Cost-of-illness of cholera to households and health facilities in rural Malawi

Abstract

Cholera remains an important public health problem in many low- and middle-income countries. Vaccination has been recommended as a possible intervention for the prevention and control of cholera. Evidence, especially data on disease burden, cost-of-illness, delivery costs and cost-effectiveness to support a wider use of vaccine is still weak. This study aims at estimating the cost-of-illness of cholera to households and health facilities in Machinga and Zomba Districts, Malawi. A cross-sectional study using retrospectively collected cost data was undertaken in this investigation. One hundred patients were purposefully selected for the assessment of the household cost-of-illness and four cholera treatment centres and one health facility were selected for the assessment conducted in health facilities. Data collected for the assessment in households included direct and indirect costs borne by cholera patients and their families while only direct costs were considered for the assessment conducted in health facilities. Whenever possible, descriptive and regression analysis were used to assess difference in mean costs between groups of patients. The average costs to patients’ households and health facilities for treating an episode of cholera amounted to US$65.6 and US$59.7 in 2016 for households and health facilities, respectively equivalent to international dollars (I$) 249.9 and 227.5 the same year. Costs incurred in treating a cholera episode were proportional to duration of hospital stay. Moreover, 52% of households used coping strategies to compensate for direct and indirect costs imposed by the disease. Both households and health facilities could avert significant treatment expenditures through a broader use of pre-emptive cholera vaccination. These findings have direct policy implications regarding priority investments for the prevention and control of cholera.

Determinants of healthcare seeking and out-of-pocket expenditures in a “free” healthcare system: evidence from rural Malawi

“…In particular, prior evidence suggests that due to funding shortages and inefficiencies in health service delivery, Malawians are still exposed to considerable out-ofpocket expenditures (OOPE) when seeking care, even in public facilities [19][20][21][22]. OOPE deter health service utilization, especially among the very poor, given the prospect of having to pay substantial amounts to receive care [14,16,20,22,23], while also imposing a considerable financial burden on those who seek treatment [22,24]. Moreover, additional evidence from Malawi indicates that current levels of OOPE often lead to catastrophic expenditure [25,26] resulting in considerable impoverishment rates [22,27].…”

“…This substantial literature on OOPE suffers from two weaknesses, however: an exclusive focus on certain populations [20,22] and/or certain conditions [20][21][22][23][24], and the application of statistical methods that do not account for the peculiarity of modelling health expenditure data. More specifically, modelling OOPE needs to account for the selection bias that emerges as a consequence of the fact that a positive expenditure can only be observed for those who decide to seek care in the first place [28][29][30][31].…”

Food insecurity and self-reported cholera in Haitian households: An analysis of the 2012 Demographic and Health Survey

“…On the other hand, an episode of cholera in a household may also increase subsequent risk of food insecurity, in part as a result of the direct and indirect costs of illness and healthcare utilization. Despite the typically short duration of illness, cholera has been found to have substantial household costs in both the epidemic and endemic setting [27–29].…”

“…As in other health-related settings, it is plausible that food insecurity may increase risk of cholera, or the severity of cholera, through multiple pathways–including malnutrition, by impairing immune or gut barrier function [25, 26]; behavioral pressures, by increasing the likelihood of drinking unsafe water or eating unsafe food; by impacting mental health; or through other mechanisms. An episode of cholera has also been found to cause significant financial strain on a household [27–29], and may increase the downstream risk of food insecurity.…”

Evaluating the costs of cholera illness and cost-effectiveness of a single dose oral vaccination campaign in Lusaka, Zambia

“…While some studies report vaccine delivery costs disaggregated by activities, several others disaggregate costs by inputs such as vaccine purchase, shipment, insurance, cold chain management, personnel incentives, training, transportation, social mobilization and local delivery. The delivery costs of OCVs via mass campaigns differ by country and even within the same country and the same setting [20,41–45]. The variations in cost estimates could considerably impact the scale up of OCV campaigns to prevent cholera outbreaks, hence the need to ascertain associated costs for individual settings.…”