title: Are vaccination programmes delivered by lay health workers cost-effective? A systematic review.
abstract: BACKGROUND
  A recently updated Cochrane systematic review on the effects of lay or community health workers (LHWs) in primary and community health care concluded that LHW interventions could lead to promising benefits in the promotion of childhood vaccination uptake. However, understanding of the costs and cost-effectiveness of involving LHWs in vaccination programmes remains poor. This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving LHWs.
  
  
  METHODS
  Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Studies were included after assessing eligibility of the full-text article. The included studies were then reviewed against a set of background and technical characteristics.
  
  
  RESULTS
  Of the 2616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. Methodologically, the studies were strong but did not adequately address affordability and sustainability and were also highly heterogeneous in terms of settings and LHW outcomes, limiting their comparability. There were insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability.
  
  
  CONCLUSIONS
  The included studies suggest that conventional economic evaluations, particularly cost-effectiveness analyses, generally focus too narrowly on health outcomes, especially in the context of vaccination promotion and delivery at the primary health care level by LHWs. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.
authors.affiliation: Health Systems Program, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe Street, Baltimore MD 21205, USA. acorluka@jhsph.edu
authors.forename: Adrijana
authors.initials: A
authors.lastname: Corluka
authors.forename: Damian G
authors.initials: DG
authors.lastname: Walker
authors.forename: Simon
authors.initials: S
authors.lastname: Lewin
authors.forename: Claire
authors.initials: C
authors.lastname: Glenton
authors.forename: Inger B
authors.initials: IB
authors.lastname: Scheel