title: Cost and sustainability of a successful package of interventions to improve vaccination coverage for children in urban slums of Bangladesh.
abstract: OBJECTIVE
  To estimate the incremental economic costs and explore satisfaction with a highly effective intervention for improving immunization coverage among slum populations in Dhaka, Bangladesh. A package of interventions based on extended clinic hours, vaccinator training, active surveillance, and community participation was piloted in two slum areas of Dhaka, and resulted in an increase in valid fully immunized children (FIC) from 43% pre-intervention to 99% post-intervention.
  
  
  METHODS
  Cost data and stakeholder perspectives were collected January-February 2010 via document review and 10 key stakeholders interviews to estimate the financial and opportunity costs of the intervention, including uncompensated time, training and supervision costs.
  
  
  RESULTS
  The total economic cost of the 1-year intervention was $18,300, comprised of external management and supervision (73%), training (11%), coordination costs (1%), uncompensated staff time and clinic costs (2%), and communications, supplies and other costs (13%). An estimated 874 additional children were correctly and fully immunized due to the intervention, at an average cost of $20.95 per valid FIC. Key stakeholders ranked extended clinic hours and vaccinator training as the most important components of the intervention. External supervision was viewed as the most important factor for the intervention's success but also the costliest. All stakeholders would like to reinstate the intervention because it was effective, but additional funding would be needed to make the intervention sustainable.
  
  
  CONCLUSIONS
  Targeting slum populations with an intensive immunization intervention was highly effective but would nearly triple the amount spent on immunization per FIC in slum areas. Those committed to increasing vaccination coverage for hard-to-reach children need to be prepared for substantially higher costs to achieve results.
authors.affiliation: Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205 USA. Electronic address: khayford@jhsph.edu.
authors.forename: K
authors.initials: K
authors.lastname: Hayford
authors.affiliation: Centre for Equity & Health Systems, icddr,b, 68 Shahed Tajuddin Ahmed, Sarani, Mohakhali, Dhaka 1212, Bangladesh. Electronic address: jasim@icddrb.org.
authors.forename: M J
authors.initials: MJ
authors.lastname: Uddin
authors.affiliation: Headquarters, United States Marine Corps, The Pentagon, Washington, DC, WA, USA. Electronic address: traceylynnk@hotmail.com.
authors.forename: T P
authors.initials: TP
authors.lastname: Koehlmoos
authors.affiliation: Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. Electronic address: dbishai@jhsph.edu.
authors.forename: D M
authors.initials: DM
authors.lastname: Bishai
mesh_terms: D001459:Bangladesh; D002648:Child; D002947:Cities; D017048:Health Care Costs; D006801:Humans; D017589:Immunization Programs / Q000191:economics* / Q000458:organization & administration; D010865:Pilot Projects; D011204:Poverty Areas; D012189:Retrospective Studies
keywords: Bangladesh; Cost; Economic analysis; Economic evaluation; Immunization; Urban slum; Vaccination coverage