The economic burden of pediatric gastroenteritis to Bolivian families: a cross-sectional study of correlates of catastrophic cost and overall cost burden

Worldwide, acute gastroenteritis causes substantial morbidity and mortality in children under five years of age, with 1.4 billion episodes and 1.7 to 3 million deaths each year [1]. Diarrhea accounts for 21% of all child deaths in low and middle income countries (LMIC) [2]. Gastroenteritis presents an economic burden to both healthcare systems and patient families [3‐5]. Though various studies have attempted to quantify the costs associated with pediatric diarrhea from the state perspective [3‐12], fewer studies have specifically examined the perspective of the patient’s family [8‐10, 13‐16], despite the burden that these costs may represent. Though health insurance may cover some costs associated with pediatric diarrhea, patient families often still incur substantial “direct” (i.e., out-of-pocket) and “indirect” (i.e., lost income) expenses [16‐19]. Studies have estimated average total familial costs (direct and indirect) per episode of hospitalized pediatric diarrhea ranging from US$19.86 in Kenya (2007USD [6]) to US$215.88 in Mexico (2003USD [11]). Direct costs, alone, for a pediatric diarrhea episode have ranged from US$12.89 per case in Brazil (2007USD [13]) to US$31.83 per case in Vietnam (2004USD [4]). In a low-resource setting, these costs can represent a large proportion of a family’s overall budget. In one study in India, direct costs incurred per diarrheal episode ranged 2.2 – 5.8% of the household’s annual income [14]. The ratio of total incurred costs for a single diarrheal episode as a percentage of annual family income, termed the “cost burden,” has been infrequently studied. Nonetheless, large cost burdens incurred from healthcare expenses can have a serious effect on a family’s overall current and future economic situation, especially for families already on the edge of poverty (reviewed in [20, 21]). Healthcare costs that cause poverty (e.g. by forcing a family to spend money needed for food or other basic necessities) are termed “catastrophic” [22]. There is little consensus in the literature as to the exact calculations and cut-offs that are most appropriate for defining catastrophic costs [23, 24]. Some advocate the use of a cut-off based on expenditures as a percentage of “capacity to pay” (non-subsistence spending) [22, 25, 26]. However, when detailed information on household expenditures is not available, the use of a cut-off based on cost burden may be useful. While a cost burden of 10% of annual income is often used to define “catastrophic cost” [24, 27], lower limits can also be catastrophic for poor households [21, 28]. For example, in a study of catastrophic healthcare costs in Thailand, a cost burden of 10% of monthly income was utilized, which is equivalent to approximately 1% of annual income [29].

Bolivia has one of the lower GDPs in South America (per-capita 2013 GDP US$5,500) [30] and has high rates of child mortality. As of 2012, for every 1,000 live births in Bolivia, 41 children die before age five, with an estimated 8% of these deaths from diarrhea [31]. The cumulative financial impact of these diarrheal episodes may be severe in this setting, where 30% of the population lives on under US$2 per day (2009 est.) [30]. Although Bolivia does have a health program (Seguro Universal Materno-Infantil, SUMI) that covers children under five, families must register to benefit from free care [32]. In addition, free treatment to registered families may not be enforced (e.g. oversight, intentionally), benefits are only available at public healthcare settings, and not all potential treatments are eligible for coverage. Further, if medications are out of stock at the treating facility, caregivers may need to purchase drugs from pharmacies where SUMI does not apply. Thus, Bolivian families may still incur substantial costs related to pediatric diarrhea.

The goal of this study was to characterize the financial effects and potential predictors of costs due to an episode of pediatric diarrhea on the caregivers of Bolivian children (under five) who sought treatment for diarrhea from 2007 through 2009, prior to full implementation of the vaccine against rotavirus (a major cause of pediatric diarrhea [33]) into the immunization schedule [34‐36].

This work was done in collaboration with, but independently from, the Rotavirus Surveillance Project of Bolivia.

The goals of this study were to quantify the financial impact of a single episode of pediatric diarrhea on families in Bolivia and to identify predictors of cost burden and catastrophic cost, for those seeking treatment in a hospital. The mean cost incurred for just one pediatric diarrhea episode was US$34, which could account for five to eight days of food and fuel (for cooking and heating) for an average Bolivian family with five members, depending on the family’s level of food security [39]. Nearly half the study population experienced a cost burden of over 1%, which, for a family with the median annual income of US$2,274, translates into US$22.74 spent on a single episode of diarrhea, or three to five days of food and fuel for the “average” family described above. This amount is nearly twice the average monthly expenditure on intra-city transportation for Bolivians of “moderate” poverty in 2000 [40]. In this study, cost burden increased, and the risk of catastrophic cost grew, for children who were hospitalized (versus outpatients), children whose parents had sought prior treatment for this episode of diarrhea, and children who had been sick for longer prior to the current visit. Lastly, we observed that children seen in Albina Patiño (a private hospital) showed a higher cost burden and were more likely to report a catastrophic cost, versus children seen elsewhere.

In our sample, indirect costs (lost wages) were a substantial burden on families. For families reporting lost wages, indirect costs represented an average of 62% of incurred costs for inpatients (41% for outpatients) and translated to 1.1% and 0.8% of annual income, respectively (equivalent to 3 – 4 days of income). While two studies of costs associated with pediatric diarrhea, in Canada and Britain, also found indirect costs to be important contributors to overall cost burden [18, 19], most studies from LMIC settings found indirect costs to be minimal, if present [8‐10, 14]. Only one study, in China, showed indirect costs to be an important component of cost burden [41]. While methodology was similar (most of the studies in LMIC settings also calculated indirect costs based on caregiver reports), the study populations may have been different from our Bolivian study population [16]. In particular, we hypothesize that our study found high indirect costs because many families earned income from both spouses (30%), instead of just one. We recommend that future economic studies and cost-effectiveness analyses of the societal costs of pediatric diarrhea include indirect costs.

As significant predictors of cost burden and catastrophic cost, we identified inpatient status, previous treatment, and number of days the child had been ill with diarrhea prior to the current visit. A higher cost burden for inpatients was consistent with other literature [14, 15, 41], and, in Bolivia, may also reflect the higher costs associated with hospitalization versus outpatient visits (e.g. additional medications, fees, lost wages) [7]. In most other ways, inpatients were similar to outpatients (although hospitalized patients were more likely to seek previous care, to report SUMI, and had slightly larger households). The higher cost burden and risk of catastrophic cost associated with previous treatment likely reflected costs associated with that treatment, including non-medical costs as well as medical costs which may or may not have been SUMI-eligible. We believe that the measure of number of days with diarrhea captures an element of illness severity both independently and as modified by complications. Children who are sick for a long time before their parents seek hospital treatment may develop illness of a greater severity, potentially causing higher treatment costs. Additionally, these children may come from families that are less equipped or inclined to seek hospital care; perhaps parents are more fearful of incurring costs, regardless of actual ability to pay. Data was not collected on the fear of incurring costs, but we found no significant association of number of days ill with diarrhea with income per capita or monthly household income. Although rural residence was associated with cost burden in the bivariate analysis, consistent with some other studies [16], the association was no longer significant once we controlled for other variables such as hospital type and treatment-seeking behavior. Overall, these results point to the importance of treatment-seeking behavior and illness severity to overall familial cost burden.

Though few studies address the specific impact of hospital type on familial-incurred cost, we found that patients at the private hospital (Albina Patiño) had a higher cost burden and were significantly more likely to incur a catastrophic cost. This is consistent with other research. For instance, one study of pediatric diarrhea in Vietnam found indirect costs to be significantly higher in a private urban clinic, versus public and rural settings [4]; another study of illness in Indian neonates found familial expenditure to be higher for private consultations versus public (government) physicians [42]. The higher costs we observed in the private hospital are also likely related to the fact that care in private facilities in Bolivia is not covered by SUMI, Bolivia’s public insurance program for children. SUMI provides free healthcare to children under five, but only after registration (reported by 85% of our study population with this data) and only in public facilities (attended by 62%). In our study, families at the private hospital also had significantly higher average costs for previous treatments, perhaps because previous treatments also weren’t SUMI-eligible, because they had more previous visits, or because they had some preference or willingness to spend more on their child’s health. Families may elect to pay for private consultations believing that the quality of care is better [43], or for other unexplored reasons. While SUMI status and hospital type were correlated, and non-SUMI families paid significantly more in hospital fees (consult costs) overall, non-medical direct expenditures were similar between SUMI and non-SUMI families, and both presented to private and public hospitals. Overall, these data indicate a need for further investigation into why Bolivian parents take their children to private instead of public facilities, and why SUMI-registered families still incur direct costs even at public hospitals.

Several strengths and limitations of the study should be noted. One strength was the representativeness of the study results to Bolivia given the wide breadth of sites, covering multiple regions and two types of healthcare settings (outpatient and inpatient). A second strength was the consistency of the significant results between our linear and logistic models. A third strength was the care and detail taken in the gathering of cost and income data. Cost data was reported as that which the caregiver paid, regardless of whether the cost was SUMI-eligible. A sensitivity analysis excluding diapers and food (which might have been purchased anyway) from direct non-medical costs led to similar significant model results, with the exception that the interaction term in the logistic model was non-significant, while the complications term was borderline significant and in the other direction. Household income was calculated based on direct report, and we have no reason to believe that participants inflated or underreported their income. One important limitation was missing information: not all potential predictors could be assessed, with one important covariate being SUMI status, given its high percentage of missingness and our inability to confidently impute this. Similarly, patients with missing income data were necessarily excluded from analysis. However, these patients were generally similar to included patients, though they were more likely to be inpatients, non-SUMI, and single-income households. A second limitation was that we had only one private facility in our sample, making it difficult to generalize conclusions about private versus public hospitals. The study was also limited in that it was a cross-sectional assessment of financial burden; cost burden as measured may or may not correlate to future financial difficulties.

In conclusion, we have shown that hospital type, treatment behavior, and appointment type were significant predictors of overall cost burden and catastrophic cost associated with pediatric diarrhea episodes in Bolivia. These costs can represent five to eight days of food for an average family, and even a cost burden of 1% can be important in a setting where the median expenditure on food and fuel amounts to over 60% of per capita daily expenditure, leaving little for other purposes [39]. We also demonstrated that indirect costs represented a substantial burden for most families. The total incurred costs of pediatric diarrhea, extrapolated to the national level, may have represented approximately US$3MM annually in societal burden during the time period prior to full implementation of the Rotarix® vaccine into the national immunization schedule [16]. This number is expected to be less in the current setting, where vaccine coverage reached ~80% as of 2011 [44].

Further research is needed in Bolivia to understand why parents are still incurring treatment costs despite accessing public hospitals (where care should be covered by SUMI), and why some elect private over public facilities. Future research should also assess the societal cost burden in the post-vaccine era in Bolivia, as this estimate of familial economic impact would be a useful way to assess the overall economic impact of the vaccine, particularly in a setting where health care costs can be difficult to estimate given subsidized care programs like SUMI. Overall, our analysis highlights the economic importance of pediatric diarrhea to Bolivian families and suggests areas of intervention to reduce cost burden and catastrophic cost associated with pediatric diarrhea.