cost-effectiveness and user characteristics of clinic based services for the treatment of diarrhea:...

Soc. ScL Med. Vol. 17, No. It, pp. 721-729, 1983 0277-9536/83/I 10721-09503.00/0 Printed in Great Britain. All rights reserved Copyright © 1983 Pergamon Press Ltd

C O S T - E F F E C T I V E N E S S A N D USER CHARACTERISTICS O F CLINIC BASED SERVICES FOR THE T R E A T M E N T

O F D I A R R H E A : A CASE S T U D Y IN B A N G L A D E S H

SUSAN HORTON t and PIERRE CLAQUIN 2

1Department of Economics, University of Toronto, 150 St George Street, Toronto M5S I AI, Canada and -'International Center for Diarrheal Disease Research, Dacca. Bangladesh, c/o Department of State,

Washington, DC 20520, U,S.A.

Abstract--This study compares the cost-effectiveness of three services for the treatment of diarrhea, in a rural area of Bangladesh. It also examines patterns of user composition, and how these depend on factors other than disease severity and incidence. The three services are a large hospital-style treatment center, an ambulance system bringing patients from greater distances, and a small treatment center staffed by paramedics.

The results show that the long run average cost per patient is about $16 at the large center, with an additional $13 if the patient came by ambulance, compared to $3 at the small center. Corresponding costs per death averted were $1300, an additional $360, and $190 respectively. Previous studies have suggested that there is no more cost-effective alternative for the prevention of diarrhea, although in future home-based oral rehydration therapy may be a potential alternative.

Each service exhibits use patterns suggesting that males and especially small boys receive preferential access to treatment. This bias is exacerbated as distance from the center increases, or ifa fee is charged.

The study concludes firstly that diarrhea treatment costs in clinics are relatively high, and secondly that unintended biases in service use should be an important consideration in service design.

INTRODUCTION

The present study has two purposes. One is to compare the cost-effectiveness of three services with the same end, namely, the treatment of diarrhea and the prevention of diarrhea related deaths. The other is to examine in more detail the characteristics of users of such services, and hence to suggest some factors which determine who uses a particular treatment service. The information on cost-effectiveness is of use when considering how to allocate scarce resources to health services. The information on user characteristics is of interest for understanding the biases in use of particular services.

The study uses three criteria for cost-effectiveness. These are the cost per patient treated, the cost per patient of severe dehydration level treated, and the cost per 'death averted'. It is assumed that dehydration is a proxy for the severity of illness for watery diarrhea. The methodology used to estimate the numbers of deaths averted is explained below, and employs (controversial) existing estimates of the probability that an individual with a given level of dehydration will die.

The study uses several criteria to consider 'who benefits' from different services. Information is pro- vided on age, sex. distance travelled to service, method of transport and severity of dehydration of users. This can be combined with the information on costs, to determine the cost-effectiveness of different services in treating various subsets of users of particular interest.

The three services examined are a large Western- style treatment center at Matlab in rural Bangladesh, an ambulance service bringing more distant patients and a smaller treatment center at Sotaki about 10 miles from Matlab, staffed by paramedics. The two

centers make an interesting comparative study, since the Sotaki center opened with community initiative when one of the ambulances from Sotaki to Matlab closed down. There exist data from both before and after the switch in service.

In the past, effectiveness studies have been made twice at Matlab treatment center (TC) [1,2]. For 1969-1970, Mosley et al. [1] found that it was effective when compared to an immunization program against cholera. They estimated that during the cholera outbreak in 1969-1970 the treatment center admitted 318 cases requiring treatment and averted 159 deaths, whereas a vaccine would have averted fewer than 143 of the hospital cases and hence correspondingly fewer dea ths . Moreover the cholera vaccine could not have helped non-cholera diarrheas, whereas the treatment center did. Their figures suggest that a hospital would be more cost effective.

For 1975, Oberle et al. [2] calculated cost effectiveness. They found that cost per person in the region served was quite low ($0.14 per capita in 1975 prices). Costs per death averted were estimated as $38-81 and varied with age and etiology. The cost-effectiveness of an immunization program was not explicitly calculated, but indicated to be higher.

The previous studies relied on aggregated financial records to estimate costs. The present study adopts an alternative, that of directly estimating economic resource costs by using actual price and quantity records. Further details of the calculations can be obtained from [3].

BACKGROUND

Both the Matlab TC and Sotaki TC are in Matlab thana, which is situated 40 miles southeast of Dacca, Bangladesh. The area is near a big river, and there are

721

722 SUSAN HORTON and PIERRE CLAQUIN

large amounts of surface water, particularly at certain seasons. Selected villages in the thana have been under demographic surveillance since 1966, and cholera vaccine trials have been performed. Demographic and other characteristics of the area have been de- scribed in annual volunes, and periodic census information is obtained 1"4].

The Matlab TC is not referred to as a hospital, since patients without diarrhea are supposed to use the government health facilities. The center is located in Matlab bazaar, and serves people from Matlab thana as well as more distant thanas and districts. About 65~ of patients come from outside the surveillance area, and about 40~o from outside Matlab thana.

The treatment center opened in 1963. It has five medical officers, a ward master, five nurses, and eight nursing and ward attendants, in addition to non- medical staff. It occupies a kutcha building (of local materialst, and part of a pucca (more permanent) building. Daily admissions vary somewhat by year and by month, depending on disease incidence, and in 1979-1980 were on average 29. During the year of the study patients stayed between 0 and 11 nights in the center, on average 1.6 nights.

The TC has a small pathology laboratory with two staff, to perform stool, blood and other tests. In addition there is a microbiology laboratory with four staff who spend about 20~o of their time doing routine samples on census area patients and selected other hospital patients, the rest on more research oriented work. The buildings are used for other activities such as a family planning clinic, as the headquarters of research and demographic surveillance activities, and as the site for preparation of oral rehydration salts. The co-existence of serices in one location, with joint use of personnel equipment, was one difficulty encountered in estimating costs. Treatment center costs here include the center itself and pathology laboratory only.

Treatment is with intravenous fluids for more serious cases initially and most patients receive some oral fluid. In addition, various medicines are used, typically for worms, or antibiotics for respiratory problems as well as certain diarrheal illnesses. At least 50~o of children have either worms, tonsillitis, or respiratory problems in addition to diarrhea (doctor's estimate).

Part of the surrounding area has been involved in two trials for home based oral therapy. The effect of these on hospitalization has been, and is being, examined elsewhere I-5, 6]. Cost effectiveness figures for such preventive services are not as yet available

About 40~o of all patients at Matlab TC come by ambulance. There are five ambulances for the treatment center. Four are 35 h.p. speedboats based at distances of 30-70 min from the treatment center, and one is a car or jeep 9 miles away. A fifth ambulance boat at Sotaki, 90 min away, was withdrawn on 30 November, 1979. The transport is used mainly but not exclusively for ambulance work. Patients go to the ambulance stations and request transport. There have been attempts to restrict the ambulances to patients referred by the community workers, but the system is not fully operational as yet. Either one or two patients come at a time, with their attendants, on

average 1.4 patients per trip. Ambulance patients have to come greater distance than the average hospital patient. Eighty per cent come from outside the census area and 60~o from outside Matlab thana. There is no charge to patients using the Matlab TC and amLulances.

The closure of the fifth ambulance boat based at Sotaki, led to community efforts to obtain an alternative service for the treatment of diarrhea. A treatment center was opened in an ICDDR, B building at community initiative on 1 December 1980. The ICDDR, B supplied free of charge hospital and office supplies, and trained four volunteers to give oral and intravenous fluids, and certain drugs. A patient fee of 15 takas (about $1) per visit is used to cover local expenses, including a nominal wage for the volunteers. A local committee administer that center, take charge of financial management, and report monthly to the Matlab center, giving information ag to the numbers of patients and stock of drugs, and making supply requests. The center was used by 891 people in its first year.

MATERIALS AND METHODS

Cost information was obtained from financial, supply, and worker time use records, and equipment use logs. Costs were imputed where there was no financial transaction, such as for rent on buildings. Where possible, costs were estimated directly from quantity records and price records, rather than financial amounts. This was partly to help allocate costs jointly incurred between the TC and other services. For example, information on doctors' salaries was obtained, and doctors were asked to estimate the proportion of their time worked in the TC, as against that in other services. Cost figures are presented in two ways. They are presented both by operationally useful categories such as wages, rent, etc. and by economic categories such as short and long run average costs and average variable costs.

The different economic cost concepts are presented for different policy purposes. Short run average variable costs estimate the average cost imposed by one additional patient, and include items such as drugs and food. Short run average costs represent the cost per patient of continuing an existing service for a year, and include wages and rents, in addition to variable costs. This is the cost figure which would be used when considering whether or not to continue an existing service for another year. Long run average costs in addition include an annual cost of the resources tied up in equipment. The calculation method used for the latter was to amortize the current replacement cost of all equipment, using straight line depreciation over an estimated lifetime. Long run average costs would be used for policy decisions concerning whether or not to set up a new service.

The figures exclude private costs to patients. These include items such as cost of transport to hospital if not by ambulance, cost of food for attendants and for patients where applicable and opportunity cost of time of both patients and attendants spent travelling to and from, and remaining at, the hospital. It will be argued later that these costs, though possibly small in relation to the reported costs of services, are neverthe-

Cost-effectiveness and user characteristics of clinic based services 723

less large enough to provide a deterrent to the use of a service by some individuals. The private costs differ somewhat between the services. For instance, at Mat- lab, patients and nursing mother attendants receive free food, whereas at Sotaki they do not.

The figures on users of each service were obtained as far as possible for the complete financial year July 1979 to June 1980, to avoid seasonal effects. Infor- mation was obtained from the admissions registers at Matlab and Sotaki, and from treatment records at Matlab.

RESULTS

Table 1 presents the economic resource costs of the three services, and shows that the long run average cost of treating a patient at Matlab is about $16-$17, with an additional $13 if the patient comes by ambulance, as compared to just over $3 at Sotaki. Using a shadow exchange rate does not alter the rankings of the services, but increases the cost levels. The use of a shadow exchange rate is to remove the distortionary effect of an overvalued exchange rate. Calculations based on the actual exchange rate make a service with high foreign exchange costs seem artifically cheap, relative to the resource costs. The ambulance service for example, uses imported fuel and equipment, and is therefore more costly relative to the other services when a shadow exchange rate is used rather than the actual one.

Shadow wages were not used, since it is difficult to estimate these. Probably the costs at Sotaki are rather low because the volunteers accepted low wages and administration was by an unpaid committee. A more

realistic wage figure might increase short and long run average costs by 25y~ or another $1. However the costs at Matlab are also underestimated. Since there are controls on the emigration of doctors from Bang- ladesh, doctors ' salaries are probably below their scarcity value. Thus the costs at Matlab would also be correspondingly higher if a shadow wage were used.

Table 2 presents costs of the three services, by operational categories. Table 3 summarizes the cost effectiveness figures and compares them with previous studies at Matlab. The cost per patient at Matlab TC is similar to that of previous studies. Costs per patient in any case vary somewhat between years, being relatively lower in years of high usage when the fixed costs are spread over more users. The estimates of cost per death averted use Chen's [7-1 assumption that 50~o of the patients who were severely dehydrated on admission would have died. This latter estimate should be treated with caution. The 50%0 criterion is rather arbitrary, since there is an ethical problem in obtaining information as to the probability of a severely dehydrated patient dying if untreated, and in any case the estimates of dehydration level on admission are subjective. If the probability of mortality of a severely dehydrated patient were as low as 10°'o, for example, the cost figures per death averted would be considerably higher. (They would be $6310-$6762 at Matlab, plus $1785 for ambulance users, as compared to $935 at Sotaki.)

Sotaki performs even better relative to the other services using a 'deaths averted' criterion. This could be because the fee deters the less seriously dehydrated patients. However it is also possible that the dehydration categories at Matlab and Sotaki are non-comparable, and that those at Sotaki overestimate dehy-

Table I. Estimated resource costs by economic categories, Matlab treatment centre, ambulances and Sotaki (FY 1979-1980)*

Matlab? V1 V2 Ambulance Sotaki

Cost in U.S. dollars Short run average variable cost 3.91 3.91 7.98 1.83 Short run average cost 15.56 16.68 11.47 3.10 Long run average cost 15.65 16.77 12.80 3.36

Cost in taka Long run average cost using actual exchange rate~ 234.75 Long run average cost using shadow exchange rate~ 246.85

251.55 193 .35 50.40

266.20 228 .61 55.83

*FY 1979-1980 is July-June for ICDDR.B, and December- November for Sotaki.

For Matlab. two variants are presented. V1 (minimum estimate) excludes the microbiology laboratory, excludes expatriate supervision, and replaces existing pucca building with rented kutcha one. V2 (maximum estimate) includes the microbiology laboratory, includes expatriate supervision, and includes existing pucca building.

~Actual exchange rate was taken as $1 = 15taka. Shadow exchange rate was taken as $1 = 20 taka, as used by World Bank. Dacca.

s.s.m. 17 l ] - - c

724 SUSAN HORXON and PIERRE CLAQUIN

Table 2. Estimated resource costs by operational categories, Mat- lab TC, ambulance and Sotaki TC (FY 1979-1980~

Cost in U.S. dollars Matlab Matlab

VI V5 Ambulances Sotaki

Short run costs uarying with patient numbers

Food, drugs, Fuel 41,546 41,671 34,768 1673

Other short run costs Wages 79,509 84,009 8896 891 Other supplies 33,583 34,097 - - - - Maintenance 151 151 3646 - - Rent 1600 3800 172 200 Administration 8869 8869 2504 - -

Lony run costs Equipment 922 922 6217 302 Training - - - - - - 380

User numbers 10,618 10,618 4359 891

Short run average variable costs equal short run costs varying with patient numbers, divided by numbers of patients. Short run average costs equal short run costs varying with patient numbers, plus other short run costs, divided by numbers of patients. Long run average costs equal the sum of all the costs in the table, divided by numbers of patients.

dration, and hence bias the figures on cost per 'death averted' downwards.

The level of cost per death averted is quite high. At Sotaki the cost is $187 and at Matlab it is $1262-$1352, with an additional $357 if the patient came by ambulance, which is rather higher than for previous studies. Oberle [2] used a more complex criterion for determining the probability of death of untreated cases, based on fluid loss and weight gain in hospital, but the implied probability of death (between 1 in 2 and 1 in 5 in certain age and sex categories) seems improbably high. Information necessary for a calculation similar to Oberle's was not available for the present study. Future empirical research would be helpful to improve the estimates of probability of death for untreated cases. For example the correlation of the level of diarrhea related mortality, and distance from the treatment center, could be used, in conjunction with information on how the population-attendance rate decreases with distance.

Tables 1-3 showed that the costs of diarrhea treatment services are quite .high. Since the services are heavily subsidized, it is interesting to consider who benefits. Tables 4-6 address this issue, by examining the characteristics of users of each service.

Tab le4 shows that children less than 5 form a higher proport ion of treatment center users than of the population, and similarly males more than females. Tab le4 also shows that males, especially those less than 5, form an even higher proport ion of users of Sotaki TC than Matlab TC.

Table 5 present the relative dehydration levels of service users. The noncomparabil i ty of classification systems at Sotaki and Matlab makes it seem as if Sotaki patients are more seriously dehydrated. As explained earlier, this may be an artefact of different r epor t ing systems. Ambulance users are more seriously dehydrated than other patients. Baby taxis and rickshaws, which are quicker methods of land travel than walking, but more expensive, bring

Table 3 Summary cost-effectiveness figures, in U.S. dollars, Matlab TC, ambulances and Sotaki TC

Matlab TC Matlab TC VI V2 Ambulance Sotaki Oberle* Mosley*

Long run average cost per patient 15.65 16.77 12.89 3.36 23.51 14.91 Long run average cost per severe patient 631.04 676.21 178.53 91.59 - - - - Long run average cost per 'death averted' 1262.10 1352.40 357.06 1 8 7 . 1 9 48-102 603.48

*Figures are from [1, 2], revised to 1979-1980 prices using 1-19].


Table 4. Percentages of all users of services, in specific age and sex groups

Age categories (years) Total <5 5-14 15-44 45-59 60+ Total number

Males, as percentage of all users Population* 8.0 13.3 20.7 6.3 2.0 50.4 88,165 Matlab TCt 32.4 8.3 9.9 4.0 1.7 56.3 1270 Ambulance:~ 32.7 11.5 7.8 2.6 1.7 56.9 827 Sotaki TC§ 38.2 8.5 8.5 4.8 2.1 62.9 560

Females, as percentage of all users Population* 7.6 12.5 22.1 5.7 1.7 49.6 86,781 Matlab TCt 20.1 6.1 13.1 3.7 0.7 43.7 985 Ambulance:[: 17 .1 7.9 14.8 1.9 0.8 43.1 626 Sotaki TC§ 18.3 3.6 13.4 2.7 0.1 37.1 330

*Figures from area under demographic surveillance. tFigures from selected villages in census area (census subsample area). ~.AII patients coming by ambulance for 4 months (October 1979-January 1980). §All patients. December 1979-November 1980 (Sotaki opens 1 December 1979).

pat ients who are relatively more dehydra ted than those who come on foot.

Table 6 shows the effect of distance on hospitaliz- a t ion rates, which tbr M a t l a b decline from 31.9 users per year per thousand popula t ion at distance less than 30 min travel, to 8.3 per thousand at distances of 2.5-3 hours travel, using a speed of travel of three miles per hour on foot or in a country-boat . Use rate for Ma t l ab are h igher than for Sotaki at a given distance from the" appropr ia te t rea tment center. A large par t of the difference is due to the ambulances , which br ing people to Ma t l ab but no t to Sotaki. However even if one subtracts out all ambulance patients, the rates remain higher for Mat lab , which suggests that the fee at Sotaki may deter some patients, and particularly those closest to the center.

Tables 7-9 provide more detailed informat ion on the user characterist ics of M a t l a b TC, and show that usage is related to different individual characteristics. Table 7 shows that pat ients coming from greater distances are more likely to come by ambulance and less likely to walk, and their level of dehydra t ion is

greater. Since user costs increase with distance, it is not surprising that pat ients coming from further away tend to be more sick.

Table 8 shows tha t as distance travelled increases, the p ropor t ion of males age 0--2 increases from 45.1~o at less tha t 5 miles from Mat lab , to 55.4~o at 5 or more miles. The rat io of males to females similarly increases from 1.25:1 to 1.46:1. The increase is due mainly to the zero to two age group where the rat io increases from 1.36:1 to 2.29:1.

Table 9 compares dehydra t ion status by age and sex, with the relative popula t ion-a t tendance rat io for the same age and sex group. The latter represents the rat io of the popula t ion-a t t endance rate for the age and sex group, to the overall popula t ion-a t tendance rate. The table shows that males have generally higher popula t ion-a t t endance rates than females, and lower dehydra t ion rates. This is also true for the age group less than five, as corripared to the populat ion.

Table 10 compares medical and other characteristics of three groups of pat ients: those who used to come from the area sur rounding Sotaki to Ma t l ab

Table 5. Composition of users of services, by dehydration status (row percentages)

Dehydration level Sample Average 0 1 2 3 4 size dehydration

Matlab TC 19.4 50.9 21.3 5.9 2.5 2255 1.21 Sotaki 0.0 11.0 55.2 30.2 3.6 891 2.26

Matlab users only, by method of transport Speedboat 13.0 38.4 32.6 9.4 6.5 138 1.58 Car/jeep 17.8 39.3 25.0 7.1 10.7 15 1.54 Country-boat 18.6 50.0 25.5 5.9 0.0 102 1.19 Rickshaw 27.3 37.9 22.7 9.1 3.0 66 1.44 Foot 12.5 60.0 17.5 7.5 2.5 40 1.28 Launch 28.0 75.0 0.0 0.0 0.0 4 0.75 Baby-taxi 0.0 31.8 10.7 10.7 7.1 15 1.36 Don't know 42.9 28.6 0.0 0.0 0.0 7 0.86

Source: Matlab users (line 1) are a subsample, and represent all patients from selected villages in the census area (Census area subsample). Sotaki users represent all users. Matlab users by method of transport represent a sample of 100 users from each month, October 1979-January 1980. Classification system for dehydration is O--none (Matlab only), 1--mild, 2--moderate. 3--moderate/severe. 4--severe. Classification systems at Matlab and Sotaki are not necess- arily comparable. See text.

726 SUSAN HORTON and PIERRE CLAQUIN

Table 6. Population-attendance rate per 1000 person-years, by categories of hours travelled for treatment

Distance, in hours travelled 0.0--0.5 0.6-1.0 1.1-1.5 1.6-2.0 2.1-2.6 2.6-3.0

Matlab TC 31.9 20.4 17.0 16.5 14.8 8.3 Matlab TC, excluding ambulance 31.6 19.0 14.8 9.0 8.0 2.4 Sotaki 14.8 16.2 14.5 5.3 2.7 6.8

Source: Since information is from different sources, results should be inter- preted with caution. Hours to Matlab were calculated from water distance, or land distance if no water distance available, using field workers estimates, and assuming a speed of travel of 3 miles per hour. Hours to Sotaki are paramedics" estimates. Matlab data is for census subsample, as in Table 5. Sotaki data is for all villages sending more than 1 person per year to Sotaki.

Table 7. Composition of users of Matlab TC by method of transport and distance travelled

(column percentages)

Distance in miles 0-4 O~)er 5

Ambulance 7.6 55.8 Country-boat 57.1 29.2 Foot 40.5 1.2 Rickshaw 32.8 8.2 Other/don't know 2.5 5.8 Total 100.0 100.0 Average Dehydration Level 1.136 1.309

Census area subsample patients only, as in Table 5.

TC, of those who cont inue to come, and those of the average users of Mat lab. Eleven villages were ident- ified whose residents previously used the Sotaki ambulance, from which some people a t tended the new Sotaki center, and from which at least one person came to Ma t l ab in a 1 year period despite the re- moval of the ambulance. The compar ison shows that it is not the most seriously dehydra ted pat ients who cont inue to come. However cont inued users are more likely than the other two groups to have non- diarrheal complicat ions such as the presence of fever

or abnormal pulse on admission, are more likely to use antibiotics and to stay longer in hospital. In the case of children this probably indicates respiratory complications. These cont inued users are also more likely to be less than 6 years old, and almost 50% are males less than 2 years old.

DISCUSSION

Previous studies have concent ra ted on showing that the t rea tment of d iarrhea in a large center is more cost-effective than either immuniza t ion against cholera, or than env i ronmenta l and sani ta t ion im- provements. Possibly in the future home-based oral rehydra t ion therapy may be shown to be a viable alternative.

The conclusions to be drawn from the current study are less optimistic. The Mat lab t rea tment center is very costly, by several criteria. Firstly, a comparative study shows that a local t rea tment center staffed by paramedics is much more cost effective. This is likely to be even more true if the relative price of gasoline for ambulances, a necessary expendi ture to justify the existence of a large center, cont inues to rise. Even if the costs at Sotaki are unusual ly low due to communi ty efforts, a small center is still likely to be preferable on grounds of cost effectivenesss.

Secondly, the foreign exchange burden imposed by Mat lab ($2.39 per patient, plus $10.56 if the pat ient came by ambulance, compared to $1.13 at Sotaki) is

Table 8. Age and sex composition of users of Matlab TC, by distance travelled

Age category (years) Miles 0-2 3-4 5-14 15-44 45-64 65 + Total

Row percentages, males 0-4 45.1 8.6 15.5 19.5 7.6 3.7 100.0

Over 5 55.4 6.5 11.7 17.2 6.5 2.7 100.0

Row pereenta~les, Jemales 0-4 41.2 5.8 13.0 29.4 8.8 1.7 100,0

Over 5 38.0 5.8 14.0 32.4 8.6 1.2 100,0

Male-fi, nude ratio within a qe and distance cateffory

0-4 1.36 1.84 1.49 0.83 1.07 1.25 Over 5 2.30 1.63 1.22 0.77 I. 1 I 1.46

Census area subsample patients only, as in Table 5.


Table 9. Dehydration status of users of Matlab TC, by age and sex. compared to relative population-attendance (P.A.) ratio

Age (years) 0-2 3-4 5-14 15-44 45-64 65+

Average dehydration Relative P.A. rate

Average dehydration Relative P.A. rate

0.88 1.02

4.03

0.95 1.19

2.64

Row percentages, males

1.47 1.40 1.59 1.44

0.62 0.48 0.64 0.85 Row percentages, females

1.62 1.68 1.72 1.39

0.49 0.59 0.65 0.43

Relative population-attendance (P.A.) rate is calculated as the number of treatment center users of a given age and sex, divided by the corresponding number in the population, as a ratio of the same figure for all users. Thus a rate above 1.00 indicates that a particular age and sex group is over-repre- sented amongst users relative to the population. Sample is Census area subsample patients only, as in Table 5.

Table 10. Selected characteristics of average users of Matlab TC, and users of Matlab from 11 selected villages close to Sotaki, before and after

opening of Sotaki

Selected All 11 villages, 11 villages characteristics users* before Sotakiq after Sotaki,*

Percentages Age ~< 6 49.0 52.9 81.3 Male 57.0 63.0 52.9 Male, age < 2 25.8 30.8 47.1 Watery diarrhea§ 55.0 67.9 64.7 Bloody diarrhea§ 31.0 5.6 12.5 Vomiting§ 55.0 86. l 87.5 Abdominal pain§ NA 28.4 25.0 Fever§ 60.0 44.3 75.0 Dehydration§ > mild 27.0 3 I. 1 17.7 Pulse abnormal§ NA 45.4 70.6 Respiration abnormal§ NA 30.6 23.5 Used antibiotics¶ 46.0 32.4 56.3

Average value I.V. intake, liters¶ 0.61 0.82 0.26 OT intake, liters¶ 1.39 1.91 1.69 Days in hospital 1.73 1.41 2.35

Sample size 100 108 17

*Obtained from study of 100 charts. September 1979. tObtained from Matlab admissions records. December 1978-May 1979. ~Obtained from Matlab admissions records. December 1979-May 1980. ~On arrival. ¶In hospital.

high. Reduct ion in dependence on foreign exchange is frequently a desirable a im in developing countr ies with scarce exchange reserves. In heal th areas dependence might not be el iminated totally until generic p roduc t ion of drugs is possible (such produc t ion is beginning in Bangladesh), but it can be minimized.

Thirdly, the costs per pat ient are high relative to local resources. Individual heal th expendi ture in Bangladesh was abou t 37 takas per capita per a n n u m in 1978, or jus t over $2 [8]. The costs of t rea tment by al ternat ive practi t ioners, excluding the cost of medi- cine, are relatively lower. B a r n u m et al. [9] report the costs of office and home visits by palli chitisaks as 4.5 and 9 takas respectively. Claquin [10"] quotes figures

of 14.15 takas for qualified a l lopaths and 5 and 4.5 takas for ayurvedic healers. Thus, it does not seem that pat ients would be able to afford to bear anyth ing but a token par t of the cost of t rea tment at Mat lab . However at Sotaki, substantial numbers did seem willing to pay the 15 takas necessary, which covered at least the variable costs.

Fourthly, the cost per person covered by the service is high. If one makes a generous assumpt ion of an average popula t ion-a t t endance rate of 20 per 1000 for Ma t l ab TC, represent ing the rate at 2 miles distant, then the cost per person covered is 5 takas or $0.33 per person per year. This seems small, bu t however equals half of the government heal th budget. Govern-

728 SUSAN HORTON and PIERRE CLAQU1N

ment expenditure per person was 7.66 takas in 1975-1976 [8] which would be equivalent to 11.3 takas in 1979-1980. Sot~ki would cost about 1 taka per person covered per year, in comparison.

Fifthly, the costs per death averted are high, though as stated before, these figures are somewhat subjective. The cost at Matlab TC ($1262-$1352) is comparable to that reported for hospitals elsewhere. Barlow's [-11] figure for 1971'for a small hospital in Morocco 1971 was $2360. However there is a widespread opinion that Western-style, hospital based care, is not highly appropriate for developing countries. It might be more useful to make a comparison with other medical interventions. For example, Barlow I-11] estimated the cost per death averted, again for Morocco in 1971, was $126 for vaccination against TB, and $190 against diphtheria, tetanus and whooping cough•

There are two further questions as to cost-effectiveness which the present study does not answer. One is whether it would be more cost-effective to integrate the treatment of diarrhea into an existing primary health care system. Sotaki's experience shows that paramedics can be successfully trained in rehydration techniques. The success of the Savar health care system, in a different area of Bangladesh, suggests that the limited private resources can be mobilized to pay for primary health care via an insurance scheme. Rehydration therapy could be included as part of such a system of health care. The other question is whether it is justified to use scarce health resources for the treatment of diarrhea, or whether there are more cost-effective alternative uses. Both questions would require further research.

It might seem superfluous to ask 'who benefits' from the Matlab service, since its use is free to anyone with diarrheal illness. However, there are private costs which cause factors other than the severity of illness, to affect whether an individual seeks treatment. These costs include that of transport. It costs about 10 takas to rent a country-boat for 3 miles, about 1 taka per mile for a rickshaw and more for a baby-taxi, and carrying a seriously ill adult to hospital might require several people. The costs of food for an attendant, purchased in the local bazaar, might be 15 takas a day, certainly more expensive than eating at home. There is also an opportunity cost of the attendant 's time whilst the patient remains at the center. At Sotaki, patients as well as attendants have to buy food, as well as pay the 15 takas admission fee. These costs compare to an agricultural wage in 1980 of about 12-15 takas per day. Thus although private costs are small relati~,e to total cost of the service, they may be sufficiently large to deter some potential users.

There are also social obstacles to use of a treatment center. For women there are social barriers against travel, and against coming into contact with non- family members. The center may seem large and im- personal and patients may prefer more traditional medical practitioners.

The existence of such costs and obstacles may explain patterns of use of treatment centers, beyond the variations due to disease incidence. Incidence data for the corresponding time period and area is not presently available. There are however other data for Bangladesh. Khan e t al. 's results [13] suggest that

attack rates for cholera were higher for children below age 9, and higher for males than females. How- ever, the rates for cholera and non-cholera diarrheas may differ. Rahaman et al. [14] found that attack rates for all diarrheas decreased with age. For two separate villages the rates per 1000 person-years were 323 and 277 at age less than 1, 226 and 241 at ages 1--4, 91 and 100 at ages 5-9, and 94 and 83 at ages over 10.

Thus, the age patterns of use partly correspond to incidence patterns. However, the overall higher use by males, especially small boys, would seem to reflect societal preference rather than disease incidence. There is no incidence data by sex to confirm this hypothesis. However the figures in Table 9 suggest that relatively high use. by small children, especially males, is accompanied by relatively low dehydration levels within this category, suggesting that this group receives preferential access to care. There is further evidence in Table 4 to support this hypothesis. Com- paring a free to a fee-paying service (Matlab to Sotaki), there is a bias favoring males and small boys receiving treatment by the fee-paying service. The same pattern is observed for the effect of distance, in Table 8. As distance increases, and hence presumably the private costs of seeking treatment, the proportion of boys less than two amongst patients increases. Thus it seems that households are more willing to bear the costs of seeking treatment for males and especially small boys.

There is other evidence from Bangladesh to support the existence of this type of societal preference. There are sex differences in mortality rates [15] and in feed- ing practices [16] which favor males. Aziz [17] found that females were less likely to receive medical atten- tion, and less was spent on such care, prior to death. Khan et al. [18] surveyed the amount that users of the ICDDR,B's Dacca clinic spent, prior to seeking treatment at the clinic. They found that male children below 9 received more expenditure than females. However in the 20-49 age group more was spent on women. Rahaman et al. [12] found that in Teknaf, the

• case-attendance rate for females was-lower than for males at all ages, at distances of over one mile from a treatment center. However they found that adults had a higher case-attendance rate than children, the high- est rates being found for men in prime working ages.

Thus, it seems that service design is an important factor in determining who benefits. Larger, more distant treatment centers, and those charging a fee, dis- proportionately benefit males and especially small boys. One might expect similar biases in usage favoring those with higher incomes, and children of earlier birth orders, especially first and only sons.

Table 10 presents some final evidence on one aspect of effectiveness, namely whether or not the users per- ceive that the treatment at Matlab is superior on medical grounds to that at the (cheaper) Sotaki center. The table shows that the group preferring Matlab even when Sotaki was available, were not the most severely dehydrated patients. Rather, they con- sisted largely of children with respiratory complications. Since the paramedics at Sotaki were not explicitly trained for these problems, it would not be surprising for users to prefer Matlab for these particular cases.


CONCLUSIONS

The study suggested that the cost of clinic based curat ive care for d iarrhea is high relative to the resources available in a developing country. Earlier studies showed tha t preventive measures such as immuniza t ion and env i ronmenta l improvement , may be no more cost-effective. The present study showed tha t a larger, more e labora te center, was less cost- effective than a smaller center staffed by paramedics. The study also found that pa t te rns of service use depended on societal preferences as well as on disease incidence. Smaller, more local centers would also be preferable on equity grounds. N or do users appar- ently regard the larger center as provid ing bet ter t r ea tment for diarrhea. There remains the wider ques- t ions as to the emphas is which should be placed on clinic based curat ive t rea tment for diarrhea, as against o ther heal th interventions.

Acknowledgements--The authors would like to thank the following people: Dr W. B. Greenough for encouraging the study, Dr M. Yunus and Mr J. Chakraborty for permission to use some data, Dr H. Barnum, Dr O. Gish. Dr M. Roehmer, Dr M. Alamgir, Ms S. Zimicki and Dr D. Shepard for comments on earlier drafts, and finally the staff at Matlab and Sotaki treatment centers for answering many questions. Responsibility remains with the authors.

REFERENCES

1. Mosley W. H., Bart E. J. and Sommer A. An epidemio- logic assessment of cholera control programs in rural East Pakistan. Int. J. Epid. 1, 5, 1972.

2. Oberle M. W., Merson M. H., Islam M. S., Rahman A. S. M. M., Huber D. H. and Curlin G. T. Diarrheal disease in Bangladesh: epidemiology, mortality averted and costs at a rural treatment center. Int. J. Epid. 1, 9, 1972.

3. Horton S. E. and Claquin P. Cost effectiveness study of hospital and of ambulance services at Matlab treatment center. International Center for Diarrheal Dis- ease Research, Bangladesh, Working paper No. 26, 1982.

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distribution of oral rehydration therapy packets Bangladesh. Am. J. trop. Med. Hyg. 29, 285, 1980.

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9. Barnum H., Claquin P. and Farrell M. The Palli Chik- itsak Program of Bangladesh. Submitted to USAID by Health Services International, 1980 (mimeo).

10. Claquin P. Private health care providers in rural Bang- ladesh. Soc. Sci. Med. 15ilk 153, 1981.

11. Barlow H. Health planning in Morocco. Int. J. Hlth Serv. 6, 103, 1976.

12. Rahaman M. M., Aziz K. M. S., Munshi M. H., Patwari Y. and Rahman M. Utilization of a diarrhea clinic in rural Bangladesh: influence of distance, age and sex on attendance and diarrheal mortality. International Center for Diarrheal Disease Research, Bangladesh Scientific Report No. 37, 1980.

13. Khan M., Alam A. K. M. J. and Rahman A. S. M. M. Ten years review of the age and sex of cholera patients. Cholera Research Laboratory Scientific Report No. 14, 1978.

14. Rahaman M. M.,- Aziz K. M. S., Patwari Y. and Mun- shi M. H. Diarrheal mortality in two Bangladeshi villages with and without community-based oral rehydration therapy. Lancet 2, 809, 1979.

15. D'Souza S., Bhuiya A. and Rahman M. Socio- economic differentials in mortality in a rural area of Bangladesh. International Center for Diarrheal Disease Research, Bangladesh Scientific Report No. 40, 1980.

16. Ahmed K., Muda N. and Nath P. C. Nutrition survey of rural Bangladesh 1975-6. Dacca University Institute of Nutrition and Food Science, Dacca, Bangladesh, 1977.

17. Aziz K. M. A. Present trends in medical consultation prior to death in rural Bangladesh. Bangladesh reed. J. 6, 53, 1977.

18. Khan M., Curlin G. T. and Shahidulla. Pattern of medical care for diarrheal patients in Dacca urban area. Cholera Research Laboratory Scientific Report No. 2, 1977.

19. World Bank. Table of wholesale prices of agricultural and industrial products, all Bangladesh: In Country report: Bangladesh---current economic position and short run outlook, 1980.

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