Commentary: Pneumonia, Diarrhea, and Measles force Bangladeshi households to make difficult financial decisions when illnesses arise

By Dagna Constenla and Gatien de Broucker

The Decade of Vaccine Economics study continues to shed light on the importance of preventing common childhood illness

Few diseases have as much power to cause wide-ranging impact among the population as pneumonia, diarrhea, and measles. These three illnesses can cause long-term disability and can require a significant amount of care. In addition to the pain and the risk of death or disability, people experiencing these illnesses face economic consequences now rising like out-of-pocket expenditures.

To assess how severe these consequences are, the International Vaccine Access Center (IVAC) and International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) collected primary data on the costs of illness associated with pneumonia, diarrhea, and measles for Bangladesh,* for the fourth part of the Decade of Vaccine Economics study (DOVE IV).

Preliminary results show that over three-quarters of households used savings and up to one in two borrowed money to pay for pneumonia, diarrhea, and measles in children under five. Read more about the study below.


Photo taken by Mr. Md. Rabiul Hasan, icddr,b
From left to right: Dr. Arman Chowdhury, Dr. Sultan Md. Shamsuzzaman,Mr. Abu Momtaz Saaduddin Ahmed, Dr. Dagna Constenla at the October 2018 seminar “Facility assessment and cost of illness for selected vaccine-preventable diseases in Bangladesh”

Measuring the cost of illness for childhood diseases in Bangladesh

It’s critical that policy makers understand the full burden of childhood diseases, including the economic burden. We also need evidence to support ongoing investments in the vaccines targeting these diseases.

To share what we’ve learned through our DOVE IV research, icddr’b recently organized a seminar in Dhaka to brief key policy makers on the preliminary findings of this study.

At least 45 participants attended the October 2018 seminar, entitled “Facility assessment and cost of illness for selected vaccine-preventable diseases in Bangladesh,” including Bangladesh’s Director General of Health Services and WHO and UNICEF representatives. Among those presenting on our findings were Acting Director of Health Services Dr. Quamrun Nahar, icddr,b’s local principal investigator of the study Dr. Md. Jasim Uddin, icddr’b Associate Scientist Dr. Ziaul Islam and IVAC’s principal investigator of the study Dr. Dagna Constenla.

Photo taken by Mr. Md. Rabiul Hasan, icddr,b
D
r. Ziaul Islam (left) and Dr. Md. Jasim Uddin (right) at the October 2018 seminar “Facility assessment and cost of illness for selected vaccine-preventable diseases in Bangladesh”

Capturing multiple perspectives: Understanding expenses borne by both the healthcare system and caretakers

The study collected utilization, cost, and expenditure data for the 2017-18 fiscal year, using a micro-costing approach. Results provide new empirical evidence on the broader economic impact of pneumonia, diarrhea, and measles. Our team developed five different surveys to understand the expenses from the perspective of both the patients’ caretakers and the healthcare system. The healthcare system perspective encompasses costs collected in facilities from the public and private—both for-profit and not-for-profit—sectors, from rural and urban settings, and at every level of care. Our team collected out-of-pocket expenditure data from primary caregivers during the acute phase of illness with a follow-up of up to 10 days.

Our analysis of health expenditures showed a potential hidden impact on households and suggests that further research is needed to quantify the long-term impact of disease. The results show that continued investments in preventive programs including pneumococcal conjugate, and measles vaccines are needed as well as new investments for vaccines like rotavirus that are not yet available in Bangladesh.

Photo taken by Mr. Md. Rabiul Hasan, icddr,b
Dr. Ziaul Islam at the October 2018 seminar “Facility assessment and cost of illness for selected vaccine-preventable diseases in Bangladesh”

Majority of households faced catastrophic expenses for measles, diarrhea, and pneumonia

The high costs associated with pneumonia, diarrhea, and measles are emblematic of the larger trend of increasing healthcare costs. While spending per capita on healthcare has increased steadily since 2000 in the 15 countries most affected by pneumonia, diarrhea, and measles, governments are not contributing to investments in vaccines at the same level as other countries.

Out-of-pocket expenditures have remained a large proportion of the national total health spending—67% of all healthcare expenditures in Bangladesh are out-of-pocket payments, according to National Health Accounts. Catastrophic consequences are all too common in high-burden countries like Bangladesh. In fact, the current study estimated the majority of the households faced catastrophic expenditure due to measles, diarrhea, and pneumonia.


Photo taken by Jorge Martin del Campo

Between 75-86% of households used savings and 51% borrowed money to pay for pneumonia, diarrhea, and measles in children under five.

Beyond healthcare costs

In addition to out-of-pocket expenditures, caregivers of ill children bear the cost of not being able to work or carry out daily activities. Unpaid time off from work taken by caretakers to seek healthcare is an economic cost to households as important as direct costs. It represents a major proportion of the overall economic burden of these diseases, as shown by current study findings. This burden disproportionately impacts the most vulnerable and poorest households who are also at the greatest risk of experiencing infectious diseases like pneumonia, diarrhea, and measles. These households often lack the savings necessary to help pay for health expenses and are forced to:

  • Reduce other expenses in the short term, such as food,
  • Sell assets, such as livestock, and
  • Borrow money to pay for health expenditures.

This vicious cycle can be stopped. Investments to prevent and control pneumonia, diarrhea, and measles, including immunization programs, would not only reduce the health impact of the diseases, but would also minimize their related overall healthcare costs and, thus, reduce the proportion of households potentially facing catastrophic health expenditures.

Investment in programs to prevent and control pneumonia, diarrhea, and measles are smart investments. As countries are transitioning away from external funding and subsidies, new strategies to increase or sustain funding are needed.

Detailed final results will be available soon. Stay tuned!

Dhaka, Bangladesh
October 24, 2018

The same study is being conducted as part of DOVE IV in Uganda by IVAC and Makerere University School of Public Health.

This work is supported by the Bill & Melinda Gates Foundation.