Economic Evaluation of the Integration of Immunization and Birth Registration Services Using Community-Based Volunteers in Zambia

Background: Birth registration and immunization services are key components of health systems; data show coverage for both is low in Zambia. From March to October 2017, we launched a pilot intervention in rural Zambia (Mumbwa and Chibombo districts) to increase uptake of birth registration and immunization services using community-based volunteers (CBVs) in two selected health facility catchment areas. A cost-effectiveness analysis was conducted to document the costs per child receiving birth registration or immunization services.

Methods: The intervention utilized CBVs to refer eligible children aged <5 years for birth registration and immunization. In Mumbwa, CBVs deposited birth notifications in health facilities and delivered birth certificates to homes, while in Chibombo parents deposited birth notifications and retrieved birth certificates at the health facility. Immunization services were delivered according to the national immunization program standards at health facilities in both sites. Data collected included the number of children visited at homes and referred for each service, services received, and intervention costs from the funder and Zambian public health sector perspectives. Costs were collected on start-up of the intervention and during implementation. Cost data included actual resources expended and opportunity cost of resources used for the intervention, measured through CBVs’ recorded time logs. Effectiveness measures included the number of birth notifications sent to the district registrar’s office, the number of children receiving a birth certificate, and the number of children receiving any immunization. Average cost-effectiveness ratios were calculated separately for each catchment area.

Preliminary Results: The target population for the intervention was children <5 years, however CBVs referred children aged <18 years due to the demand. During the intervention, 2,416 children were referred for birth registration (1,608 in Chibombo and 808 in Mumbwa) and 1,109 children were referred for immunization (768 in Chibombo and 341 in Mumbwa). Of children referred, 1,077 received a birth certificate (616 in Chibombo and 461 in Mumbwa) and 507 received immunizations (231 in Chibombo and 276 in Mumbwa). Six CBVs spent 5,569 hours in the field during 126 business days. Total economic costs were $77,762 and financial costs were $61,530. Initial intervention start-up costs were $22,180 (economic) and $16,775 (financial). Implementation costs were $55,582 (economic) and $44,755 (financial). Average cost per child receiving an immunization was $153 (economic) and $121 (financial), and per birth certificate received was $72 (economic) and $57 (financial).

Conclusions: Decentralizing the birth registration process to the health facility provided children with access to birth registration and might increase uptake of immunization services. During the intervention, there was a higher uptake of birth registration compared to immunization services. Future efforts to integrate birth registration and immunization services at the health facility should consider the costs identified during this intervention.