Three Things We Learned about the Cost of Pandemic Vaccine Delivery in Low-Income Countries: Insights from Malawi

By Anika Ruisch, Christian Suharlim, and Damian Walker

It may not be possible to predict when and where the next global health crisis will strike, but effective planning and budgeting are critical to addressing it.  

When the COVID-19 pandemic was at its height, the world called for the swift development and distribution of vaccines as a crucial step toward ending the crisis. However, ensuring the equitable distribution of vaccines proved to be a profound challenge, particularly for low-income countries. These countries encountered not only delays in receiving limited vaccine supplies but also significant barriers in reaching target populations, especially since the adult population is not usually included in routine immunization programs. The cost of vaccine delivery in such contexts remained largely uncertain, complicating planning and budgeting for both national leaders and international funders. The following lessons may inform responses to future crises. 

The real cost is higher than expected.

This was the subject of recent research by our team of health financing experts at Management Sciences for Health (MSH). Determining the real cost of delivering vaccines means a detailed accounting of resources required to get vaccines to people: labor, travel and per diem, training and meeting expenses, capital costs such as vehicles, and others.  

Our study calculated the cost per dose to be between $3 and $6. Meanwhile, an earlier model developed by COVAX (the global alliance working on vaccine access during the COVID-19 pandemic) indicated a lower cost, although ranges overlap. Half of the recorded spending was on transportation and travel costs, as vaccinators had to navigate hard-to-reach geographies for door-to-door campaigns. This costs significantly more than it does for medical providers to vaccinate people in health facilities. Initial estimates that relied on existing immunization data, which predominantly includes information from routine vaccination services for children or specific campaigns in schools (like the HPV vaccine). Reaching the adult population was more complicated as this population does not interact as often with health services.  

Low demand for the vaccine also played a role. Fears about the perceived risks of the vaccine meant that fewer people opted to get vaccinated, making the cost per administered dose higher.  

Who delivers vaccines matters.

Our study revealed that few new health workers were recruited specifically for the COVID-19 vaccination campaign. Without new “surge” staff, Malawi relied on existing staff, which meant reallocating staff away from their usual activities toward COVID-19 vaccination delivery. 

Reallocation of staff toward COVID-19 vaccination means deprioritizing other essential health services, jeopardizing and in some cases reversing years of hard-won health gains. Malawi and other countries experienced declining immunization rates, outbreaks of vaccine-preventable diseases, lower quality of maternal care, and disruptions of other services, among others. Over-reliance on existing staff often also meant an increased workload among health workers.  

True pandemic preparedness requires investments in strengthening health systems.

Strengthening health systems means tackling chronic domestic underinvestment in health and providing adequate resources to improve health systems resilience. Like other health systems strengthening measures, this is best done in advance of a crisis like the COVID-19 pandemic so that the systems, platforms, and workforce are prepared to handle shocks like pandemics, conflicts, or natural disasters when they happen.  

As we continue to face new health challenges such as the Mpox outbreak in DRC and develop innovative vaccines, improved planning and budgeting remains critical if we are to successfully introduce vaccines and safeguard public health. Findings from our costing work in Malawi give insights as to what it may cost to vaccinate populations that are not usually targeted through routine immunization programs.    

Read the full study here.