain vaccines Mode of transportation to provide outreach sessions Mobile sessions
Univariate model
Multivariate model
B
95% confidence interval
B
95% confidence interval
304,335.00 665.37 20,132.29 11,142.13 12,186.93 11,437.10 16,813.37 193,096.08 261,951.81 239,029.65 486,388.31
(197,005.45–411,664.54)*** ( 173.85–1504.59) (4,973.39–35,291)** (6,646.61–15,637.64)*** (7,876.66–16,497.21)*** (9,086.62–13,787.59)*** ( 39,121.22–5,494.47) (59,664.75–326,527.40)** (200,915.73–322,987.89)*** (171,456.44–306,602.86)*** (351,977.65–620,798.96)***
58,825.50 190.44 2,921.87 1,203.66 5,752.50 8,749.50 571.58 1,475.86 66,614.06 138,166.40 224,589.11
( 20,948.81–138,599.81) ( 379.09–759.99) ( 7,882.69–13,726.43) ( 6,134.67–3,727.35) (914.22–10,590.79)* (6,805.79–10,693.21)*** ( 12,484.12–13,627.29) ( 87,673.58–90,625.31) ( 14.88–133,243.00)* (68,771.11–207,561.68)*** (123,973.00–325,205.22)***
1USD = 1,362 MMK on 31st Dec 2016. B: Unstandardized beta. MMK: Myanmar Kyat. *** p < 0.001. ** p < 0.010. * p < 0.050.
R2 linear=0.165
Operational costs (in MMK)
R2 linear=0.369
Distance between sub-center and the health facility for vaccines collection (miles)
Working days for outreach sessions
Fig. 1. Scatter plot of the operational costs (in MMK) and factors of sub-centers.
of transportation used to provide outreach sessions, the number of working days per outreach session, and the number of mobile sessions, were the characteristics of sub-center that were associated with operational costs in both the univariate and multivariate analyses. This study found that the distance between the sub-center and the health facility for vaccine collection was associated with operational costs. For every one mile increase in distance, the operational costs increased by 11,437.10 MMK in the univariate model, and by 8,749.50 MMK in the multivariate model. This finding is not consistent with the study from Benin, which found that the distance in kilometers to the vaccine point was negatively associated with routine facility immunization costs [18]. In Myanmar, however, there are no cold chain facilities below the township level, which means that vaccinators need to collect their vaccines from the designated health facilities before each immunization service. This study also found that the operational costs for vaccine collection at township health department cold rooms were higher than the operational costs for vaccine collection at RHC. These factors led to increases in the operational costs for routine immunizations, and also increased the vaccinators’ workloads. The Ministry of Health and Sports needs to consider providing cold chain facilities to sub-centers below the township level, in order to reduce operational costs and save vaccinators’ time.
Myanmar’s public transportation system is not well developed. Vaccinators often needed to use their own motorcycles, and sometimes pay to rent vehicles, in order to perform routine immunization activities. Moreover, depending on their geographic location, some vaccinators were forced to hire cars or boats to provide routine immunizations. The study found that the modes of transportation used to obtain vaccines and deliver outreach sessions were also associated with operational costs. The comprehensive multiyear plan for 2017–2021 pointed to limited funding for routine immunizations as one of the reasons for low national immunization coverage [1]. Timor-Leste has the same transportation problems as Myanmar. Some areas of Timor-Leste are difficult to reach in all seasons because of geography and an undeveloped public transportation system. These challenging conditions affect immunization coverage, but the Ministry of Timor-Leste is trying to solve the problem by providing vehicles for routine immunizations, and all vehicles used for immunization purposes are maintained by the government [19]. Providing vehicles and fuel is a well-established requirement for governments to achieve high immunization coverage. Another option is for the Ministry of Health and Sports to consider amending the current rule for claiming transportation allowances to include a transportation allowance for routine immunizations in the government’s budget. This support would reduce the out-of-pocket expenses of vaccinators
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and motivate them to conduct regular outreach sessions, increasing the frequency of outreach sessions and promoting national immunization coverage. In total, Myanmar has 3,063 wards, 13,618 village tracts, and 64,134 villages, with 8,404 sub-centers designated to cover them [8]. This means that each sub-center needs to cover several villages. The study also found that, since the maximum catchment area for each sub-center was 25 villages/wards, outreach and mobile sessions were necessary to provide routine immunization services. These in turn increase vaccinators’ workloads, which could increase the chance of overlooking children who need immunizations. In addition, previous studies have reported that higher workloads for health facilities were strongly associated with higher operational costs [18,20–25]. This study found that travel costs accounted for the highest percentage (42.2%) of operational costs for routine immunizations, and the number of working days spent on outreach sessions was correlated with operational costs. In Cambodia and Lao PDR, routine immunizations are mainly conducted through outreach sessions, and travel cost is the highest percentage of total operational costs [26,27]. This study lends strong support to the concept of establishing new strategically located sub-centers to offer more facility-based services, thereby reducing transportation and other outreach costs. This study found that average operational costs in rural areas were higher than in urban areas. This finding is consistent with previous studies conducted in Zambia and Honduras [22,28]. However, studies from Ghana and Benin reported that operational costs in urban areas were higher than in rural areas [18,29]. This study also found that the difference in average operational costs between rural and urban areas was highest in the delta area and lowest in the hilly plateau area. In Myanmar, transportation is easily accessible in urban areas but not in rural areas. In the rural delta area, boats are commonly used as the main mode of transportation. The rental charge for boats is very high, which is why the operational costs in rural areas are higher than in urban areas, and also why the urban/rural difference was highest in the delta area. Transportation is also difficult throughout the hilly plateau area, and some parts of the hilly plateau area are self-administered regions and conflict areas where vaccinators can only provide routine immunizations with the approval of local governments. Applications for approval must be submitted at least two weeks before the immunization services, and permission to perform routine immunization activities is not granted for every submission. Because of security concerns and the geographical situation, transportation costs in the hilly plateau area are very high in both urban and rural areas. While the national immunization program invested a lot of resources and effort to deliver immunizations in those areas, political commitment and government support are required to provide routine immunizations in these areas. Currently, the annual government budget allocates the same amount of funds to all townships at the beginning of the fiscal year. Budgets are sufficient in some areas, but lacking in others. This study found that the average operational cost varied significantly between geographic areas (p = 0.006). For example, in the delta and coastal areas, vaccinators need spend more to hire boats to deliver routine immunizations. Therefore, the Ministry of Health and Sports needs to consider changing the current budget allocation system because it does not meet the demands of the actual situation. The budget breakdown should allocate funds according to geographical conditions, security concerns, and other relevant factors. The operational costs for routine immunizations, including transportation costs, are covered by governments in many countries [30–34]. In Myanmar, the transportation costs for routine immunizations were partially supported by international nongovernmental organizations in selected areas, [1] such as the rural
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delta and coastal areas. However, the majority of vaccinators still needed to spend their own money to conduct routine immunization activities, due to funding constraints and underestimation of their operational costs [1]. The immunization programs of all developing countries in the world depend on donor agencies such as Gavi, the World Health Organization, and the United Nations Children’s Fund. However, Gavi’s co-financing plan includes a transition process whereby all countries will eventually have to fully finance their own national immunization programs [4– 5,19,26,27]. Therefore, all governments need to take into account the operational costs of routine immunizations in their budgets while moving towards full self-financing of their national immunization programs. This study had several limitations. First, the information on operational costs for routine immunizations was collected retrospectively, and the costs were self-reported, so costs might have been under or over-reported. Second, the researchers were not able to double-check the bills and receipts for every item. Most of the operational costs were covered by vaccinators’ out-of-pocket money, so they were not registered in the record. Third, actual operational costs may differ because international nongovernmental organizations in some areas paid the United Nations’ rate, which does not always reflect actual local operational costs. Fourth, the data were collected in only 5 out of 14 states/regions and 1 union territory. Therefore, the study’s findings may not be representative of the entire country. Finally, the sample size was relatively small, resulting in limited statistical power. However, the study’s findings will be very useful for planning the government’s budget for the national immunization program, regardless of its small sample size and geographical distribution. In conclusion, this study found that the operational costs of many sub-centers were underestimated. It found variations in the operational costs for routine immunizations in different geographic areas. The Ministry of Health and Sports should consider amending its current budget allocation system and its rules for claiming travel allowances, in order to reflect the actual situation. The operational costs at the sub-center level for routine immunizations should be included in the government budget line. These operational costs may be reduced by increasing support for some resources, such as installing cold chain facilities below the township level. These changes will be important steps for the Myanmar government as it moves towards the fully self-financing phase of the Gavi transition process in its national immunization program.
5. Disclosure statement The authors have nothing to disclose. Acknowledgements We would like to express our special thanks to State/Regional Health Directors, Township Medical Officers and Team Leaders and all staff of national immunization program, Ministry of Health and Sports, Myanmar. This study would not be possible without their collaboration and agreement to participate in this study. References [1] Ministry of Health and Sports. Comprehensive multi-year plan (2017– 2021). Myanmar: Ministry of Health and Sports; 2016. [2] The World Bank. World development indicators – 2016. Washington, DC, United States of America. Available at: https://data.worldbank.org/country/ myanmar [access on 1st December 2017]. [3] Shen AK, Weiss JM, Andrus JK, Pecenka C, Atherly D, Taylor K, et al. Country ownership and GAVI transition: comprehensive approaches to supporting new vaccine introduction. Health Aff 2016;53:S57–60.
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[4] The Global Alliance for Vaccine and Immunization. Eligibility and transition policy. Geneva, Switzerland. Available at: http://www.gavi.org/about/ program-policies/eligibility-and-transition/. [access on 1st December 2017]. [5] The Global Alliance for Vaccine and Immunization. Co-financing policy. Geneva, Switzerland. Available at: http://www.gavi.org/about/programpolicies/co-financing/ [access on 1st December 2017]. [6] Ministry of Labor, Immigration and Population. Census Atlas Myanmar – The 2014 Myanmar Population and Housing Census. Ministry of Labor, Immigration and Population, Myanmar. Available at: http://themimu.info/ sites/themimu.info/files/documents/Census_Atlas_Myanmar_the_2014_ Myanmar_Population_and_Housing_Census.pdf [access on 17th April 2018]. [7] Sein TT, Myint P, Tin N, Win H, Aye SS, Sein T. The republic of the union of Myanmar health system review – health systems in transition. World Health Organization; 2014. [8] Ministry of Health and Sports. Health infrastructure – 2018. Nay Pyi Taw, Myanmar. Available at: http://www.mohs.gov.mm/ [access on 17th April 2018]. [9] Ministry of Health and Sports. Comprehensive multi-year plan (2012– 2016). Myanmar: Ministry of Health and Sports; 2011. [10] Ministry of Health and Sports. Immunization in practice guideline for basic health staff. Myanmar: Ministry of Health and Sports; 2009. [11] World Health Organization. Immunization in Practice. World Health Organization, Geneva; 2015. Available at: http://apps.who.int/iris/bitstream/ 10665/193412/1/9789241549097_eng.pdf [access on 1st December 2017]. [12] Ministry of Health and Sports. Preventive and Social Science Medicine, Volume 3. Myanmar: Ministry of Health and Sports; 2016. [13] Ministry of Finance. The union budget law. Myanmar: Ministry of Finance; 2015. [14] World Health Organization. Myanmar EPI fact sheet 2016. WHO regional office for the South-East Asia; 2016. Available at: http://www.searo.who.int/entity/ immunization/data/myanmar.pdf [access on 1st December 2017]. [15] Myanmar Insider. Myanmar-The rural-urban divide. Yangon, Myanmar. Available at: https://www.myanmarinsider.com/myanmar-the-rural-urbandivide/ [access on 17th April 2018]. [16] Brenzel L. Common approach to the costing and financing analyses for rou-tine immunization and New Vaccine Introduction (NUVI). Mimeograph. Bill & Melinda Gates Foundation; 2014. [17] Central bank of Myanmar. Reference exchange rate. Yangon, Myanmar; Available at: http://forex.cbm.gov.mm/index.php/fxrate [access on 17th January 2018]. [18] Ahanhanzo CD, Huang XX, Le Gargasson JB, Sossou J, Nyonator F, Colombini A, et al. Determinants of routine immunization costing in Benin and Ghana in 2011. Vaccine 2015;33(S1):A66–71. [19] Ministry of Health. Multi-year Plan for Immunization (2011–2015). TimorLeste: Ministry of Health; 2011.
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Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage? Hnin Nwe Ni Aye a,b, Yu Mon Saw b,c,⇑, Aye Mya Chan Thar d, Nwe Oo e, Zaw Zaw Aung f, Htun Tin g, Thet Mon Than h, Tetsuyoshi Kariya b, Eiko Yamamoto b, Nobuyuki Hamajima b a
Expanded Programme on Immunization/Communicable Diseases Unit, Mandalay Regional Public Health Department, Ministry of Health and Sports, Mandalay, Myanmar Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan c Nagoya University Asian Satellite Campuses Institute, Nagoya, Japan d Central Expanded Programme on Immunization, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar e Department of Food and Drug Administration, Ministry of Health and Sports, Nay Pyi Taw, Myanmar f Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar g Central Epidemiological Unit, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar h Department of Medical Services, Ministry of Health and Sports, Myanmar b
a r t i c l e
i n f o
Article history: Received 10 July 2018 Received in revised form 13 October 2018 Accepted 15 October 2018 Available online 28 October 2018 Keywords: Routine immunization Operational cost Sub-center Myanmar
a b s t r a c t Background: Myanmar’s national immunization program was launched in 1978. Routine immunization is mainly provided at sub-center level with midwives assigned as main vaccinators. The vaccinators at the sub-centers have to obtain vaccines from their designated township health department’s cold room for immunization services. This study aimed to calculate the operational costs of routine immunization at sub-centers in Myanmar. Methods: A cross-sectional study was conducted among 160 sub-centers throughout the country. Faceto-face interviews were conducted with the main vaccinator at each sub-center using a pre-tested questionnaire. The study analyzed the operational costs per facility and the associations between sub-center characteristics and operational costs. Results: In Myanmar, the average operational costs of routine immunization per sub-center ranged from 434,700–990,125 MMK for rural areas and 235,875–674,250 MMK for urban areas. The operational costs increased by 8,749.50 MMK (95% CI: 6,805.79–10,693.21; p < 0.001) per mile and 5,752.50 MMK (95% CI: 914.22–10,590.79; p < 0.05) per working day. Conclusion: This study indicated that the operational costs at sub-centers were high and varied significantly among the different geographical areas. The operational costs could be reduced by additional support for the resources, for example, installing cold chain facilities at sub-centers and opening new sub-centers throughout the country. Ó 2018 Elsevier Ltd. All rights reserved.
1. Introduction Myanmar’s national immunization program was launched in 1978 to combat vaccine-preventable diseases [1]. Since then, the immunization program for Myanmar children has been expanded to improve their access to new and underused vaccines. In 2012, the Myanmar government committed to co-financing new ⇑ Corresponding author at: Department of Healthcare Administration, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya 4668550, Japan. E-mail address: [email protected] (Y.M. Saw). https://doi.org/10.1016/j.vaccine.2018.10.051 0264-410X/Ó 2018 Elsevier Ltd. All rights reserved.
vaccines with Gavi, the Global Vaccine Alliance for Vaccine and Immunization [1]. Currently, Myanmar is in the preparatory phase of the transition process of Gavi’s co-financing plan [2]. During the transition process, Myanmar needs to gradually increase the share its government pays for the vaccines [3]. At the end of the process, the Myanmar government will completely self-finance the national immunization program [4,5]. Myanmar comprises 330 townships, and every township health department includes three types of health facilities: maternal and child health centers (MCH), rural health centers (RHC), and urban health centers (UHC) [6–8]. MCH and UHC provide health services to the urban population, while RHC target the rural population [9].
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These health facilities are subdivided into sub-urban health centers and sub-rural health centers (hereafter sub-centers) to provide health services to the community. As the smallest health care units, sub-centers are the front line of public health services, which includes providing routine immunizations to the communities [8]. In Myanmar, the primary vaccinators are midwives, who also have other roles in as maternal and child health services and school health services [10]. Vaccinators perform immunizations through a combination of strategies categorized as fixed immunization sessions, outreach immunization sessions, mobile immunization sessions, and crash immunization sessions [1,11]. A good cold chain system plays a vital role in delivering immunization services. Every township’s health department has a cold room for vaccine storage. Generally, there are no cold chain facilities below the township level, so vaccinators at the sub-centers have to pick up vaccines from their corresponding cold rooms. In order to procure the vaccines from cold rooms while maintaining the cold chain, vaccinators need vaccine carriers with ice packs. However, ice packs are not adequately distributed by township health departments’ cold rooms. Accordingly, vaccinators have to make their own arrangements to maintain the cold chain with wet ice. These arrangements increase the workload of vaccinators and reduce their willingness to perform routine immunization activities [1]. The catchment areas of sub-centers are determined by population density; there is generally one sub-center for every 3000 people [12]. The rule for claiming travel allowances is based only on the distance, without taking geographical conditions into account [13]. Therefore, the current rule for travel allowances does not cover the actual transportation and delivery costs of immunization services. National immunization coverage in Myanmar has declined slightly in recent years [14]. This downward trend in immunization coverage may be due to low immunization coverage in self-administered regions and conflict areas, an increased number of mobile people who are not properly registered, inadequate resources for the sub-centers, and limited funding for vaccinators’ operational costs [1]. The comprehensive multiyear immunization plan for 2017– 2021 was developed based on the routine immunization expenditures in 2015. However, the sub-center level operational costs for routine immunization activities were not included in the plan due to a lack of data regarding the operational costs [1]. Consequently, sub-center level operational costs for routine immunizations were underestimated. This study aims to calculate the operational costs for routine immunizations at the sub-center level in Myanmar, with details for each line item of the operational cost.
2. Methods A cross-sectional study was conducted in 160 sub-centers in both urban and rural areas, as defined by the General Administration Department (GAD) of Myanmar’s Ministry of Home Affairs [6,15]. This study followed the common approach of multicountry studies to determine the cost and financing for routine immunizations [16], adapted to reflect the context of Myanmar. Myanmar is composed of 14 states/regions and one Union Territory [6] and data collection from each states/regions is not possible. The study utilized a two-stage sampling procedure. In the first stage, five states/regions were selected: one state/region each from the hilly plateau, delta, central plain, mountain range, and coastal areas. In the second stage, two townships were chosen from each selected state/region through a sampling procedure, stratified by transportation accessibility. In total, 160 sub-centers from 10 townships were selected (80 sub-centers from urban areas and 80 sub-centers from rural areas). One vaccinator from each
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sub-center was interviewed during the period from June to August 2017. The questionnaire was developed by reviewing the literature and consulting with technical experts from the Ministry of Health and Sports. It was designed to collect information on the characteristics of the sub-centers, working days for immunization activities, and the operational costs related to immunization services. The interviews were conducted face-to-face, at the health facilities, using the pre-tested questionnaire. 2.1. Cost categories Operational costs were estimated based on the operating cost line items. The costs were subdivided into vaccine transport, vaccinator’s travel, labor, cold chain energy, social mobilization, waste management, meals, and accommodation costs. Vaccine transport costs were defined as the transportation charges for vaccines, syringes, and other items related to immunization services. Travel costs were the transportation charges vaccinators incurred when they delivered immunization services. Vaccine transport and travel costs included bus fare, fuel, and boat rental costs. Labor costs included the cost of labor to carry heavy cold boxes, especially for vaccine collection, and to provide mobile sessions when motor vehicles were unavailable. Cold chain energy costs represented the cost of wet ice. Social mobilization costs included the rental costs for microphones, speakers, and sound boxes used to advertise immunization services, as well as the phone charges related to recruiting and/or reminding parents to avail immunization services. Waste management costs were defined as the cost of the fuel to run an incinerator. Meal costs were the vaccinators’ meal costs incurred while they delivered immunization services. Accommodation costs were defined as the room rental charges during vaccine collection and mobile sessions. Operational costs excluded crash immunization session costs and the operating costs of supplemental immunization activities. All operational costs were calculated in the local currency, the Myanmar Kyat (MMK). The costs were shown in US dollars for reference, with the exchange rate being 1 USD to 1,362 MMK at the end of 2016 [17]. 2.2. Data analysis This study applied the outline method of a common approach to analyze the costs and financing of routine immunizations [16]. This study calculated only the operational costs of routine immunization activities at the sub-center level; therefore, the costs of the vaccines, syringes, salaries, and other suppliers were not included. The operational costs were analyzed using the Statistical Package for the Social Sciences version 24 (IBM SPSS Inc.). This study examined sub-center level operational costs and analyzed the variation in operational costs by geographic area. Furthermore, the relationship between sub-center characteristics and operational costs were examined using the percentage frequency, minimum, maximum, mean, and standard deviation of the operational costs, and was calculated using linear regression analysis with a 95% confidence interval (CI). The variation of the operational costs by geographic area was analyzed using an ANOVA test. 3. Results Table 1 displays the characteristics of the urban and rural subcenters. Sixty-one sub-centers in both urban and rural areas each covered more than 3,000 people. The study found 10 sub-centers in rural areas that covered 11–25 villages/wards, while five subcenters in urban areas covered 11–25 villages or wards. Thirteen sub-centers in rural areas, and four sub-centers in urban areas,
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Table 1 Characteristics of sub-centers (N = 160). Characteristics
Urban (N = 80)
Rural (N = 80)
Total (N = 160)
N
%
N
%
N
%
Catchment population 712–3,000 3,001–6,000 6,001–18,171
28 35 17
35.0 43.8 21.2
33 30 17
41.3 37.5 21.2
61 65 34
38.1 40.6 21.3
Catchment infant population 12–60 61–120 121–454
26 36 18
32.5 45.0 22.5
29 32 19
36.3 40.0 23.7
55 68 37
34.4 42.5 23.1
Catchment area (wards/villages) 1–5 6–10 11–25
54 21 5
67.5 26.3 3.2
46 24 10
57.5 30.0 12.5
100 45 15
62.5 28.1 9.4
Working days for routine immunization 1–3 4–7
68 12
85.0 15.0
48 32
60.0 40.0
116 44
72.5 27.5
Working days for outreach sessions 1–3 4–6
76 4
95.0 5.0
67 13
83.8 16.2
143 17
89.4 10.6
Distance between sub-center and the health facility for vaccines collection 1–25 miles 55 68.8 26–50 miles 21 26.2 51–87 miles 4 5.0
46 21 13
57.5 26.3 16.2
101 42 17
63.1 26.3 10.6
Health facility of vaccines collection Rural health center Township health department
31 49
38.8 61.2
8 72
10.0 90.0
39 121
24.4 75.6
Mode of transportation to obtain vaccines Motorcycle Bus Boat
68 8 4
85.0 10.0 5.0
47 6 27
58.8 7.5 33.8
115 14 31
71.9 8.8 19.4
Mode of transportation to provide outreach sessions Motorcycle 77 Boat 3
96.3 3.8
55 25
68.8 31.3
132 28
82.5 17.5
Mobile sessions Yes No
15.0 85.0
16 64
20.0 80.0
28 132
17.5 82.5
12 68
N: number of sub-center.
were located 51–87 miles away from the designated health facilities where vaccines were stored. Most of the sub-centers (75.6%) picked up vaccines from the cold rooms of their designated township health departments, while 24.4% of sub-centers collected their vaccines from RHC. Vaccinators from 115 sub-centers used a motorcycle to obtain the vaccines (85.0% of sub-centers in urban areas and 58.8% of sub-centers in rural areas). Vaccinators from 28 sub-centers opened mobile sessions during the study year, which composed 15.0% of the sub-centers in urban areas and 20.0% of the sub-centers in rural areas.
Table 2 presents the line item operational costs by geographic area. For routine immunizations, travel costs were the highest (42.2%) of the overall operational cost. Among the different geographic areas, the delta area incurred the highest travel costs (39.6%), while the central plain area incurred the lowest (34.4%). Social mobilization was the second highest line item cost (13,842,000 MMK) for routine immunizations. Waste management was the lowest at 1.5% of the total operational cost. Operational costs were highest in the hilly plateau area (21,570,000 MMK), and lowest in the mountain range area (11,594,400 MMK).
Table 2 Differences between geographical areas of sub-center level operational costs by line items (in MMK). Line items
Vaccine transport cost Travel cost Labor cost Cold chain energy cost Social mobilization cost Waste management cost Othera Total operational cost a
Hilly plateaus area (N = 32)
Delta area (N = 32)
Central plain area (N = 32)
Coastal area (N = 32)
Cost
%
Cost
%
Cost
%
Cost
3,572,000 7,648,000 1,256,000 1,298,000 3,844,000 314,000 3,638,000 21,570,000
16.5 35.5 5.8 6.0 17.8 1.5 16.9 100.0
2,548,000 7,774,000 994,000 1,544,000 3,876,000 428,000 2,452,000 19,616,000
12.9 39.6 5.1 7.9 19.8 2.2 12.5 100.0
2,802,000 4,758,000 0 1,329,600 2,844,000 382,600 1,734,000 13,849,200
20.2 34.4 0.0 9.6 20.5 2.8 12.5 100.0
2,660,000 10,310,000 1,232,000 1,870,000 2,150,000 114,000 490,000 18,826,000
Mountain range area (N = 32)
Total cost (N = 160)
%
Cost
%
Cost
%
14.1 54.8 6.6 9.9 11.4 0.6 2.6 100.0
2,036,000 5,586,000 360,000 856,000 1,104,000 66,000 1,586,400 11,594,400
17.6 48.2 3.1 7.4 9.5 0.6 13.6 100.0
13,748,000 36,392,000 3,902,000 6,927,600 13,842,000 1,303,600 9,992,400 86,107,600
16.0 42.2 4.5 8.1 16.1 1.5 11.6 100.0
Meal/Accommodation cost, N: number of sub-center, MMK: Myanmar Kyat (1USD = 1362 MMK on 31st Dec 2016).
P value
0.144 0.003 0.910 0.018 <0.001 0.001 <0.001 0.006
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Table 3 exhibits the operational costs for routine immunizations at the sub-center level in urban and rural areas. Average rural operational costs were higher than urban costs in all geographic areas except the hilly plateaus. The difference between the average operational costs of rural and urban areas was highest in the delta area (754,250 MMK) and lowest in the hilly plateau area (375 MMK). The average rural operational cost per sub-center ranged from 434,700 to 990,125 MMK. For routine immunization in urban areas, the average operational cost per sub-center ranged from 235,875 to 674,250 MMK. Table 4 presents the variation in operational costs, stratified by geographic area. A statistically significant difference in the average operational cost by geographic area was found (p = 0.006). The highest average operational cost per sub-center was 674,062 MMK in the hilly plateau area, with a standard deviation of 440,041.2 MMK (95% CI: 515,410.7–832,714.3), and the lowest was 382,700 MMK in the mountain range area, with a standard deviation of 221,580.7 MMK (95% CI: 302,811.6–462,588.4). Table 5 presents the linear regression analysis of sub-center level operational costs. Geographical area (urban/rural) had a statistically significant positive association with operational costs in the univariate model (B: 304,335.0 MMK, with a 95% CI of 197,005.45–411,664.54; p < 0.001), although there was no significant association in the multivariate model. Each working day of outreach sessions increased the operational costs by 12,186.93 MMK (95% CI: 7,876.66–16,497.21; p < 0.001) in the univariate model, and 5752.50 MMK (95% CI: 914.22–10,590.79; p < 0.050) in the multivariate model. There was a positive association between the operational costs and the distance from the sub-center to the
health facility for vaccine collection. The operational costs increased by 11,437.10 MMK for each additional mile traveled in the univariate model (95% CI: 9,086.62–13,787.59; p < 0.001), and by 8749.50 MMK per mile in the multivariate model (95% CI: 6805.79 – 10,693.21; p < 0.001). In the univariate model, operational costs also varied according the type of health facility. The operational costs for vaccine collection at township health department cold rooms was 193,096.08 MMK (95% CI: 59,664.75 – 326,527.40; p < 0.010) greater than the operational costs of vaccine collection at RHC. The mode of transportation used to obtain the vaccines was also positively associated with operational costs. Traveling by bus or boat increased the operational costs by 239,029.65 MMK in the univariate model (95% CI: 171,456.44 – 306,602.86; p < 0.001) and 138,166.40 MMK in the multivariate model (95% CI: 68,771.11 – 207,561.68; p < 0.050). Fig. 1 shows the relationship between the operational cost per sub-center by its distance from the health facility and working days per outreach session. 4. Discussion This was the first study to calculate the operational costs of routine immunizations at sub-centers in Myanmar. The highest operational costs (21,570,000 MMK) were in the hilly plateau area, while the lowest were in the mountain range area (11,594,400 MMK). The average operational costs in rural areas were higher than urban areas in all geographic areas except the hilly plateau area. The distance between the sub-center and the cold room, the mode of transportation used to obtain the vaccines, the mode
Table 3 Operational costs at sub-center level by urban/rural (in MMK). Geographical area
N
Minimum
Maximum
Mean
Standard deviation
Difference means between urban and rural
P value
Hilly plateaus area Urban Rural
16 16
84,000 84,000
1,436,000 1,436,000
674,250 673,875
403,986.0 486,802.6
375
0.998
Delta area Urban Rural
16 16
102,000 504,000
390,000 1,896,000
235,875 990,125
79,831.3 428,540.1
754,250
<0.001
Central plain area Urban Rural
16 16
336,000 162,000
552,000 607,200
430,875 434,700
68,802.9 108,223.3
3,825
0.906
Coastal area Urban Rural
16 16
102,000 318,000
1,328,000 1,654,000
327,500 849,125
310,670.2 325,664.0
521,625
<0.001
Mountain range area Urban Rural
16 16
126,000 174,000
726,400 780,000
261,525 503,875
177,228.7 196,811.2
242,350
0.001
1USD = 1,362 MMK on 31st Dec 2016. N: number of sub-center. MMK: Myanmar Kyat.
Table 4 Geographical variation of operational costs at sub-center level (in MMK). Geographical area
Hilly plateaus area Delta area Central plain area Coastal area Mountain range area 1USD = 1,362 MMK on 31st Dec 2016. MMK: Myanmar Kyat.
Mean
674,062 613,000 613,000 588,312 382,700
Standard deviation
440,041.2 488,626.8 488,626.8 410,166.6 221,580.7
95% confidence interval
P value
Upper bound
Lower bound
515,410.7 436,831.3 436,831.3 440,431.7 302,811.6
832,714.3 789,168.7 789,168.7 736,193.3 462,588.4
0.006
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Table 5 Liner regression analysis on sub-center level operational costs (N = 160) (in MMK). Factors
Geographical areas (urban/rural) Catchment infant population Catchment area (wards/villages) Working days for routine immunization Working days for outreach sessions Distance between sub-center and the health facility for vaccines collection Number of vaccine collection times Health facility of vaccines collection Mode of transportation to obtain vaccines Mode of transportation to provide outreach sessions Mobile sessions
Univariate model
Multivariate model
B
95% confidence interval
B
95% confidence interval
304,335.00 665.37 20,132.29 11,142.13 12,186.93 11,437.10 16,813.37 193,096.08 261,951.81 239,029.65 486,388.31
(197,005.45–411,664.54)*** ( 173.85–1504.59) (4,973.39–35,291)** (6,646.61–15,637.64)*** (7,876.66–16,497.21)*** (9,086.62–13,787.59)*** ( 39,121.22–5,494.47) (59,664.75–326,527.40)** (200,915.73–322,987.89)*** (171,456.44–306,602.86)*** (351,977.65–620,798.96)***
58,825.50 190.44 2,921.87 1,203.66 5,752.50 8,749.50 571.58 1,475.86 66,614.06 138,166.40 224,589.11
( 20,948.81–138,599.81) ( 379.09–759.99) ( 7,882.69–13,726.43) ( 6,134.67–3,727.35) (914.22–10,590.79)* (6,805.79–10,693.21)*** ( 12,484.12–13,627.29) ( 87,673.58–90,625.31) ( 14.88–133,243.00)* (68,771.11–207,561.68)*** (123,973.00–325,205.22)***
1USD = 1,362 MMK on 31st Dec 2016. B: Unstandardized beta. MMK: Myanmar Kyat. *** p < 0.001. ** p < 0.010. * p < 0.050.
R2 linear=0.165
Operational costs (in MMK)
R2 linear=0.369
Distance between sub-center and the health facility for vaccines collection (miles)
Working days for outreach sessions
Fig. 1. Scatter plot of the operational costs (in MMK) and factors of sub-centers.
of transportation used to provide outreach sessions, the number of working days per outreach session, and the number of mobile sessions, were the characteristics of sub-center that were associated with operational costs in both the univariate and multivariate analyses. This study found that the distance between the sub-center and the health facility for vaccine collection was associated with operational costs. For every one mile increase in distance, the operational costs increased by 11,437.10 MMK in the univariate model, and by 8,749.50 MMK in the multivariate model. This finding is not consistent with the study from Benin, which found that the distance in kilometers to the vaccine point was negatively associated with routine facility immunization costs [18]. In Myanmar, however, there are no cold chain facilities below the township level, which means that vaccinators need to collect their vaccines from the designated health facilities before each immunization service. This study also found that the operational costs for vaccine collection at township health department cold rooms were higher than the operational costs for vaccine collection at RHC. These factors led to increases in the operational costs for routine immunizations, and also increased the vaccinators’ workloads. The Ministry of Health and Sports needs to consider providing cold chain facilities to sub-centers below the township level, in order to reduce operational costs and save vaccinators’ time.
Myanmar’s public transportation system is not well developed. Vaccinators often needed to use their own motorcycles, and sometimes pay to rent vehicles, in order to perform routine immunization activities. Moreover, depending on their geographic location, some vaccinators were forced to hire cars or boats to provide routine immunizations. The study found that the modes of transportation used to obtain vaccines and deliver outreach sessions were also associated with operational costs. The comprehensive multiyear plan for 2017–2021 pointed to limited funding for routine immunizations as one of the reasons for low national immunization coverage [1]. Timor-Leste has the same transportation problems as Myanmar. Some areas of Timor-Leste are difficult to reach in all seasons because of geography and an undeveloped public transportation system. These challenging conditions affect immunization coverage, but the Ministry of Timor-Leste is trying to solve the problem by providing vehicles for routine immunizations, and all vehicles used for immunization purposes are maintained by the government [19]. Providing vehicles and fuel is a well-established requirement for governments to achieve high immunization coverage. Another option is for the Ministry of Health and Sports to consider amending the current rule for claiming transportation allowances to include a transportation allowance for routine immunizations in the government’s budget. This support would reduce the out-of-pocket expenses of vaccinators
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and motivate them to conduct regular outreach sessions, increasing the frequency of outreach sessions and promoting national immunization coverage. In total, Myanmar has 3,063 wards, 13,618 village tracts, and 64,134 villages, with 8,404 sub-centers designated to cover them [8]. This means that each sub-center needs to cover several villages. The study also found that, since the maximum catchment area for each sub-center was 25 villages/wards, outreach and mobile sessions were necessary to provide routine immunization services. These in turn increase vaccinators’ workloads, which could increase the chance of overlooking children who need immunizations. In addition, previous studies have reported that higher workloads for health facilities were strongly associated with higher operational costs [18,20–25]. This study found that travel costs accounted for the highest percentage (42.2%) of operational costs for routine immunizations, and the number of working days spent on outreach sessions was correlated with operational costs. In Cambodia and Lao PDR, routine immunizations are mainly conducted through outreach sessions, and travel cost is the highest percentage of total operational costs [26,27]. This study lends strong support to the concept of establishing new strategically located sub-centers to offer more facility-based services, thereby reducing transportation and other outreach costs. This study found that average operational costs in rural areas were higher than in urban areas. This finding is consistent with previous studies conducted in Zambia and Honduras [22,28]. However, studies from Ghana and Benin reported that operational costs in urban areas were higher than in rural areas [18,29]. This study also found that the difference in average operational costs between rural and urban areas was highest in the delta area and lowest in the hilly plateau area. In Myanmar, transportation is easily accessible in urban areas but not in rural areas. In the rural delta area, boats are commonly used as the main mode of transportation. The rental charge for boats is very high, which is why the operational costs in rural areas are higher than in urban areas, and also why the urban/rural difference was highest in the delta area. Transportation is also difficult throughout the hilly plateau area, and some parts of the hilly plateau area are self-administered regions and conflict areas where vaccinators can only provide routine immunizations with the approval of local governments. Applications for approval must be submitted at least two weeks before the immunization services, and permission to perform routine immunization activities is not granted for every submission. Because of security concerns and the geographical situation, transportation costs in the hilly plateau area are very high in both urban and rural areas. While the national immunization program invested a lot of resources and effort to deliver immunizations in those areas, political commitment and government support are required to provide routine immunizations in these areas. Currently, the annual government budget allocates the same amount of funds to all townships at the beginning of the fiscal year. Budgets are sufficient in some areas, but lacking in others. This study found that the average operational cost varied significantly between geographic areas (p = 0.006). For example, in the delta and coastal areas, vaccinators need spend more to hire boats to deliver routine immunizations. Therefore, the Ministry of Health and Sports needs to consider changing the current budget allocation system because it does not meet the demands of the actual situation. The budget breakdown should allocate funds according to geographical conditions, security concerns, and other relevant factors. The operational costs for routine immunizations, including transportation costs, are covered by governments in many countries [30–34]. In Myanmar, the transportation costs for routine immunizations were partially supported by international nongovernmental organizations in selected areas, [1] such as the rural
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delta and coastal areas. However, the majority of vaccinators still needed to spend their own money to conduct routine immunization activities, due to funding constraints and underestimation of their operational costs [1]. The immunization programs of all developing countries in the world depend on donor agencies such as Gavi, the World Health Organization, and the United Nations Children’s Fund. However, Gavi’s co-financing plan includes a transition process whereby all countries will eventually have to fully finance their own national immunization programs [4– 5,19,26,27]. Therefore, all governments need to take into account the operational costs of routine immunizations in their budgets while moving towards full self-financing of their national immunization programs. This study had several limitations. First, the information on operational costs for routine immunizations was collected retrospectively, and the costs were self-reported, so costs might have been under or over-reported. Second, the researchers were not able to double-check the bills and receipts for every item. Most of the operational costs were covered by vaccinators’ out-of-pocket money, so they were not registered in the record. Third, actual operational costs may differ because international nongovernmental organizations in some areas paid the United Nations’ rate, which does not always reflect actual local operational costs. Fourth, the data were collected in only 5 out of 14 states/regions and 1 union territory. Therefore, the study’s findings may not be representative of the entire country. Finally, the sample size was relatively small, resulting in limited statistical power. However, the study’s findings will be very useful for planning the government’s budget for the national immunization program, regardless of its small sample size and geographical distribution. In conclusion, this study found that the operational costs of many sub-centers were underestimated. It found variations in the operational costs for routine immunizations in different geographic areas. The Ministry of Health and Sports should consider amending its current budget allocation system and its rules for claiming travel allowances, in order to reflect the actual situation. The operational costs at the sub-center level for routine immunizations should be included in the government budget line. These operational costs may be reduced by increasing support for some resources, such as installing cold chain facilities below the township level. These changes will be important steps for the Myanmar government as it moves towards the fully self-financing phase of the Gavi transition process in its national immunization program.
5. Disclosure statement The authors have nothing to disclose. Acknowledgements We would like to express our special thanks to State/Regional Health Directors, Township Medical Officers and Team Leaders and all staff of national immunization program, Ministry of Health and Sports, Myanmar. This study would not be possible without their collaboration and agreement to participate in this study. References [1] Ministry of Health and Sports. Comprehensive multi-year plan (2017– 2021). Myanmar: Ministry of Health and Sports; 2016. [2] The World Bank. World development indicators – 2016. Washington, DC, United States of America. Available at: https://data.worldbank.org/country/ myanmar [access on 1st December 2017]. [3] Shen AK, Weiss JM, Andrus JK, Pecenka C, Atherly D, Taylor K, et al. Country ownership and GAVI transition: comprehensive approaches to supporting new vaccine introduction. Health Aff 2016;53:S57–60.
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