https://orcid.org/0000-0003-2628-5983
Figures
Abstract
Background
In Burkina Faso, typhoid fever remains a major public health concern, particularly among children under 15. In January 2025, a nationwide campaign introduced the typhoid conjugate vaccine targeting children aged 9 months to 14 years. This study aimed to estimate the cost of typhoid conjugate vaccine delivery during the national campaign and to identify the main cost drivers across different administrative levels.
Methods
We conducted a retrospective cross-sectional costing study using a microcosting approach from the perspective of the Ministry of Health. We collected data from fifty health facilities, eight health districts, five health regions, and the national level. Financial and economic costs were estimated for each level, excluding vaccine and syringe costs. All costs were converted to 2024 USD using the official exchange rate. Parameter uncertainty was explored through one-way sensitivity analysis on key assumptions.
Findings
Vaccinators administered a total of 10.5 million typhoid conjugate vaccine doses. The average financial cost per dose was $0.47 (95% CI: $0.39–$0.51), and the economic cost was $2.16 (95% CI: $1.71–$2.56). Human resources and per diem payments were the main contributors to costs. Costs varied by geography, delivery strategy, and security context, with higher costs observed in rural and conflict-affected areas. The mobile–temporary posts strategy had the highest economic cost per dose ($2.02; 95% CI: $1.64–$2.40), while the fixed strategy had the highest financial cost per dose ($0.41; 95% CI: ($0.32–$0.49). Sensitivity analyses indicated robust cost estimates, with volunteer time valuation having the greatest influence.
Conclusion
The financial cost per dose remained within Gavi’s operational support range. The observed cost variations highlight the need for targeted funding and enhanced logistical support to ensure equitable access, particularly in rural and insecure areas. This study provides evidence to inform future vaccination campaigns and supports decision-making for typhoid conjugate vaccine introduction in other countries in the region.
Citation: Koulidiati J-L, Zoma RL, Nebié EI, Yameogo S, Neya Ouedraogo C, Kiendrébéogo JA, et al. (2026) Cost analysis of a nationwide typhoid conjugate vaccine campaign in Burkina Faso. PLoS One 21(6): e0351148. https://doi.org/10.1371/journal.pone.0351148
Editor: Leonard Ighodalo Uzairue, De Montfort University Faculty of Health and Life Sciences, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
Received: December 16, 2025; Accepted: May 24, 2026; Published: June 10, 2026
Copyright: © 2026 Koulidiati et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The minimal data set is available at Harvard Dataverse via https://doi.org/10.7910/DVN/CHBLZK.
Funding: This work was undertaken as part of the Typhoid Vaccine Acceleration Consortium (TyVAC). TyVAC is a partnership between the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine; the Oxford Vaccine Group at the University of Oxford; and PATH, an international nonprofit. This work was supported, in whole or in part, by the Gates Foundation [INV-030857]. Under the grant conditions of the Gates Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. J-LK, as an independent consultant and RLZ, DAVYCAS International staff, received consulting fees from PATH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Typhoid fever remains a significant public health challenge globally, with more than 7 million cases and 93,000 deaths estimated in 2021 [1]. The burden of disease is disproportionately high in South Asia and sub-Saharan Africa, where poor sanitation and lack of access to clean water—main transmission routes of the disease—are common [2]. In sub-Saharan Africa, more than three million infections and 33,000 deaths occur annually, with incidence rates reaching up to 383 cases per 100,000 person-years in some countries [3,4]. The region has also seen an increase in typhoid outbreaks, such as the 2023 outbreak in the Democratic Republic of Congo that recorded nearly 1,200 suspected cases, with typhoid intestinal perforations occurring in 3.7% of cases [5].
In response to this persistent threat, the World Health Organization (WHO) recommended the introduction of the typhoid conjugate vaccine (TCV) in endemic countries in 2018. Two vaccines—Typbar TCV® and TYPHIBEV®—are currently available for Gavi-eligible countries in liquid form in five-dose vials [6]. Despite the high disease burden, only five African countries have introduced TCV to date [7].
Burkina Faso faces a substantial typhoid fever burden. Surveillance conducted in 2024 revealed an incidence rate of 133 cases per 100,000 person-years, with rates reaching up to 234 per 100,000 person-years among children aged 2–4 years. Children younger than 15 years, who constitute more than half of the population, accounted for 88% of reported cases [8]. In 2023, the country recorded over 120,000 suspected cases [9]. Progress has been made in disease surveillance, including the establishment of two sentinel sites under the Typhoid Surveillance in Africa Program (TSAP) [10,11], which enabled hospital-based monitoring and blood-culture confirmation. Also, in January 2025, Burkina Faso launched a national TCV campaign targeting children aged 9 months to 14 years old, reaching more than ten million recipients [12]. Following this campaign, the Ministry of Health integrated TCV into its routine immunization program.
Understanding the financial and economic costs associated with vaccine delivery is essential for informed decision-making. Financial costs included direct expenditure, while economic costs included the value of all resources used—including volunteer time and donated materials—regardless of financial transactions [13]. Despite its relevance to policymakers, evidence on the costs of TCV introduction remains limited, particularly in Francophone Africa. This study addresses this gap by estimating the costs of TCV delivery during the national introduction campaign in Burkina Faso. The findings provides evidence to support future planning and regional vaccine introduction efforts.
Methods
Study design
We conducted a retrospective cross-sectional costing study using a microcosting approach to estimate both financial and economic costs of the national TCV campaign in Burkina Faso. We adopted the perspective of the Ministry of Health, covering the campaign period—from preparatory activities to post-campaign review.
Study sites and sampling
Burkina Faso’s health system is a hierarchical pyramid structure, comprised of 13 health regions, 70 health districts, and approximately 2,670 Health and Social Promotion Centers (CSPS), which serve as the primary level of care and the first point of contact for communities. All CSPS involved in the national vaccination campaign formed the sampling frame. We used a stratified random sampling approach and the EPIC Sample Design Optimizer (SDO) tool [14] to randomly select 5 regions, 8 districts, and 50 CSPS for inclusion. The 50 CSPS from 5 regions were chosen based on budgetary constraints. We stratified the sample based on urban versus rural location.
Data collection
Data collection took place in March 2025, two months after the campaign ended, to reduce recall bias. Prior to fieldwork, data collectors received training on the use of standardized data collection tools. They conducted visits at selected CSPS, district health offices, regional directorates, and the Ministry of Health central level. Due to security concerns, we replaced five inaccessible CSPS with alternative facilities matched on key characteristics. Replacement facilities were selected based on catchment area population size and the number of measles vaccine doses administered in 2024, with further stratification by urban or rural location.
Enumerators collected primary data through interviews with key informants, including head nurses, Expanded Programme on Immunization (EPI) focal points, district and regional health managers, and staff from the Directorate of Vaccination Prevention (at the central level). Tailored questionnaires for each level captured information on campaign activities and cost categories as described in Table 1.
Secondary data focused on unit prices, such as salary scales for campaign personnel and replacement costs for equipment and vehicles, sourced from government and international organizations (Appendix 1 in S1 File).
Data analysis
At each administrative level, we estimated the financial and economic costs of vaccine delivery for the campaign. We multiplied resource quantities by unit prices or opportunity costs to estimate activity-specific costs. Additionally, we calculated delivery costs by campaign activity and cost category excluding vaccine procurement and consumables (i.e., auto-disable syringes, safety boxes). Then, we aggregated costs per dose for each administrative level [15–17].
At the CSPS level, we calculated weighted average costs to obtain overall cost estimates. Furthermore, we calculated costs per dose by administrative level, delivery strategy, and geographic setting (urban or rural) and security status (conflict-affected or non conflict-affected zones).
We collected all costs in West African CFA francs and converted them to 2024 USD using the World Bank exchange rate (1 USD = 606.35 FCFA) [18]. We annualized capital costs using replacement values, expected useful life, and a 3% discount rate (Appendix 2 in S1 File) [17]. We assessed uncertainty around cost estimates using sampling-based variance across sampled facilities. We calculated standard errors were based on the variability in cost estimates across the sampled administrative levels. We constructed 95% confidence intervals using the normal approximation. We explored parameter uncertainty through one-way sensitivity analysis on key assumptions, including the discount rate, valuation of volunteer time, and replacement costs of capital items. We also conducted a scenario analysis excluding facilities replaced due to security constraints. We performed data analysis using Stata version 14 (StataCorp, TX, USA). Reporting follows CHEERS 2022 guidelines for economic evaluations (S2 File).
Results
Description of the study sample characteristics
The study sample comprised 50 CSPS, 8 health districts, 5 regions, and the central level. Of the 50 selected CSPS, 74% were in rural areas, and 28% were in conflict-affected zones. Three CSPS (6%) also administered 212 doses of HPV and 14 doses of MR vaccines in addition to TCV, representing less than 1% of total doses. We excluded these doses from the analysis.
Nearly all CSPS (98%) implemented all three delivery strategies during the campaign. The mobile and temporary posts strategy—conducted in schools, markets, churches and mosques —was predominant, accounting for 50% of doses administered, followed by outreach at regular posts (35%), and the fixed strategy (15%).
Campaign costs
Tables 2 and 3 present the financial and economic costs incurred across administrative levels. At the CSPS level, the weighted average financial cost was $2,164, and the economic cost was $12,054. Service delivery accounted for the largest share of economic costs (41%), followed by social mobilization (24%). Per diems represented 89% of financial costs, while human resources contributed 81% of economic costs. Across all 50 CSPS, a total of 439,601 TCV doses were administered, with an average of 8,792 doses per facility. The financial cost per dose was $0.39 (95% CI: $0.31–$0.40), and the economic cost per dose was $1.90 (95% CI: $1.62–$2.18).
At the district level, the average financial cost was $5,277, and the average economic cost was $40,209. Supervision and campaign management were the activities with the highest shares of both financial and economic costs. Human resources accounted for 85% of economic costs. Vaccinators administered 2,068,560 doses across the eight districts, resulting in a financial cost per dose of $0.02 (95% CI: $0.01–$0.03) and an economic cost per dose of $0.15 (95% CI: $0.01–$0.28).
At the regional level, the average financial cost was $7,759, and the average economic cost was $22,363. Supervision and campaign management were again the dominant cost activities, accounting for 48% and 22% of economic costs, respectively. Human resources (61%) and per diems (19%) were the largest cost categories. A total of 5,568,493 doses were administered in the five regions, with a financial cost per dose of $0.01 (95% CI: $0.00–$0.01) and an economic cost per dose of $0.02 (95% CI: $0.01–$0.03).
At the central level, the financial cost was $893,860 and the economic cost was $964,099. Data management and social mobilization were the main activities driving costs. Printing, communications, and stationery accounted for 65% of financial costs and 61% of economic costs, followed by per diems (15% and 14%, respectively). Nationally, 10,552,806 doses were administered, with both financial and economic costs per dose estimated at $0.09.
Across all levels, the average financial cost per TCV dose was $0.47 (95% CI: $0.39–$0.51), and the economic cost was $2.16 (95% CI: $1.71–$2.56) (Table 3).
Cost distribution by activity and cost category
Fig 1 illustrates the breakdown of economic cost per dose by activity and cost category. Vaccine administration and social mobilization contributed $0.79 (37%) and $0.47 (22%) of the $2.16 economic cost per dose, respectively. Human resources accounted for $1.69 (78%) and per diems for $0.32 (15%).
Cost variation by geography, delivery strategy, and security context
Table 4 shows cost variations by CSPS location, security status, and delivery strategy. Financial cost per dose was higher in rural areas ($0.40; 95% CI: $0.34–$0.45) than urban areas. The fixed strategy had the highest financial cost per dose ($0.41; 95% CI: $0.32–$0.49), while the mobile and temporary posts strategy had the highest economic cost ($2.02; 95% CI: $1.64–$2.40). CSPS in conflict-affected zones had a higher financial cost per dose ($0.39; 95% CI: $0.34–$0.44) than those in non-conflict-affected zones.
Regional disparities and dose-cost relationship
Among the five regions, the East region had the highest financial cost per dose ($0.63), while the North region had the lowest ($0.39). The Hauts-Bassins region recorded the lowest economic cost per dose ($1.94), whereas the East had the highest ($2.53) (Fig 2).
Fig 3 shows the relationship between the number of doses administered and the associated costs at the CSPS level. The financial cost per dose decreased as the number of doses administered increased.
Sensitivity and scenario analysis
The sensitivity analysis indicated that the valuation of volunteer time had the greatest impact on the estimated cost per dose. Varying this parameter by ±20% resulted in a three percent change in the economic cost per dose, ranging from $ 2.13 (95% CI: $1.62–$2.46) to $ 2.19 (95% CI: $1.67–$2.52).
Also, excluding inaccessible health facilities from the analysis did not change the financial cost per dose, which remained at $ 0.47. However, the economic cost per dose slightly increased by 1.4%, from $ 2.16 in the base-case analysis to $ 2.19 (95% CI: $1.67–$2.53).(Appendix 3 in S1 File).
Discussion
This study estimates the financial and the economic costs of the national TCV campaign in Burkina Faso, covering all levels of the health system. The findings reveal substantial variability in cost per dose across administrative levels, geographic settings, and delivery strategies, offering critical insights for future immunization planning.
The average financial cost per dose of $0.47 observed in this study is lower than estimates from similar campaigns in other low- and middle-income countries. For instance, a typhoid outbreak response (TCV campaign) in Zimbabwe in 2019 reported a financial cost of $0.79 per dose [19], while Malawi’s 2023 integrated campaign yielded a financial cost per dose of $0.49 per dose [20]. The lower cost in Burkina Faso may be attributed to the strategic use of existing infrastructure and the implementation of multiple delivery approaches, which enhanced operational efficiency. Importantly, the financial cost per dose remains within the operational support range provided by Gavi ($0.45–$0.65) [21], suggesting that the campaign was financially viable under current donor frameworks. Nevertheless, the observed cost variability underscores the importance of context-specific budgeting and resource allocation.
A key finding is the predominance of human resources and per diems as cost drivers. Human resources accounted for the majority of economic costs, while per diems dominated financial costs. This pattern aligns with previous studies conducted in similar settings [21–23], where labor-intensive activities significantly influence immunization costs. Vaccine administration emerged as the main activity contributing to economic costs, followed by social mobilization. The latter’s prominence is unique compared to other campaign cost studies [19,20,22]. This reflects the substantial investment made during the campaign to address vaccine hesitancy and engage communities, political leaders, and education stakeholders. This emphasis on communication and outreach is particularly relevant given the increasing skepticism toward vaccines in various contexts.
At the central level, data management was the most resource-intensive activity, driven largely by the printing of over eleven million vaccination cards. This finding highlights the need to explore cost-saving alternatives, such as digital data collection and reporting systems, which could streamline operations and reduce expenditure.
Furthermore, the analysis also revealed that the fixed strategy incurred the highest financial cost per dose, likely due to the lower volume of doses administered through this approach. This suggests the presence of economies of scale [22], where higher throughput leads to reduced unit costs. Conversely, the economic cost per dose for the fixed strategy was lower than for mobile and temporary posts and outreach at regular posts strategies, possibly due to reduced reliance on additional human resources.
Regional disparities in cost were notable, with the East, Centre-North, and North regions—areas affected by insecurity—recording the highest economic costs. These elevated costs are probably due to increased logistical challenges and the need for additional personnel to ensure safe and effective vaccine delivery [22]. The higher opportunity costs in these regions further contribute to the overall economic burden. These findings emphasize the importance of tailoring campaign strategies and resource allocation to the specific needs of vulnerable and hard-to-reach populations.
The inverse relationship between the number of doses administered and financial cost per dose at the CSPS level further supports the existence of economies of scale [22]. Facilities administering larger volumes of vaccines achieved lower per-dose costs, reinforcing the value of optimizing delivery efficiency in future campaigns.
The generalizability of these findings should be interpreted in light of the specific contextual features of Burkina Faso. While some cost drivers—such as increased transport and logistical costs in conflict-affected zones—are context-specific to Burkina Faso, key findings are likely transferable. In particular, the dominance of human resources and per diem payments as major cost drivers, as well as variations by delivery strategy and economies of scale, is consistent with evidence from other low-income settings.
Policy implications
The findings of this study offer actionnable evidence for immunization policy and strategic planning. First, the high costs observed in rural and conflict-affected zones underscore the need for targeted financial and logistical support to ensure equitable vaccine access during campaigns. Tailored resource allocation strategies are essential to address geographic and security-related disparities.
Second, the substantial contribution of human resources to overall economic costs highlight the importance of investing in workforce development. Policymakers should prioritize training, retention, and efficient deployment of health personnel. Strengthening Burkina Faso’s community health strategy [24] could be instrumental in building a cadre of trained, community-based health workers capable of delivering essential services, including vaccination.
Third, the study identified data management—particularly at the central level—as a major cost driver. Transitioning to digital health information systems for real-time monitoring and evaluation could improve operational efficiency and reduce expenditures associated with printing and manual data handling [25].
Study limitations
This study has several limitations. First, the retrospective nature of data collection may introduce recall bias or incomplete reporting. However, conducting data collection within two months of the campaign likely minimized this risk. Second, as the analysis adopted an incremental campaign costing approach, we did not include depreciation of long-term infrastructure (EPI building,office infrastructure) which may lead to underestimation of total economic costs. Third, economic costs included estimates for volunteer time, but these may have been underreported due to reliance on self-reported data and lack of standardized valuation methods for non-financial contributions. Finally, due to insecurity, five CSPS were replaced with alternatives. This substitution may have introduced selection bias, but we selected facilities likely close in cost structure or campaign implementation to the replacing ones to reduce this bias. Moreover, the scenario analysis excluding these health facilities indicated that their replacement had no substantial impact on either financial or economic costs estimates.
Conclusion
This study estimates of the financial and economic costs of the national TCV campaign in Burkina Faso. The average financial cost per dose fell within the operational support range provided by Gavi, indicating financial feasibility. Human resources and per diems were the major cost drivers. Geographic and contextual variations in cost highlight the need for adaptive planning and targeted support. These findings offer valuable evidence to inform future vaccination campaigns and support TCV introduction in other countries facing similar public health challenges.
Supporting information
S1 File. Overview of the campaign costs estimation and sensitivity and scenario analysis results.
https://doi.org/10.1371/journal.pone.0351148.s001
(DOCX)
S3 File. Supporting information for data availability.
https://doi.org/10.1371/journal.pone.0351148.s003
(DOCX)
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