Voice of America, June 2014
At the second anniversary of USAID's Child Survival Call to Action, USAID...
Studies on the cost-effectiveness of rotavirus vaccines might sound like pretty dry pursuits. Though I find science fascinating, nothing makes my eyes glaze faster than talk of monetization and math. But when I learned about the paths that investigators tread to learn how a new vaccine will impact communities where diarrhea is a matter of life or death, I found out that cost-effectiveness has a pretty personal side.
I asked Deborah Atherly and Mercy Mvundura, both health economists at PATH, to share their experiences conducting these studies and explain why costing research is essential to vaccine advocacy and saving lives. They are currently conducting cost-of-illness studies on childhood diarrhea in Rwanda and Malawi.
What does cost-effectiveness mean in the context of new vaccine introduction?
Deborah Atherly: Cost-effectiveness analysis is a method to help decision-makers understand the true value of a vaccine; that is, what are the benefits, and how much does it cost to realize those benefits?
So a main objective is to gather data to make the case for new vaccines to policymakers.
DA: The data help them understand how important vaccination is, particularly in areas where vaccination rates are low. For example, we did a study in Senegal for Hib meningitis and found that the direct costs to families for one child’s illness literally equaled the average annual income. Yes, Hib meningitis is a more rare occurrence than childhood diarrhea—but not for the child who gets it, not for their family.
We were able to communicate this finding to the government, and they walked away saying, “Wow, we really need to make sure that people can access the Hib vaccine.” They were a bit startled by the cost.
A sad reality that we see in these studies, though, is that the people who show up to the hospital are the ones who can afford it. Who we’re missing are the kids who die because their families can’t afford care. That makes universal vaccination all the more important.
Mercy Mvundura: You see this in the studies that we’re doing, where you ask families about the sources of funds to pay for hospitalization, and you can see that even with a simple diarrhea hospitalization, they may have to sell assets, rely on support from their communities, borrow from relatives, or tap into savings—if they have them—in order to be able to pay for a hospitalization.
What are the steps to gather these data from families? Walk me through the study methods.
DA: In Rwanda and Malawi we are conducting cost-of-illness studies, working with the Ministries of Health, WHO and also in partnership with the US CDC and University of Liverpool, respectively, which are conducting disease surveillance. The CDC and Liverpool researchers identify all child diarrhea cases that come into a hospital. If their participants also consent to enroll in our study, our investigator asks caregivers a series of questions about how long a child’s been ill, where they were seen before the hospital, what costs they have incurred to date. These are clinic costs, but we also ask about transportation costs to get to the hospital.
When the child is in the hospital, we collect information from their medical record: the medications they were given, staff time in caring for them, lab tests. We try to cost out all parts of their hospital care.
MM: Afterwards, when they are discharged, we follow up with caregivers to understand how much they paid for the hospital visit and the sources of the money they used to pay. We also try and capture information around their economic status. We ask whether they missed work, how many days, what is their salary.
Finally, we collect data from the hospital billing department to bring it all together.
DA: Ideally, we want to determine, from start to finish, the average cost of treating a child for diarrheal disease. We break that down into household costs and costs borne by the government or system. Thanks to the parallel CDC and Liverpool studies, we will also know the rotavirus status, so we can stratify according to whether rotavirus or another cause is responsible for the diarrheal episode.
MM: We also can look at the length of hospital stay, to see whether it differs between children who are diagnosed with rotavirus versus other types of diarrhea.
How do you relate that back to explaining to a government how introducing rotavirus vaccine is going to offset these costs?
DA: We use this cost-of-illness data to discuss cost-effectiveness. Health and finance ministers have to consider how much a new vaccine is going to cost. But what they might not think about are the potential cost offsets. That’s the perspective that our data provide: a very quantitative estimate of the financial impact: reduced costs through introducing rotavirus vaccine.
We take the cost of vaccine minus the costs that would be offset to determine the total net cost of vaccine introduction. Then you put that into the equation against the actual benefits of the vaccine. We take our cost per hospitalization and multiply it by the number of hospitalizations averted, drawing from the surveillance data that the CDC and Liverpool are collecting. This helps us reach a financial estimate of what we think a country could save with universal, routine rotavirus vaccination.
Because Rwanda and Malawi have already introduced rotavirus vaccines, how are the data useful to them, and how are they useful to other countries?
DA: In a couple years, several countries will graduate beyond the GAVI Alliance subsidy for rotavirus vaccines and need to take on the full cost. As the bill goes up, Ministries of Finance will want to know, what is the value? Data on how many deaths can be averted speak volumes. Cost-effectiveness helps to show that. We also include information on how the demand for public health services will go down because fewer children are coming to the hospital with severe diarrhea. We make the case for keeping GAVI-funded vaccines in the public health system when the country’s investment costs increase.
In your research experiences, have there been findings that surprised you?
DA: When we ask what kind of work they are missing, many mothers say “childcare.” That is so much more real than I ever imagined. Families typically don’t just have one child. They have many children. If one is sick, then to take them to the hospital, which may not be down the street, they’re leaving their other children with someone else. Here, we think of it differently. We often can easily find care or pay someone to watch other children. These mothers have to make sacrifices we might not consider in terms of their other kids. We also find that many women won’t go to the hospital until the child is literally close to death, because it’s such a big sacrifice to leave, find care for the other children, and find the transport to get to the hospital.
MM: And our perspective is coming from a society that generally undervalues staying at home. When you start trying to quantify “productivity loss” for a primary caregiver, you may think to apply minimum wage, as opposed to someone who has a set salary.
Which most stay at home mothers would argue is not enough.
DA: Yes, exactly. That’s universal no matter where you live.Read more
What appealed to you about joining PATH?
I was a research scientist conducting large scale clinical trials mostly on vaccines. However, after the trial results were declared there was nothing more I could do in terms of advocacy, preparedness planning, and execution. As a public health person, I would like to see the introduction of the some of these critical vaccines in the national programs.
As the lead on the Multi-Country Japanese Encephalitis (JE) Project, how do you propose to shape the project? What kind of achievements are you expecting?
Since the JE vaccine has been pre-qualified (an approval issued by the World Health Organization (WHO)), there are several countries that would be willing to adopt the vaccine in their EPI program. However, most countries do not have robust surveillance system in place. Our first commitment will be to set this up in collaboration with WHO in countries like Myanmar, Indonesia, and Bhutan. For countries having proper surveillance in place, we will help them apply to GAVI to help afford the vaccines. For non-GAVI countries (like Philippines) we will need to have some innovative plans. We will also organize bi-regional meetings (via the WHO regional networks) for uniformity across the board. The final achievement will be strategies to ensure strong surveillance and introduction of the vaccines into the national program in JE endemic countries.
You are a well known expert on diarrheal diseases and cholera. Could you tell us about the GEMS research that you recently concluded?
It was a multi-country case-control study to identify the causative organisms of moderate to severe diarrhea in children less than 5 years of age. The study showed excess risk of infection (ERI) highest for rotavirus infection in all seven countries, followed by Shigella, cholera, etc. according to different age groups. The final objective of this study was prioritization of vaccine introduction in each country.
What kind of projects will you be handling in your new position at PATH?
Mostly challenging immunization issues – and supporting Indian authorities with technical help in the introduction of vaccines and formulating vaccination strategies for the national programs. These will include support in the form of manpower development, advocacy, micro- planning and related issues.
Do you think that leaders in India recognize the high toll of diarrheal disease?
Unfortunately no! Probably because it is seen as a disease of the poor and is not given enough importance. Also there is no glamour around those working with diarrheal diseases in comparison to some of the high profile health campaigns in the country.
What is needed to help everyone pay more attention to this challenge?
Proper surveillance data is needed to convince policy makers and advocacy for the available and affordable vaccines. Also scientists need to be more vocal in their approach to decision makers.
You have come from a respected Indian Government organization. What learning do you bring to PATH?
There are many issues which are beyond the capacity or purview of government organizations to resolve. This is where the role of agencies like PATH becomes so vital. PATH has to support and co-ordinate these activities with the government so that the public health services are delivered to the community efficiently and effectively.Read more
You’ve heard of shopping, of course. Clothes shopping, grocery shopping, even furniture shopping. But how many of you have ever thought about toilet shopping? Did you ever stop to wonder who picked out that light blue toilet in your neighbor’s house? Or that plain while toilet in your office building? How about the toilet in your very own home?
Until a few weekends ago, toilet shopping was not part of my repertoire. But now that my husband and I are renovating our house, I’m shopping for all sorts of interesting things – like toilets!
Luckily for us, there is a place for home renovators who need toilets – a bathroom emporium. Sinks! Toilets! Bath tubs! All there for you to test, try, and possibly make your own. While bathroom shopping at the emporium, we were able to test all sorts of toilets – high end, low end, modern, traditional.
While considering the color, shape, and model of our new toilet, I couldn’t help but think about PATH’s global health work. Part of our scope of work – like so many of our partners - includes a focus on reducing diarrhea and pneumonia morbidity and mortality, and a proven way to reduce these diseases is by improving access to sanitation and hygiene. But in the countries where we work and travel, how many people have access to improved sanitation, let alone a toilet emporium? How many toilet emporiums exist in Ethiopia? What about India? How many people can just point to a toilet and have it delivered to their home, confident that it will be connected to water and sewer and flushing in no time?
In how many countries could a woman unashamedly go toilet shopping with her husband? What I was able to do freely and without ridicule, many women would never dream. In many countries a husband or father makes decisions about family expenditures and whether or not a latrine is a valuable expense. Forget color and size, or choosing the modern model. In so many countries where we work, a standard latrine slab is the only choice. You either get one or you don’t.
I developed a new appreciation for the ease with which I can find a toilet or wash my hands – at home, at work, at a restaurant, or on a plane. Not every community needs a toilet emporium of their own, but every community does need access to clean, safe, hygienic sanitation facilities.
Next time you go to the bathroom, consider how comfortable you are. How high or low the toilet is. Whether it automatically flushes, or you have to face the grimy handle. And then consider the more than 2 billion people globally who don’t have this luxury. They’re unable to access any time of improve sanitation, let alone a self-flushing, shiny, new model. As we race towards 2015, the sanitation Millennium Development Goal looms far in the distance. What really matters are the millions of boys, girls, women, and men we need to reach with a toilet. A simple, clean, functioning toilet.
For more information:
-- PHOTOS: WaterAid in America sponsored a different kind of bathroom emporium to commemorate World Toilet Day.
-- You use the toilet every day; why not celebrate it every day? Download our Places We Go 2014 calendar.
-- PHOTOS: What if every time you flushed you could make a wish?Read more
Originally posted on the PATH blog.
Recently, Bill and Melinda Gates released their annual letter, which took on three persistent myths that block progress for the poor. In the same spirit, this week we’re debunking six myths that impede progress in global health. Today we tackle:
Mythbuster: Dr. Alfred Ochola, technical advisor for child survival and development for PATH’s Kenya Program.
As a doctor and as a father, I am saddened by this myth because it costs many innocent children their lives. Even though diarrhea is a leading killer of children here in Kenya, mothers believe that it is “just diarrhea”—that it is not a serious problem. In fact, it is because of this myth that parents often bring their children to the hospital with complications like dehydration only after it is too late.
The reason diarrhea is a killer of children less than five years old is because dehydration is dangerously rapid in young children—often developing within just a few hours. And to make it worse, mothers believe other dangerous myths, for example, that one should withhold fluids from a child with diarrhea. Nothing could be worse!
The good news is that diarrhea is preventable and treatable. Throughout rural Kenya, my colleagues and I have set up 365 oral rehydration therapy corners in clinics, where children receive a simple mixture of sugar, water, and salt called oral rehydration solution that quickly treats dehydration, along with zinc tablets. It is amazing to see their eyes become bright and cheerful after just a few hours, especially after their situations were so dire.
The hours children spend in oral rehydration therapy corners also provide an opportunity to teach mothers about the importance of breastfeeding, hygiene, and other ways to prevent dangerous diarrhea from recurring. We also use radio programs and community health workers as opportunities to share these important health messages with the community.
Political will is important to continue the fight, and I am thrilled that the Government of Kenya adopted a national policy for diarrheal disease prevention and treatment. We have the solutions. What we need is improved access and greater awareness to fight dangerous myths and practices. All children get diarrhea, but I hope for a day where no child will die from it.
For more information:
-- VIDEO: Follow Alfred through Western Kenya as he demonstrates how a cup, a corner, and a community are defeating diarrhea
-- PHOTOS: Restoring oral rehydration therapy corners in Western KenyaRead more
The State of the Union (otherwise known as the “SOTU” to political wonks like myself) is a big deal inside the Beltway, where people either flock to bars like it’s Super Bowl Sunday or hold watch parties with bingo cards filled with policy buzzwords.
During last year’s State of the Union, President Obama stated that the United States would join our allies to eradicate extreme poverty and save the world’s children from preventable deaths. So, I, along with many who watched last night, was all ears to hear what would be said about global health as a national priority this year.
This year’s message about global health hit close to home for the work we do at PATH: innovation, research, and developing new tools to fight global bugs. I’m sure you can imagine my delight (I said I’m a wonk!) when President Obama mentioned “federally-funded research” and recognized that “there are entire industries based on vaccines that stay ahead of drug-resistant bacteria.” While this statement was modest compared to last year, the President’s recognition of these important US contributions to global health is significant. Without lifesaving research, we would be unable to reevaluate existing technologies, and search for new and innovative ways to deliver lifesaving solutions to people around the world.
In an age where policy issues are in constant competition for attention from our leaders, the global community should acknowledge that the US President made note of global research in a largely domestic speech. As I listened last night, I was encouraged by this recognition. I hope that the global health community saw this as a win as well, and believe that we should celebrate the fact that our messages are resonating with policymakers and galvanize us to do more to influence policymakers to make strong investments in global health, and particularly in innovation.
Photo credit: SXCRead more