The burden of pediatric diarrhea: a cross-sectional study of incurred costs and perceptions of cost among Bolivian families

BMC Public Health The burden of pediatric diarrhea: a cross-sectional study of incurred costs and perceptions of cost among Bolivian families Rachel M Burke 1 Paulina A Rebolledo 0 1 Sally R Embrey 1 Laura Danielle Wagner 1 Carter L Cowden 1 Fiona M Kelly 1 Emily R Smith 1 Volga Iiguez 2 Juan S Leon 1 0 Division of Infectious Diseases, Emory University School of Medicine , Atlanta, GA , USA 1 Hubert Department of Global Health, Emory University, Rollins School of Public Health , Mailstop 1518-002-7BB, 1518 Clifton Road NE, Claudia N Rollins Bldg. 6050, Atlanta, GA 30322 , USA 2 Instituto de Biologia Molecular y Biotecnologia, Universidad Mayor de San Andres , La Paz , Bolivia Background: Worldwide, acute gastroenteritis represents an enormous public health threat to children under five years of age, causing one billion episodes and 1.9 to 3.2 million deaths per year. In Bolivia, which has one of the lower GDPs in South America, an estimated 15% of under-five deaths are caused by diarrhea. Bolivian caregiver expenses related to diarrhea are believed to be minimal, as citizens benefit from universal health insurance for children under five. The goals of this report were to describe total incurred costs and cost burden associated with caregivers seeking treatment for pediatric gastroenteritis, and to quantify relationships among costs, cost burden, treatment setting, and perceptions of costs. Methods: From 2007 to 2009, researchers interviewed caregivers (n=1,107) of pediatric patients (<5 years of age) seeking treatment for diarrhea in sentinel hospitals participating in Bolivia's diarrheal surveillance program across three main geographic regions. Data collected included demographics, clinical symptoms, direct costs (e.g. medication, consult fees) and indirect costs (e.g. lost wages). Results: Patient populations were similar across cities in terms of gender, duration of illness, and age, but familial income varied significantly (p<0.05) when stratified on appointment type. Direct, indirect, and total costs to families were significantly higher for inpatients as compared to outpatients of urban (p<0.001) and rural (p<0.05) residence. Consult fees and indirect costs made up a large proportion of total costs. Forty-five percent of patients' families paid 1% of their annual household income for this single diarrheal episode. The perception that cost was affecting family finances was more frequent among those with higher actual cost burden. Conclusions: This study demonstrated that indirect costs due to acute pediatric diarrhea were a large component of total incurred familial costs. Additionally, familial costs associated with a single diarrheal episode affected the actual and perceived financial situation of a large number of caregivers. These data serve as a baseline for societal diarrheal costs before and immediately following the implementation of the rotavirus vaccine and highlight the serious economic importance of a diarrheal episode to Bolivian caregivers. Societal costs; Economic burden; Diarrhea; Pediatrics; Health economics - Background In the developing world, acute gastroenteritis presents an enormous public health threat to children under five years of age, with an incidence of one billion episodes and 1.9 to 3.2 million deaths per year [1]. Pediatric diarrhea incidence has been shown to be inversely related to socioeconomic status, with children in poverty much more vulnerable to acute diarrheal episodes [2]. Bolivia (per capita GDP of $4,700 [3]) is one of the lowest-ranking countries in the Americas region in terms of the Human Development Index (taking into account measures of health, education, and income) according to the United Nations Human Development Report [4] and suffers from high rates of diarrhearelated infant mortality. Out of every 1,000 live births, 54 children die before the age of five, with an estimated 15% of these deaths attributable to diarrheal illness [5]. The costs of these diarrheal episodes can have severe financial consequences in a setting where 15.6% of the population lives on less than $1.25 per day (2008 estimate) [5]. Acute gastroenteritis presents an economic burden to both healthcare systems and patient families [6-8]. Although there is a universal insurance program that benefits Bolivian children under the age of five, not all medications or diagnostic tests are covered. Further, if medications are out of stock at the hospital, the family may have to pay out-of-pocket at a non-hospital pharmacy. Thus, Bolivian patient families may still face substantial out-of-pocket expenses and productivity losses associated with pediatric gastroenteritis-related hospitalizations and outpatient visits. Direct (out-of-pocket) expenditures include all costs paid directly by the family, encompassing medical costs (such as medications, tests, or consult fees) as well as non-medical costs (such as transportation or extra diapers) [9]. Indirect costs are defined as the value of the time lost by a caregiver and their spouse from income-generating activities during the acute episode of diarrhea [10]. Incurred familial costs due to pediatric diarrheal episodes have been quantified in several different studies. In Kenya (GDP per capita US$1,800 [11]) and Kyrgyzstan (GDP per capita US$2,400 [11]), two countries with a relatively similar economic situation to Bolivia, the estimated average per-episode total familial costs (direct and indirect) ranged from US$19.86 (Kenya [12]) to US$47.90 (Kyrgyzstan [13]) for hospitalized children. In Vietnam (GDP per capita US$3,400 [14]) direct costs alone were found to amount to US$31.83 per case in one study [6]. Findings in somewhat wealthier countries included total incurred costs of US$215.88 [15] for hospitalized children in Mexico (GDP per capita US$14,800 [16]) and direct costs of US$12.89 [17] per case in Brazil (GDP per capita US$11,900 [18]). In a low-resource setting like Bolivia, incurred costs may sometimes represent a large proportion of a familys overall economy. This ratio, the total incurred costs for a single diarrheal episode to the annual family income, can be termed the cost burden [19]. While absolute costs associated with pediatric diarrhea have been quantified in various settings, few studies specifically examine the relative measure of cost burden as it relates to pediatric gastroenteritis. A review of the literature identified only two studies in low- and medium-income countries (LMIC) that addressed cost burden using a similar methodology as the present study. In a study set in India (GDP per capita US$3,700), Mendelssohn et al. found that direct costs incurred per diarrheal episode ranged from 2.2% to 5.8% of the households annual income [20]. In the aforementioned study in Kyrgyzstan, Flem et al. found that family-incurred costs (including direct and indirect) totaled 2.5% of the mean annual household income [13]. Several studies have shown that incurred familial costs c (...truncated)