The cost of delivering COVID-19 vaccines in four districts in Malawi

While COVID-19 vaccines became available in late 2020, low-income countries (LICs) faced challenging COVID-19 vaccine distribution efforts both in terms of a delayed and scarce vaccine supply and barriers reaching the target populations. The cost of delivering COVID-19 vaccines in LICs was uncertain which complicated the planning and budgeting for country leadership as well as major funders. Absent such data, a global model was developed by the COVAX Working Group on Delivery Costing using data on the costs of similar immunization campaigns and assumptions. This study aims to compare primary data collected in Malawi to modeled estimates, and to contribute to a growing evidence base on the cost of the COVID-19 vaccination delivery in LICs. This retrospective study used a bottom-up method to estimate the costs. Data was collected at the district level, from health facilities, and outreach posts using a COVID-19 costing survey. Data sources included existing records and key informant interviews with relevant district and facility staff. Twenty representative vaccine delivery sites were purposively selected across four districts. We focused on major cost drivers that contributed to the highest proportion and variability in delivery costs. The total financial cost of COVID-19 vaccine delivery in the 20 facilities across four districts in Malawi (from April 1, 2021-March 31, 2022) was US$ 322,786. During that period, the 20 facilities delivered 70,947 vaccines. The financial cost per dose delivered was US$ 4.55. Considering the reallocation of existing staff time towards COVID-19 vaccination, volunteer opportunity cost, and donated vehicles, the economic cost per dose delivered was four times higher at US$ 16.15. The economic cost of labor was estimated at US$ 10.75 per dose delivered and accounts for two-thirds of the total economic cost. This study is the first to provide evidence on the cost of COVID-19 vaccine delivery in Malawi. The financial cost of delivering the COVID-19 vaccine in four districts in Malawi, at US$ 4.55 [US$ 3.23 – US$ 6.33] per dose delivered. The COVAX estimate for Malawi was at $2.77, with four scenarios ranging from $2.34 - 4.36. We observed a large amount of labor reallocation towards COVID-19 vaccination, which influenced our higher estimates of the economic costs.