LRPS No.2021–9170678 for strategic support to Ministry of Health and Family Welfare for Cost-Benefit Economic Analysis of comprehensive investment in life-course vaccination

TERMS OF REFERENCE FOR INSTITUTIONAL CONTRACT

 

Title of the assignment

Strategic support to Ministry of Health and Family Welfare for Cost-Benefit Economic Analysis of comprehensive investment in life-course vaccination aligned with the Immunization Agenda 2030

Purpose

To facilitate advocacy efforts and programming strategies towards influencing resource mobilization efforts and investments for expanding the National Immunization Programme (NIP) and financing for immunization to prepare for Gavi transition and meeting the targets for Immunization agenda 2030

Location

Dhaka, Bangladesh. 

Estimated Duration

4- 6 months

Reporting to Technical Supervisor of this assignment

Health Specialist

 

1. Background

Over the past 40 years, Bangladesh has made remarkable progress on immunization and child health. The country has successfully maintained the elimination of neo-natal tetanus since 2008, received the polio-free certificate in 2014 and between 1990 and 2012, reduced deaths of children under five by 73 per cent.[i] Immunization coverage rates have remained over 80 per cent for more than ten years and 84 per cent of children under 12 months are fully immunized. Despite strong performance, gaps remain. Reaching all children continues to prove challenging. The COVID-19 pandemic provides a stark reminder of how lives and livelihoods can be upended by disease outbreaks, with knock-on effects on children's education, mental health, protection and overall well-being. Immunization gains are fragile and subject to external shocks.

Bangladesh has comparatively low spending on health care which stands at  0.7% of the public health expenditure in the Financial Year 2019. This must be increased to 2 % to reach the target established in the Government of Bangladesh’s 8th Five-Year Plan 2020-2025.[ii] Further the overall health expenditure stands at 2.34% of the Gross domestic product which is way below the global standard of 5 per cent of GDP.

Bangladesh requires US$ 803 million to fund immunization activities between 2018 and 2022 which translates to  US$ 160 million per year. Gavi, the Vaccine Alliance, is the largest external financier to the immunization program currently providing over half of the annual budget for immunization. External funding resources will steadily decrease as Bangladesh graduates from Least Developed Country to Developing Country status in 2026. Meanwhile, the immunization programme will soon enter an acceleration phase towards transitioning from Gavi co-financing towards self-financing by 2026.

Bangladesh needs to increase the budget for vaccine procurement by 20-25 per cent each year for the next five years to cover the anticipated shortfalls and build resilient and sustainable immunization services linked with the PHC platform and aligned with the SDG 2030 agenda.

Government of Bangladesh is committed to ensuring equitable and quality access to immunization, achieving the measles-rubella elimination goal as well as the introduction of new vaccines against infectious diseases. Yet, decisions are often not made in a well informed, evidence based manner, especially around the cost-benefit analysis. The proposed work under this TOR  will take stock of the current situation, understanding the impact of the investments done till date including the investments towards rolling out the COVID 19 vaccine and perform a cost benefit analysis towards reaching every child with the complete set of immunizations in  Bangladesh, which includes measles elimination, introducing new vaccines such as HPV, JE and Typhoid as well as the Covid vaccine. This will facilitate guiding  the policy makers and technical teams as well as program planners towards the further design of the immunization program as well as decision making for introducing new vaccines and sustaining the gains already made in the program with domestic financing.  

2. Purpose, Objectives and Expected Results

The primary purpose of this work is the  development of a robust investment case for immunization including the cost benefit analysis across all components of the immunization program towards achieving the targets of the Fully Vaccinated Children (FVC) and NUVI (new and under-utilized vaccines introduction) including Covid vaccine. This will facilitate advocacy towards increasing public financing with fiscal space analysis for immunization leveraging the primary care platform to prepare for Gavi transition and achieve the targets for Immunization 2030.

Objectives for the project:

• To support GOB, particularly Directorate General of Health Services (DGHS) at MOHFW, to prioritize and execute on planning and investments for immunization program in the PHC and UHC context, the immunization agenda 2030 and the COVID 19 pandemic
• To accelerate efforts and allocate resources to introduce new vaccines as part of routine immunization including rotavirus, typhoid vaccine and human papillomavirus (HPV) to prevent childhood diseases and cervical cancer in women

 

The expected results:

1. Assessment report of immunization financing mapping, bottleneck and solutions
2. Report of Investment case for immunization, including cost benefit and fiscal space analysis for immunization to prepare for Gavi transition
3. Policy paper for advocacy dialogue

 

3. Description of Assignment

 

3.1 Scope of work

The investment case including the Cost-Benefit Economic Analysis is for a comprehensive package of immunization programming instead of individual products. This includes all components for a successful evidence driven immunization program, example, the monitoring system, Human resources, cold chain, transportation and logistics, vaccines, demand etc. Vaccines to be included in the analysis will be determined through a consultative process with key stakeholders in the government and development partners (these may include HPV, Typhoid, JE, Cholera, COVID, among others).

The analysis is intended to: (i) quantify the annual fiscal and economic benefits that could be achieved in the first 20 years of the immunization program  implementation through prevented disease burden; and therefore (ii) provide evidence to support advocacy for life-course immunization leveraging the primary care platform as a strategic public policy and smart investments in UHC and PHC

The proposed analysis will present annual expected costs and benefits to guide decision makers on the positive impacts of expanding the NIP according to a life-course approach aligned with the Immunization agenda 2031 and post Gavi transition and interlinked with SDG 2030 and UHC goals

 

In particular, for the 2021-2030 period, and for each year within that period, the investment case will estimate:

• The cost of the proposed NIP expansion, including post Gavi transition
• Improved health outcomes through prevented cases, prevented mortality, and additional healthy life years from prevented disability
• The fiscal benefits (savings through averted cases, savings to sick-day payments, additional tax revenue)
• The productivity benefits (economic activity gains)
• The household benefits (lessened income loss due to sickness and mortality, out of pocket savings, prevented missed workdays for caregivers)
• Return on investment (ROI) of the proposed NIP expansion over time covering all key components of the immunization program

 

3.2 Major Activities

An indicative list of proposed interventions includes:

• Rapid assessment of the existing Public expenditure for immunization services and national Immunization policy, strategy and Immunization Agenda 2030
• Review of health financing bottlenecks, resource mapping and fund flow at all levels of service delivery
• Review of the evidence available in country and relevant documents for health financing including the costed Essential Services Package, the Health financing strategy etc
• Conducting key informant interviews, focus group discussions with key stakeholders, consultations etc as needed towards collecting relevant data as well as validating the findings across all stages and steps.
• Development and finalization  of the immunization investment case for Bangladesh, including targeted recommendations for key stakeholders on the importance of investment in human resources, vaccines, equipment including cold chain and data management and demand generation leveraging the primary health care platform to improve efficiency gains and financial sustainability
• Organize various dissemination activities including a Policy dialogue with key stakeholders, including government officials, political leaders, CSOs, parliamentarians, development partners and media, to increase government spending on immunization within the context of UHC and PHC and SDG 2030 to successfully transition to self-financing for immunization by 2026 and sustain high coverage and quality delivery for all vaccines ensuring equity and universal coverage.

 

This work envisages 3 major activities:

1. Rapid assessment of existing Public expenditure for immunization services, national Immunization policy, strategy and Immunization Agenda 2030 linked with the UHC/PHC and SDG 2030 agenda
2. Developing the investment case for immunization, including cost benefit analysis of FVC and NUVI including Covid vaccine, for policy advocacy on increasing public financing with fiscal space analysis for immunization to prepare for Gavi transition

• Policy advocacy with Policy maker and key stakeholders to increase government spending on immunization within the context of UHC and PHC and SDG 2030 to  successfully transition to self-financing for immunization by 2026 and sustain high coverage and quality delivery for all vaccines ensuring equity and universal coverage.

 

3.3 Methodology

A. Desk Review

• Desk review of existing Public expenditure report, health financing policy and strategy, sector programme financing, immunization multiyear plan
• Draw on secondary sources, quantitative assessment, on-going assessments

 

B. Primary Data Collection

• Review of health financing bottlenecks, resource mapping and fund flow
• A series of research visits, to collect relevant data, undertake informant interviews and hold focus group discussions with key stakeholders
• Stakeholder engagement at national and sub-national levels

 

C. Secondary Analysis of Existing Data

• Resource mapping and fund flow for essential services (national and sub-national)
• Analysis of fiscal benefits (savings through averted cases, savings to sick-day payments, additional tax revenue) and productivity benefits (economic activity gains)
• The household benefits (lessened income loss due to sickness and mortality, out of pocket savings, prevented missed workdays for caregivers)
• Return on investment (ROI) of the proposed NIP expansion over time

 

D. Develop Policy paper

• Develop policy paper of immunization investment case for Bangladesh, including targeted recommendations for key stakeholders on the importance of investment in human resources, vaccines, equipment and data management to improve efficiency and financial sustainability
• Organize a Policy dialogue with key stakeholders, including government officials, political leaders, CSOs, parliamentarians, development partners and media

 

The agency will collect the data through site visits and undertake key informant interviews with the national stakeholders to identify the challenges in the health system.

In addition to the final report, the dissemination materials should include the policy brief and PowerPoint presentation for use in policy dialogues/roundtable, and journal manuscript(s).

All data will be owned by UNICEF. The Agency, with UNICEF co-authorship, will submit a journal manuscript.

 

 

4. Deliverables:

The table below outlines the main deliverables for this project. The agency should expand this and provide a detailed timeline for each work package, key activities (including review processes), and deliverables.

 

Deliverables

Items covered/Included

Time frame

1

Inception report with assessment methodology and plan

• Inception report should include desk review, review of existing documents & data sources and specification of assessment tool/questionnaire, finalized primary data collection methodology
• Detailed implementation plan of assessment including person/facility/area
• Research plan matrix (including accompanying data analysis dummy tables)

3 weeks

2

Assessment report on financial analysis

• Assessment report of immunization financing mapping, bottleneck review and solutions

3 weeks

2

Final report

• Investment case for immunization, including cost benefit and fiscal space analysis for immunization to prepare for Gavi transition
• The cost of the proposed NIP expansion, including post Gavi transition
• The fiscal benefits (savings through averted cases, savings to sick-day payments, additional tax revenue)
• The productivity benefits (economic activity gains)
• The household benefits (lessened income loss due to sickness and mortality, out of pocket savings, prevented missed workdays for caregivers)
• Return on investment (ROI) of the proposed NIP expansion over time covering all key components of the immunization program

8 weeks

3

Policy document and Publication

• Policy document for advocacy
• Organize a Policy dialogue with key stakeholders, including government officials, political leaders, CSOs, parliamentarians, development partners and media

2 weeks

 

5. Reporting requirements

• Inception report within 3 weeks signing the contract
• Initial draft report on assessment within 9 weeks of submission of Inception report
• Final draft report on assessment within 2 weeks of submission of Initial draft report
• All raw and analysed data and final data collection tools

 

6. Payment schedule

• First payment: 20% upon approval of inception report
• Second payment: 30% upon finalization of assessment report as agreed with UNICEF
• Third Payment: 20% upon submission of final draft report as agreed with UNICEF
• Final Payment: 30% upon approval of final report and all finalized materials and raw data

 

7. Qualification requirement of the company/institution/organization

 

• Qualified agency or institute should have minimum 15 years of experience of global health, health systems, health economics and health financing expertise include budgeting and resource allocation in support of national policy objectives
• Minimum 10 years of experiences in supporting and guiding the governments particularly in LMICs for mapping and developing policy papers on health financing including immunization, experience in Bangladesh in particular area is desirable.
• Proven experiences of working with the governments, UN agencies and other partners in the South East Asian region on investment case analysis, immunization costing would be an added advantage.