Cost-effectiveness analysis of routine immunization and supplementary immunization activity for measles in a health district of Benin
© Kaucley and Levy. 2015
Received: 11 December 2014
Accepted: 10 August 2015
Published: 20 August 2015
This study was carried out at district level to describe the cost structure and measure the effectiveness of delivering supplementary immunization activity (SIA) and routine immunization (RI) for measles in Benin, a country heavily affected by this disease.
This cost-effectiveness study was cross sectional and considered 1-year time horizon. RI consists to vaccinate an annual cohort of children aged 0–1 year old and SIA consists to provide a second dose of measles vaccine to children aged 0–5 years old in order to reach both those who did not seroconvert and who were not vaccinated through RI. Ingredients approach to costing was used. Effectiveness indicators included measles vaccine doses used, vaccinated children, measles cases averted and disability adjusted life years averted. Data were collected from all the 18 health care centers of the health district of Natitingou for the year 2011. In the analysis, the coverage was 89 % for RI and 104 % for SIA.
SIA total cost was higher than RI total cost (15,796,560 FCFA versus 9,851,938 FCFA). Personnel and vaccines were the most important cost components for the two strategies. Fuel for cold chain took a non-negligible part of RI total cost (4.03 %) because 83 % of refrigerators were working with kerosene. Cost structures were disproportionate as social mobilization and trainings were not financed during RI contrarily to SIA. In comparison with no intervention, the two strategies combined permitted to avoid 12,671 measles cases or 19,023 DALYs. The benefit of SIA was 5601 measles cases averted and 6955 additional DALYs averted. Cost per vaccinated child for SIA (442 FCFA) was lower than for RI (1242 FCFA), in line with previous data from the literature. Cost per DALY averted was 2271 FCFA (4.73 USD) for SIA and 769 FCFA (1.60 USD) for RI. Analysis showed that low vaccine efficacy decreased the cost-effectiveness ratios for the two strategies. SIA was more cost-effective when the proportion of previously unvaccinated children was higher. For the two strategies, costs per DALY were more likely to vary with measles case fatality ratio.
SIA is costlier than RI. Both SIA and RI for measles are cost-effective interventions to improve health in Benin compared to no vaccination. Policy makers could make RI more efficient if sufficient funds were allocated to communications activities and to staff motivation (trainings, salaries).
KeywordsMeasles Efficiency Supplementary immunization activity Routine immunization Benin
Measles is one of the most serious infectious human diseases as it can cause severe illness, lifelong complications and death. WHO estimated 45 million measles cases and 1.1 million measles related deaths occurring each year in developing countries . Benin is one of the 47 measles high burden countries in the world . To meet measles mortality and morbidity reduction goals, WHO recommended four strategies: (1) strengthening routine immunization to achieve and sustain high coverage, (2) providing a second opportunity for measles immunization, (3) conducting epidemiologic surveillance with high laboratory confirmation of cases and outbreaks and (4) insuring that improved case management is implemented.
Benin is a small country of West Africa (112,622 Km2; 7,862,944 inhabitants) . It is a low income country divided in 33 health districts. The health district of Natitingou is located in the north east region of Benin. It is a mountainous region. It covers an area of 3760 Km2 with 222,785 inhabitants estimated in 2011 (projection from 2002 national census); most of them are farmers . There are 18 health facilities that provide immunization services.
The first dose of measles containing vaccine (MCV) is given in Benin to children at 9 months through Routine Immunization program (RI). The second opportunity for measles immunization is provided through Supplementary Immunization Activities (SIAs). These SIAs are follow-up campaigns conducted every 3 years since 2001 and targeting children aged 0–59 months. The second opportunity for measles vaccination aims at reaching children who were not vaccinated through RI and to protect children who did not seroconvert with the first dose. By doing so, the population could reach the 95 % population immunity threshold (herd immunity) necessary to stop measles virus circulation. By organizing SIAs campaigns, Benin saw a dramatic fall of measles reported cases with 334 measles cases reported in the first semester of the year 2011 while 5531 cases where annually reported on average during the decade 1991–2000 . RI consists in providing all vaccinations listed in a country immunization program schedule. Services are delivered on an ongoing basis from permanent locations throughout the year. RI usually targets children under 1 year of age. In Benin, the following vaccines are administrated through RI to children under 1 year and to pregnant women: BCG, Pentavalent (DTP-Hep-Hib), OPV, MCV, PCV13, YFV and TT. SIAs are provided from multiple permanent and temporary locations. These campaigns usually have a short duration (1 week) and target children under 5 or 15. RI target population of children aged 0–12 months was estimated to 8911 children and SIA target population was estimated to 34,131 children aged 0–59 months, both for the year 2011. During this year, 7933 children under 1 year old were reached through RI corresponding to a coverage of 89 %. SIA permitted to vaccinate 35,564 children aged 0–59 months corresponding to a coverage of 104 %. A coverage rate of >100 % is commonly observed during SIAs in Benin, usually related to an inaccurate estimation of the target population because the number of eligible children came from not up-to-date national census data.
In a context of global economic crisis and resources scarcity, efficiency of measles immunization strategies needs to be taken into account in African health districts heavily affected by this disease. The operational level needs to know the economic value of their activities as this could help them to get more results at a lesser or equivalent costs. Ignorance of measles immunization costs, neglect of these costs, ignorance of the relative weight of cost components and lack of knowledge of the financial needs cause difficulties in planning, resources mobilization and resources allocation. Nothing is known about the efficiency of SIA and RI for measles in Benin. To fill this gap, this work was initiated by the health district of Natitingou using primary data from routine immunization and measles mass campaign for the year 2011.
The first objective of this paper was to describe cost structure of measles immunization strategies (RI and SIA) in a rural health district. Secondary, this study aimed at measuring the benefits of these strategies on population health. Finally, we assessed the efficiency of each strategy and we compared the cost-effectiveness ratios with a ‘no vaccination’ strategy. Effectiveness indicators took into account not only the immediate results of immunization (vaccine doses used, vaccinated children) but also the impact on final health outcomes (measles cases averted, disability adjusted life years averted). This work will help immunization services providers at health facility level to streamline measles immunization practices for a greater efficiency. The results could also provide guidance to policy makers in Benin for resources allocation.
This study was a cross-sectional cost-effectiveness analysis of delivering measles RI and SIA for the year 2011 in the health district of Natitingou. Data were collected retrospectively and the analysis has only considered one-year time horizon. All the 18 health care centers delivering immunization services were included. Data were analyzed by Microsoft Excel software.
RI is a component of the minimum package of activities provided in health facilities in Benin. RI services were provided in the 18 health facilities through two strategies: fixed and outreach strategy. Fixed strategy was planned for children living within less than 5 km from the health center and outreach strategy was planned for children living beyond 5 km from the facility. Health workers planned two fixed strategies sessions and 1 outreach strategy session per week. All health care centers had the same configuration: one dispensary and one maternity ward. Staff consisted of 4 persons: a nurse, a midwife and two caregivers. All staffs were equitably involved in immunization activities. Vaccines were supplied monthly by the district team from the regional storehouse to three secondary storehouses of the district. Health workers were responsible for transporting vaccines from the district storehouses to their respective health facilities by motorcycle. Health facilities were equipped with cold chain materials (refrigerators, cold boxes, vaccines carriers) and motorcycles. Data on the number of vaccinated children were collected on tally sheets at each immunization session. A synthesis was made at the end of the month by the head of the health center before transmission to district team.
The Ministry of Health planned SIA for measles to vaccinate children unreached through RI and to enhance immunity of children remained susceptible despite the first dose of vaccine received. A micro planning was done at district level taking into account human, logistical and financial needs. The strategy adopted was vaccination at fixed locations to which parents should bring children. A total of 29 vaccination posts were set up. Vaccination team at a station consisted of 3 persons (2 health workers and 1 volunteer) and should vaccinate at least 250 children per day. Supervision of vaccination teams was ensured by 6 supervisors who should supervise each 6 teams per day. Supervisors and vaccinators had been trained during a 1-day training session. Communication activities were strengthened with involvement of town criers.
Costs taken into account included recurrent and capital costs. Both economic and financial costs were considered. Some costs were specific to measles immunization and others were shared with others activities. Data for SIA specific operational costs came from the campaign financial reports and micro planning tools. Shared costs for measles RI activities were supposed to represent 9 % of RI delivery total costs; as measles vaccine was one of the 11 antigens administrated in Benin RI schedule. RI recurrent costs were analyzed using ingredients approach to costing. Data on vaccines used, consumables and management tools used were empirically obtained at health facilities level from vaccine usage reports, tally sheets, vaccine management databases. Costs for personnel, transport, supervision, trainings, fuel for cold chain, electricity and maintenance were obtained from interviews, questionnaires, direct surface measurement of buildings and exploitation of documents (administrative and financial reports, log books), both at health facilities and district administration level. Costs were expressed in local currency (FCFA) and in USD, using a fixed exchange rate of 480 FCFA for 1 USD (2011 average exchange rate from http://oanda.com).
Vaccines costs were calculated by multiplying the cost per dose of MCV by the number of doses used. MCV dose unit price was 0.24 USD, derived from National EPI vaccine’s purchase orders.
Consumables included syringes (auto disable and dilution), safety boxes and cotton. Cost per unit of syringes and safety boxes were derived from WHO’s Pre Qualify Standard (PQS) devices catalogue . The amount of medical accessories used was estimated on the basis of immunization management report. The same method was used to estimate the cost of management tools (data collection spreadsheets, registers).
Personnel costs were defined by wages and allowances paid to the staff involved in immunization activities. They were calculated by exploitation of staff payment vouchers and other documents considering the estimated proportion of time spent for immunization activities. Staff devoted 2 days per week to fixed strategy sessions and 1 day per week to outreach strategy sessions. A fixed strategy session took 4 h corresponding to half of a daily working time. An outreach strategy session took all the daily working time, as vaccination teams had to travel more than 5 km before reaching the village were children should be vaccinated. Roads in Natitingou were bad and such a distance could take one to 2 h travelling by motorcycle.
Transport was related to expenditures for vaccine supply and transportation fees for outreach strategies. These costs were obtained multiplying the distance covered by the average fuel consumption of the vehicle used and by the unit price of a liter of fuel. From exploitation of vehicle user’s manuals, average fuel consumption considered was 16 L/100 km for cars and 2 L/100 km for motorcycles. The unit price of a liter of fuel was 625 FCFA for the year 2011 in the health district of Natitingou.
Maintenance included costs for cold chain, cars and motorcycles reparation and periodic maintenance. For cars and motorcycles, this shared cost was estimated applying the proportion of kilometers devoted to immunization activities. Log books available in cars allowed to estimate kilometers covered. For motorcycles, distances covered were estimated from interviews with staff conducting immunization activities.
Supervision included all costs related to supportive supervision (per diems, fuel, reproducing management tools). Data for this cost component came from exploitation of district administrative and financial reports.
Trainings corresponded to total expenditures for trainings organized for SIA or RI (venue hiring charges, training materials, per diems). No training was organized as part of RI. Data for SIA came from exploitation of the campaign financial reports available at district administration level.
Social mobilization was related to cost of communication activities (advocacy meetings, banners, news release). No expense was performed for social mobilization in RI. Data for SIA came from exploitation of the campaign financial reports available at district administration level.
Fuel for cold chain corresponded to total cost of kerosene used in health facilities where cold chain materials were working with kerosene. There were 18 refrigerators and 3 freezers used for immunization activities in the health district. The 15 kerosene-functioning refrigerators were all of the same type (RCW50 EK) and consumed on average 35 L of kerosene per month. The unit price of a liter of kerosene was 700 FCFA for the year 2011 in the health district of Natitingou.
Electricity was related to the shared cost of electricity for the 3 health care centers where cold chain materials were working with electricity. This cost component was calculated multiplying the kilowatt-hours (kWh) consumption of the cold chain material used by the unit price of a kWh fixed by the national electricity company. Energy consumption of cold chain equipment were derived from WHO’s PQS devices catalogue : 2.35 kWh per 24 h for freezers and 0.61 kWh per 24 h for refrigerators. Electricity Company pricing was 125 FCFA per kWh.
Using linear amortization method, capital costs for buildings, motorcycles, cars and cold chain materials were estimated by dividing their respective cost by the useful life time. In the case of SIA, this was later divided by 0.019 (7 days of campaign over 365 days of the year). The result obtained was later multiplied first by the proportion of use for immunization activities and secondary by the estimated proportion for measles immunization. Both time and space were considered for buildings (number of days used a week and proportion of surface used). The share of kilometer attributable to immunization activities was considered for cars and motorcycles. Useful life time considered was 50 years for buildings, 10 years for refrigerators, freezers, cold boxes and vaccine carriers, 5 years for cars and 3 years motorcycles following the amortization plan of the health district.
Four effectiveness indicators were estimated: MCV doses used and vaccinated children relate to productive efficiency while the number of measles cases averted and disability adjusted life years averted refer to allocative efficiency. The primary effectiveness indicator selected was disability adjusted life years (DALYs) averted. It is a widely used indicator that allows easy comparison with a ‘no vaccination’ strategy and with others public health interventions.
MCV doses used represents the amount of vaccines used per strategy. This was empirically obtained from district vaccine management tools (vaccine usage reports, tally sheets, vaccine management databases). Vaccinated children corresponds to the total of targeted children that received a shot, having in mind that for RI the target population is defined by children under 1 year whereas the target population for SIA extends to children under 5 years. Measles cases averted depend on both the number of vaccinated persons and vaccine efficacy. MCV efficacy after a single dose depends on the age of vaccination: 85 % of children seroconvert after receiving a shot when vaccination is done at the age of 9–11 months whereas after 1 year of age, vaccine efficacy raises to 95 % . To facilitate comparison of final outcomes with a ‘no vaccination’, we estimated DALYs averted. DALY’s calculation is explained more in depth in the following section.
Disability adjusted life years
Immunization with MCV enables to increase the target population well-being experienced by averting deaths, and by averting sufferings due to measles. The concept of disability adjusted life years, as routinely used by WHO, is a useful measure of the burden of measles on population of interest. DALYs for a specific cause are calculated as the sum of the years of life lost due to premature death (YLL) from that cause and the years of healthy life lost as a result of disability (YLD) for incident cases of the health condition as follows: DALY = YLL + YLD [8, 9].
The formula for YLD calculation is: YLD = ∑ I × DW × [1 − exp(−rL)]/r, where I is the number of incident cases; DW is the disability weight; L is the average duration of disability until remission or death and r is the discount rate. The incident cases were episodes of measles case and the classic complications associated with measles (diarrhea, pneumonia, otitis media, corneal scarring, encephalitis and subacute sclerosing pan encephalitis). Diarrhea is reported in 8 % of measles cases . Six per cent of measles cases are complicated by pneumonia and corneal scarring . Otitis media occurs in about 7 % of cases . About 1 child in every 1000 who get measles will develop encephalitis . Subacute sclerosing pan encephalitis (SSE) is a rare degenerative central nervous system disease that occurs on average in 8 per 1,000,000 reported measles cases . Duration and disease disability weights relevant for incident cases were extracted from the Global Burden of Diseases study : measles episode (2 weeks, 0.152); diarrhea (1 week, 0.105); pneumonia (2 weeks, 0.373); otitis media (2 years, 0.023); corneal scarring (34.8 years, 0.277); encephalitis (34.8 years, 0.616); SSE (36.7 years, 0.666).
Base-case and alternative values of parameters used in the sensitivity analysis
Base case values
Vaccines cost (MCV unit dose price)
Supervision cost: Increasing supervision frequency
4 supervisions per annum
6 supervisions per annum
Personnel cost : increasing total personnel cost
Inclusion of communication costs
Exclusion of capital costs
Supplementary immunization activity
Vaccines cost (MCV unit dose price)
Exclusion of capital costs
Proportion of unvaccinated children (‘zero-dose’)
Costs by component for measles RI and SIA in the health district of Natitingou in 2011
Overall (RI + SIA)
Fuel for cold chain
Cars and motorcycles
Cold chain materials
Vaccine doses used, vaccinated children and wasted doses of measles RI and SIA in the health district of Natitingou in 2011
Overall (RI + SIA)
Children receiving first dose
Children receiving second dose
Vaccine doses used
Measles cases averted, measles deaths averted and DALYs averted for RI and SIA in the health district of Natitingou in 2011
Overall (RI + SIA)
Measles cases averted
Measles deaths averted
Average costs for measles RI and SIA in the health district of Natitingou in 2011
Overall (SIA + RI)
Cost per dose used
Cost per vaccinated child
Cost per measles case averted
Cost per measles death averted
Cost per DALY averted
Results from the present study are in line with previous studies on the fact that SIAs are costlier than RI [17, 18]. In this study, total cost of SIA for measles was 15,796,560 FCFA (32,909.50 USD) versus 9,851,938 FCFA (20,524.87 USD) for RI. Personnel and vaccines costs took the large part of the two strategies total cost (respectively 36.54 and 11.35 % for RI; 30.07 and 29.93 % for SIA). ‘Personnel’ is usually cited among the highest cost components in immunization costs analysis [18–21]. In the context of Natitingou, close to that described in a Cameroonian health district , medical staff was poorly paid. The highest wage for a health professional involved in immunization activities was 100,000 FCFA (208 USD) per month corresponding to 7 USD per day. During SIA, medical staff was paid 7000 FCFA (15 USD) per day. In addition, during SIA, community health workers were recruited and paid 5000 FCFA (10 USD) per day to support health professionals whereas they did not receive any incentives for their involvement in RI activities. This explains why personnel costs of SIA were higher than that for RI. In addition, savings were made in RI because social mobilization and staff trainings were not financed. A particular attention should be paid to the part took by fuel for cold chain functioning. With 4.03 % of RI total cost, it represents the third cost component behind personnel and vaccines. In fact, 83 % of refrigerators used for immunization activities were working with kerosene. Given, following WHO recommendations, vaccines needs to be permanently stored at health facility level at a temperature between +2 and +8 °C, kerosene supply was a requisite and incompressible expenditure. The use of cold chain material working with solar energy in settings without electricity as alternative should be explored by policy makers in Benin. Savings could be possible with this material, as it requires no fuel for functioning and there is no need of regular spare parts replacement (burners, wicks, glasses) unlike kerosene-functioning refrigerators.
RI permitted to vaccinate 89 % of the target population, under the 95 % recommended by the national immunization program. In contrast, SIA reached 104 % of the target in short time of period (7 days). It permitted to vaccinate 35,564 under-five children and the benefit was 5601 supplementary measles cases averted converted to 6955 additional DALYs averted. SIA permitted to save 185 children who should have probably died from measles despite RI. This strength of SIA to reach usually unreachable children through RI make it an intervention that contributes to equity in health and a preferable platform to deliver second dose of MCV in settings where RI is not effective enough [16, 22, 23]. Fewer vaccines were lost during SIA compared to RI (3 % of vaccine wastage rate versus 15 %). It could be the direct consequence of non-financing social mobilization activities in RI. Yet, social mobilization contributes to encourage and motivate the public to fully participate in immunization activities. Thus, it helps to gather a lot of targets at vaccination location and then lowers vaccine wastage by applying open vial policy for lyophilized vaccines (MCV should be used within 6 h after the vial being opened).
In accordance with estimations in Niger (190 FCFA for SIA and 573 FCFA for RI)  and Uganda (0.58 USD for SIA and 1 USD for RI) , the cost per vaccinated child in this study was lower for SIA than RI (431 FCFA versus 1051 FCFA). SIA cost per vaccinated child was similar to findings for poliomyelitis mass campaigns conducted in West Africa [18, 20, 25]. SIA had better productive efficiency indicators because more children were reached and fewer vaccines were wasted. To improve RI productive efficiency, more political and community implication should be conjugated to higher health professionals’ motivation, media and local leaders’ mobilization. Unfortunately, as shown by cost structures’ analysis, financing communication activities and staff trainings was neglected by the health district.
Whatever is the strategy used, measles immunization is known to be a cost-effective intervention [23, 24]. In our study, in comparison with no intervention, cost per DALY averted was 2271 FCFA (4.73 USD) for SIA; 769 FCFA (1.60 USD) for RI and 1297 FCFA (3 USD) for both strategies combined. These cost-effectiveness ratios are quite under those of interventions known to be the most efficient interventions in Afro-E, a WHO defined region comprising countries in sub-Sahara Africa with high child mortality . Analysis showed that cost per DALY averted never exceeded 16 USD whatever the possible extreme variations of chosen parameters were. The cost per DALY was higher, but still under 16 USD, when measles CFR was very low (0.00 %). But it seems to be an extreme scenario as it is far to be the case in the health district of Natitingou and most of health districts of Benin, where malnutrition, vitamin A deficiency, poor cases management and intercurrent infections like malaria and HIV contribute to high measles fatality rate. A twofold increase of personnel costs did not impact negatively the cost/DALY for RI neither was inclusion of trainings and communication costs in the base-case analysis. Therefore, there is no need to make savings on these cost components. In contrary, allocating funds to this cost components would increase the attention of health professionals to RI activities and contribute indirectly to a greater efficiency. SIA was more cost-effective when the proportion of previously unvaccinated was higher. In other words, more RI failed to vaccinate targeted children, more SIA became a cost-effective intervention.
Implications for decision-making
Since non-financing communication activities is prejudicial to RI effectiveness, the health district managers should plan and finance annually social mobilization activities for RI. District administration needs also to organize short-term trainings for health professionals as it will strengthen their capacity in conducting vaccination activities and it can increase their motivation. There is a need for immunization policy makers in Benin to think about adopting low-cost cold chain materials in terms of energy consumption. As discussed above, there is possibility to make savings with solar system materials. Importantly, vaccine efficacy should be maintained at its highest level to improve the efficiency of both RI and SIA. In other words, vaccine should be properly stored and transported respecting the recommended temperature at all steps of the supply chain. Measles vaccine is very sensitive to heat and rapidly lost its efficacy when exposed to temperature over +8 °C for a long time. Usually, breaks in cold chain occurs at health facility level or at vaccination delivery point where health professionals fail to keep the vaccine in the right temperature because of poor cold chain materials maintenance.
Health districts in Benin are organized in the same way. Staffing and resources for immunization activities are allocated in the same manner. Moreover, vaccination strategies are the same and measles epidemiologic profile is not different from one health district to another. Accordingly, results from this study and the recommendations derived from it could be transposed to any other health district of the country. In the same way, the results could be useful to immunization policy makers in other sub-Saharan African countries with similar measles disease burden and with the same health system organization.
The use of primary data empirically obtained from the field is a strength of this study. Moreover, this study estimated the costs of delivering one single antigen among those administrated through RI, an unusual case in the literature. However, the study has some limitations. Transport and maintenance costs for RI may have been inaccurately estimated because distances covered by motorcycles were based on health professionals’ statements. Measles mortality may have been inaccurately estimated because we did not used measles case fatality rate in Benin due to lack of accurate data. Measles case fatality rates used came from published data for countries with a similar epidemiological profile to Benin regarding measles. Vaccine coverage should be interpreted carefully because denominators used (targeted children) came from an old national census. There are shortcomings of relying on old GBD data although GBD-2010 data were available . The comprehensive sensitivity analysis conducted with large ranges of values helped to address these uncertainties (Additional file 1).
First, SIA for measles cost more than RI for measles. However, costs structure of the two strategies was disproportionate.
Second, SIA and RI for measles are cost-effective interventions to improve health in Benin compared to no vaccination. The proportion of ‘zero-dose’ children affects significantly SIA cost-effectiveness. A twofold increase of personnel costs or inclusion of trainings and communication costs in the base-case analysis do not impact negatively the cost/DALY for RI.
Benin have set measles elimination goal for the year 2020. It is possible to meet this goal if sufficient funds are mobilized and efficiency is taken into account. This work address the question of the costs, the effectiveness and the efficiency of delivering two dose of measles vaccination combining RI and SIA at district level in Benin. Future studies should be focused on measles immunization activities financing to identify how to ensure sustainable funding.
Bacille de Calmette et Guérin
cost effectiveness ratio
case fatality ratio
disability adjusted life year
diphteria, tetanus, pertussis, hepatitis B and Heamophilus Influenza type B vaccine
Expended Program on Immunization
Franc de la Communauté Française d’Afrique
human immunodeficiency virus
measles containing vaccine
oral polio vaccine
Pre Qualify Standard
supplementary immunization activity
subacute sclerosing pan encephalitis
United States Dollar
World Health Organization
yellow fever vaccine
years of life disability
years of life lost
LK conceived the study, performed the initial study design, the data collection and analysis and the initial write up. PL critiqued the work and did the final corrections of the manuscript. Both authors read and approved the final manuscript.
LK is a District Medical Officer with an MSc in Economics and Management of Public Health in Developing Countries (EPIVAC training). Since 2007, his is working in the health district of Natitingou in Benin. PL has a PhD and is lecturer in Economics at Paris Dauphine University (France).
This work received a support from the Priority Solidarity Fund of French Ministry of Foreign Affairs through the Agence de Médecine Préventive (AMP). Valuable contributions were provided by Marjorie Nicol, Delphine Adénot and Aristide Aplogan on an earlier version of this paper. Helpful comments on measuring costs were obtained from Franck Bété, Marcel Kounnou and Jean-Bernard Le Gargasson. Thanks also to Maïmouna Sacca Bawa and Karl Dossou for their participation in data’s collection. While the support and contribution of the mentioned institutions and persons is appreciated, the authors are fully responsible for the content and view in this paper.
Compliance with ethical guidelines
Competing interests The authors declare that they have no competing interest.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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