Health Policy and Planning Advance Access published online on August 28, 2008
Health Policy and Planning, doi:10.1093/heapol/czn033
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Economic analysis of childhood pneumonia in Northern Pakistan
1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
2Interactive Research and Development, Karachi, Pakistan.
* Corresponding author. Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room W5041, Baltimore, MD 21205, USA. Tel: +1–410–955–6964. Fax: +1–410–502–6733. E-mail: hhussain{at}jhsph.edu
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Abstract |
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Objectives This study estimates household costs for treatment of pneumonia, severe pneumonia and very severe febrile disease. Combined with reported costs from the health care provider perspective, an estimate of the overall financial burden of these diseases has been developed for the Northern Areas of Pakistan.
Methods Data on the duration and economic implications of the illnesses for households were collected from caretakers of children under 3 years of age enrolled in a surveillance study who sought care at a health facility. Trained study physicians and health workers identified children with pneumonia, severe pneumonia and very severe febrile disease—as defined by protocols for the Integrated Management of Childhood Illness (IMCI).
Results From January to December 2002, 141 health facility visits for pneumonia (n = 41, 29%), severe pneumonia (n = 65, 46%) and very severe febrile disease (n = 35, 25%) were recorded for 112 children who sought care at various levels of health facilities in the Northern Areas of Pakistan. The total societal average cost per episode was US$22.62 for pneumonia, US$142.90 for severe pneumonia and US$62.48 for very severe febrile disease. For household expenditures, medicines constituted the highest proportion (40.54%) of costs incurred during a visit to the health facility, followed by meals (23.68%), hospitalization (13.23%) and transportation (12.19%).
Conclusion Pneumonia is one of the leading killers of children in Pakistan with a correspondingly high economic burden to society. The results of this study suggest that there is a strong economic justification for expanding the availability of existing interventions to fight pneumonia, and for introducing measures such as vaccines to prevent pneumonia episodes.
Key Words: Childhood pneumonia, cost, Pakistan
KEY MESSAGES
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Introduction |
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Pneumonia is the leading cause of death in children younger than 5 years of age in developing countries (Williams et al. 2002
) and accounts for approximately 20% of childhood deaths worldwide (Bryce et al. 2005a). South Asia and sub-Saharan Africa account for more than half of the total number of pneumonia episodes in children less than 5 years of age (Rudan et al. 2004). Childhood pneumonia places a large financial burden on society and is a frequent cause of visits to health care providers. Nizami et al. (1996) reported that, in Pakistan, 40% of outpatient visits among children less than 5 years of age were due to cough and cold, symptoms associated with pneumonia.
Cost-effective interventions against childhood pneumonia are available, but their implementation in low- and middle-income countries has been patchy, resulting in the persistence of a high disease burden (Rudan et al. 2007). Vaccines against Haemophilus influenzae type b (Hib) (Fendrick et al. 1999; Swingler et al. 2003; Brinsmead et al. 2004) and Streptococcus pneumoniae (Black et al. 2001; Cutts et al. 2005; Levine et al. 2006) have been shown to be efficacious as well as cost-effective. However, in view of the lack of coverage of existing interventions, the challenge is to make these vaccines affordable and to deliver them to those most in need.
In resource-poor settings such as Pakistan, decision-makers find it difficult to justify expenses for new preventive health-care interventions. In addition, out-of-pocket expenditures are a very important source of health financing, and pose a barrier to access to health care for poor populations. Cost of illness studies—combined with sound epidemiologic and economic data on the cost of interventions—are therefore useful to policy-makers who must prioritize and allocate scarce resources for competing health priorities.
Cost data for treatment of pneumonia in developing countries are scarce. In Pakistan, there are few data available on the economic burden of pneumonia. This study estimates the household costs for treatment of pneumonia, severe pneumonia and very severe febrile disease, and combines these data with cost data collected from health care providers (Hussain et al. 2006) to estimate the overall financial burden of these diseases in the Northern Areas of Pakistan.
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Methodology |
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Health care for the Gilgit and Ghizer districts of Northern Pakistan is provided by the Government of Pakistan and the privately run Aga Khan Health Services, Pakistan (AKHSP). Both the government and AKHSP have networks of primary and secondary health care facilities in the area, providing maternal and child health services, including obstetric care. The District Headquarters (DHQ) Hospital in Gilgit serves as a referral hospital. Government health facilities charge nominal fees for consultation. Hospitalization, diagnostic tests and a limited number of medicines are provided free of charge. However, patients often have to purchase their medications and diagnostic tests as resources are limited. Patients seeking care at the AKHSP facilities have to pay for their treatment, as AKHSP is a private not-for-profit organization that must recover costs for sustainability.
In the Punial and Ishkoman valleys of Ghizer district, Khan et al. (2008) carried out a longitudinal surveillance study of pneumonia, sepsis and meningitis between November 2001 and December 2002 at 15 health facilities (10 government and 5 AKHSP). As part of the surveillance infrastructure, households’ health care and indirect costs for treatment of these diseases were documented.
Health workers visited 1117 households (with at least one child 0–24 months of age) to administer a standardized 30-minute questionnaire to assess the socio-economic status of these households and to obtain data on household composition, education and the professions of children's caretakers. To measure household economic status, we used principal components analysis to combine a series of household variables, including type of toilet facility, type of cooking fuel, types of floor, number of different types of farm animals, water source, and the presence of a sewing machine. Principal components analysis groups together correlated variables to form a composite linear index capturing the underlying groupings. The index assigns values to each household based on their relative possessions and characteristics, creating a rank ordering of all households (Filmer and Pritchett 2001). Based on this index, we divided households into quintiles of socio-economic status, with the first quintile incorporating the poorest 20% of households and the fifth quintile incorporating the wealthiest 20%.
From January to December 2002, project medical officers and health workers stationed at 15 participating government and AKHSP health facilities identified children from these households who sought care for pneumonia, severe pneumonia and very severe febrile disease, as defined in the Integrated Management of Childhood Illness guidelines (WHO 2000). Project medical officers and health workers were trained in IMCI guidelines for respiratory illnesses, with refresher courses every 6 weeks (Khan et al. 2008).
Treatment costs were estimated for children who presented at the health facilities. UNICEF estimates that 66% of children under 5 years of age with pneumonia in Pakistan are taken to appropriate health facilities (UNICEF 2008); the equivalent percentage in the Northern Areas of Pakistan is likely to be lower, given the relative poverty of the region and geographic barriers to access to health services. From 1117 households, 141 health facility visits for pneumonia (n = 41, 29%), severe pneumonia (n = 65, 46%) and severe febrile disease (n = 35, 25%) were recorded for 112 children.
During the same visit and using a standardized form, information was collected on the duration and economic implications of the illnesses for households, including costs for consultation, hospitalization, medicine, diagnostic tests, meals and transport. Parents were also asked if they had visited other facilities for the same illness. If so, then the same information for those visits was collected. For hospitalized children, parents were interviewed at the time of discharge to document complete expenditures. If the cost information could not be obtained at the health facility, the questionnaire was administered at home within 2 weeks of the visit to the health facility. The cost estimation questionnaire took approximately 15–20 minutes per interview.
Health provider costs, previously reported, were estimated between August 2000 and July 2001. One primary and one secondary health care facility from each of the AKHSP and government health systems were randomly selected along with the DHQ Hospital, the only tertiary care provider in the area (Hussain et al. 2006).
Costs in 2002 Rupees were converted to US dollars using the average exchange rate of US$1 = Pak Rs 60. Data were analysed per visit to the health facility using Microsoft Access (Microsoft Corporation, Seattle, Washington) and Stata Version 9 (StataCorp LP, Texas). The protocol was approved by the institutional review boards at the Johns Hopkins Bloomberg School of Public Health and The Aga Khan University.
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Results |
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Of the 141 episodes of illness, DHQ Hospital treated 86 (61%) episodes in our study, 35 (25%) of the episodes were seen at primary and secondary government health facilities, and 19 (13%) at the AKHSP primary and secondary facilities. Of patients with severe pneumonia and severe febrile disease, 85% (85 of 100 episodes) were treated at the DHQ, and of 41 episodes of pneumonia, 90% were treated at the primary and secondary health care facilities. Of those reporting illnesses, 27 (24%) children were from the highest economic quintile, 20 (18%) were from the second, 22 (19.5%) the middle quintile, 21(19%) the fourth and 22 (19.5%) were from the poorest quintile. Household socio-economic status was not a significant predictor of where care was sought. On average, families travelled almost 3 hours to reach a health facility.
Families incurred an average cost of $7.54 per health facility visit (Table 1). Pneumonia was treated on an outpatient basis; severe pneumonia and severe febrile disease required hospital stays. For pneumonia, the mean household expenditure was $2.10 (median $0.83, SD $5.30). For severe pneumonia, the mean expenditure was $7.70 (median $5.25, SD $5.89), and for very severe febrile disease it was $13.87 (median $5.56, SD $22). Using Pakistan's Gross National Income (GNI) per capita of $490 (calculated based on the Atlas method for the year 2002), for severe pneumonia and very severe febrile disease a family loses an estimated $4.63 and $5.44, respectively, in terms of opportunity costs of time spent for careseeking.
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Medicines constituted the highest proportion (40%) of costs incurred during a visit to the health facility, followed by meals (23.6%), hospitalization (13.22%) and transportation (12.19%) (Table 2). Health care provider costs for the treatment of these diseases (presented in Table 3) were calculated in an earlier paper by Hussain et al. (2006
). When added to the household costs, the resulting societal costs were $20.51 for pneumonia, $137.62 for severe pneumonia and $52.48 for very severe febrile disease per visit to a health facility in the Northern Areas of Pakistan. The per-episode costs for pneumonia and severe pneumonia were $22.62 to $142.90, respectively (Table 4). For the health care provider costs it is assumed that each episode of illness gave rise to one outpatient health facility visit, while the inpatient costs are based on the average length of stay at the hospital.
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For children 2–35 months of age residing in the Northern Areas of Pakistan, the incidence of pneumonia and of severe pneumonia was 29.9 and 8.1, respectively, per 100 child years of observation (Khan et al. 2008). Using the per episode costs calculated above, we estimate the financial burden in this area for pneumonia and severe pneumonia to be $676 and $1157, respectively, per 100 child years of observation.
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Discussion |
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Families with children under 3 years of age in the Northern areas of Pakistan spend an average of $2.10 to access care for pneumonia and $7.70 for severe pneumonia per visit. The distribution of expenses paid by the households for these diseases is right-skewed, with outliers at the far end of the cost distribution. On average, parents also spend 2.71 days per visit to have their child treated. This estimate includes time for travel as well as time spent at the health facilities. The results indicate that medicines are the biggest expense, even though they are supposed to be provided free of charge at government health facilities. A family travels approximately 3 hours to reach a health facility and spends almost 36% of its total expenditure on transportation and meals, illustrating the difficulty in obtaining access to health care in the Northern Areas. The overall societal costs for an episode of pneumonia, severe pneumonia or severe febrile disease ranged from $22.62 to $143.00 at different levels of health facilities.
In 2002, total health care expenditures in Pakistan averaged just $13 per capita. Twenty-eight per cent of this amount came from government sources. Most of the remainder—$9.21 per person—was spent directly by households in the form of out-of-pocket expenditures (World Bank 2002). The average total cost for one episode of pneumonia—$22.62—was therefore considerably higher than the annual household out-of-pocket expenditure on health care per person.
The provider costs in our study are considerably higher than estimated by the model presented by Bryce et al. (2005b). This difference could be due to the fact that their model estimates the treatment costs only at the primary health care and community levels, whereas we have estimated costs at all levels of health care provision. If similar results hold in other countries, it may take more financial resources than previously anticipated to achieve the Millennium Development Goals (MDGs) for child survival.
Rudan et al. (2004) calculated an average global pneumonia incidence of 0.3 episodes per child per year. In Pakistan, according to the US Census Bureau (2007), there were 21.1 million children 0–4 years of age in 2002. This would mean that 6.8 million children had an episode of pneumonia, 66% of whom accessed health care. Khan et al. (2008) estimated that of all children who accessed care for pneumonia in the Northern Areas in 2002, 72% had pneumonia and 28% had severe pneumonia.
Applying our total costs calculated ($22.60 for pneumonia and $142.90 for severe pneumonia) to this proportion, Pakistan would have spent over $236 million for childhood pneumonia in 2002. It can be argued that the costs of treatment in the mountainous communities of the Northern Areas may be higher than in the rest of the country. Regardless, child pneumonia creates a substantial financial burden for Pakistan.
This high cost argues for increased access to treatment and the exploration of other strategies such as treating children for pneumonia at home with antibiotics (Hazir et al. 2008) that could potentially be cost saving for both families and health systems. In addition, preventive strategies such as vaccines for preventing pneumonia in Pakistan should be further explored. Hib and Streptococcus pneumoniae are the leading causative agents for bacterial pneumonia in children. Hib and pneumococcal vaccines have reduced morbidity in developed countries and some developing countries. Many developing countries have introduced Hib vaccine, and WHO and UNICEF now recommend that all countries incorporate this vaccine into the routine immunization schedule (WHO 2006). An initiative has been undertaken to reduce the cost of vaccines to protect against Streptococcus pneumoniae and to introduce these vaccines throughout the world with the help of international agencies (AMCV 2007).
There are some limitations to our study; our costs for very severe febrile disease may be underestimated as no inpatient with this diagnosis was admitted during the year health care provider costs were estimated. This is probably due to a change in terminology with the introduction of IMCI guidelines. Previously, these children may have been admitted under severe pneumonia or sepsis definitions. This study estimated the costs of travel time and time spent at the hospital but did not include the time parents have to take off work to care for children at home during an illness. Also, children were not followed up for any long-term sequelae of disease or mortality. The communities of Northern Pakistan have a higher disease burden than the estimated incidence rates for the rest of the country. Therefore, the average cost for treatment may be somewhat less for the rest of Pakistan.
Pneumonia is one of the leading killers of children in Pakistan and other developing countries, and the economic burden to society is high. Health services need to focus on the provision of universal access to preventive measures in order to decrease treatment costs. Increasing coverage through the delivery of treatment at community levels may also decrease the burden at health facilities. Cost-effectiveness studies of preventive strategies such as Hib and pneumococcal vaccines in Pakistan could contribute towards decreasing the burden of disease and the costs of treatment for pneumonia.
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Acknowledgements |
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The authors wish to thank Nahida Shah for coordination and data collection and Tina Proveaux for editing the manuscript.
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Accepted for publication 11 July 2008.
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