Key Evidence: It is estimated that under current vaccine coverage trends in 41 Gavi-eligible countries, enhanced Gavi funding would help to avoid out-of-pocket health expenditures in an amount that surpasses US$4.5 billion attributable to measles, US$168 million attributable to severe pneumococcal disease, and US$200 million attributable to severe rotavirus.
Cost of Treating Illness
The Cost of Treating Illness sub-topic covers both the economic costs to treat episodes of vaccine-preventable disease, and the power of immunization to help financially protect families from suffering these costs. The evidence on economic costs of illness includes both direct medical costs (e.g. medication, healthcare visits) and indirect costs (e.g. transportation, loss of work or productivity).
6 Key Concepts
Key Evidence: A study of insurance claims in the U.S. for children under five estimated that, from 2007 to 2011, rotavirus vaccination prevented more than 176,000 hospitalizations, 242,000 emergency room visits and more than 1.1 million outpatient visits due to diarrhea -- saving an estimated $924 million in direct health care costs over four years.
Key Evidence: Vaccinating children against rotavirus in Bangladesh would prevent more than 50,000 outpatient visits and 40,000 hospitalizations in children under five each year, and reduce treatment costs by US$5.8 million over 2 years -- nearly all (96%) from fewer hospitalizations. Since this study didn't take herd effects into account, the actual impact would likely be greater.
Key Evidence: If China -- one of the few remaining countries in the world that haven't introduced Hib vaccine in their national immunization program -- decides to include the vaccine in their program, it could actually be cost saving; the vaccination costs would be less than the averted costs of illness from Hib meningitis and pneumonia, if a vaccine price matching UNICEF's (US$2/dose) can be obtained. The vaccination will be cost-effective, but not cost saving, if the program pays the current market price in China of US$10 per dose.
Key Evidence: In a study using actual data on hospitalizations and costs before and after PCV-10 vaccine was introduced in Brazil, an estimated 463,000 hospitalizations from all causes of pneumonia were prevented in persons less than 65 years of age over 5 years following introduction of the vaccine -- saving an estimated US$147 million in hospitalization costs. Half of the costs averted were due to fewer hospitalizations in children under five, who were targeted for the vaccine, while the remaining half were due to fewer hospitalizations in persons 5-49 years of age, as a result of herd protection.
Key Evidence: Vaccination of infants with pneumococcal conjugate vaccines in 180, from the health system perspective, would save an estimated $3.2 billion per year worldwide in treatment costs and an additional $2.6 billion in societal costs (from reduced missed work and out-of-pocket expenditures)- for a total of $5.8 billion. These savings would partially offset the estimated global cost of vaccination of $15.5 billion per year.
From the VoICE Editors: The cost estimates were calculated in international dollars.
Key Evidence: In 41 Gavi-eligible countries, it is estimated that without any rotavirus vaccine (RVV) coverage, an estimated 2.2 million Catastrophic Health Costs (CHC) cases and 600,000 Medical Impoverishment (MI) cases would occur due to rotavirus gastroenteritis. Unfortunately these figures would not significantly decrease under the current immunization forecasts because very few countries have introduced the RVV. However, with the introduction of RVV the number of CHC cases would drop to 1.3 million and MI cases to 400,000, representing a 40% reduction.
Key Evidence: Researchers estimate that vaccinating against 10 diseases in the world’s 94 poorest countries between 2011-2020 will avert US$586 billion in costs of illness (including treatment costs, transportation costs, lost caretaker wages and productivity losses due to death and disability). The 73 Gavi-supported countries account for US$544 billion of the treatment costs averted.
Key Evidence: A study looking at the impact of pneumococcal vaccine introduction and scaling up pneumonia treatment in Ethiopia found that 30-40% of all deaths averted by these interventions would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the bottom income quintile.
Key Evidence: An analysis of the potential impact of pneumococcal conjugate vaccine (PCV) in India found that introducing PCV vaccine will protect the population from potentially catastrophic health expenditures due to treatment and hospitalizations for pneumococcal disease - saving an estimated $49-63 million in out-of-pocket expenditures each year, depending on the assumed vaccination coverage rate. Financial protection will be greatest for the poorest households, with the poorest quintile is estimated to have the greatest savings in out-of-pocket expenditures of all wealth quintiles.
Key Evidence: In a financial risk model analysis of 41 Gavi-eligible countries, the burden of Catastrophic Health Costs (CHC) and Medical Impoverishment (MI) would be greatest in the lowest income populations. With expanded vaccine coverage, the share of prevented cases of measles, pneumococcal disease, and rotavirus, in relation to the total number of cases prevented, would be larger in the lowest income populations thereby providing a larger financial risk protection (FRP) to these populations.
Key Evidence: In a standardized survey of the costs of dengue illness in three highly endemic countries, the economic burden of dengue was greatest on Vietnamese and Colombian low-income families, whose total costs, including lost wages, outpatient and inpatient cases combined, average 36-45% of their monthly household income. In Thailand, although significant, the economic burden was 17% less than the other countries, due to Thailand's universal health insurance system.
Key Evidence: A study in Bangladesh found that families are heavily borrowing or losing assets to be able to bear the cost of pneumonia in their children <5 years of age.
Key Evidence: Three studies in Bangladesh and India found that the direct medical costs for children hospitalized with pneumonia were 27% to 116% of the average monthly income of households. And, while these costs represent a major portion of a family’s monthly income, they don’t include non-medical costs, such as transport and food costs, nor the lost wages of family members who miss work to care for the child.
Key Evidence: During a meningococcal meningitis epidemic in Burkina Faso, households spent, on average, US$90 for treatment and other direct costs for family members with the disease. These costs, the equivalent of one third of the country's annual GDP per capita, were in addition to the loss of income and assets from family members caring for patients.
Key Evidence: Costs for treatment for rotavirus at a large urban hospital in Malaysia led one third of families to experience catastrophic health expenditures (CHC). When direct and indirect costs of treating rotavirus were considered, almost 9 in 10 families spent more than 10% of their monthly household income on treating rotavirus. In addition, 6% of families were pushed into poverty after paying for treatment.
Key Evidence: Children with rotavirus experience longer hospital stays than children with non-rotavirus diarrhea. In a study looking at the direct and indirect costs of treating rotavirus in Malaysia, rotavirus hospitalizations cost families 26% of their average total monthly household income, which was significantly higher than the cost for non-rotavirus diarrhea hospitalizations.
Key Evidence: In a 2002 study from Cambodia, households with a dengue patient had to borrow money at high interest rates and lose productive assets (land) to repay debts linked to healthcare costs. Public healthcare cost significantly less than private healthcare but was either not present where people lived or did not have a good reputation.
Key Evidence: In 41 Gavi-eligible countries it is estimated that, in the absence of any measles vaccine use, approximately 18.9 million households would have Catastrophic Health Costs (CHC) attributable to measles. The number of CHC decreases to 3.4 million households in these countries if the current vaccine coverage forecasts is unchanged and decreases to 2.6 million cases if coverage was enhanced with Gavi support. Overall, optimizing vaccine coverage for measles can reduce by approximately 90% the incidence of CHC due to measles disease.
Key Evidence: In rural Malawi, even though medical care for cholera is free-of-charge in the public sector, more than half of families had to borrow money or sell livestock or other assets to compensate for the lost wages of patients or caregivers and other costs (such as for food and transportation) incurred as a result of an episode of cholera.
Key Evidence: Among families participating in a study in Western Cape, South Africa, 35% of mothers who were previously employed stopped working to care for children who had survived tuberculosis meningitis with permanent disabilities. 19% of families reported experiencing financial loss as a result of caring for these disabled children.
Key Evidence: In a global review of the costs of treating childhood pneumonia, the average costs of a hospitalized case of pneumonia in children under five years of age was US$243 in primary or secondary hospitals in low- and middle-income countries (ranging from US$40 - US$563) and US$559 in tertiary hospitals (ranging from US$20 - US$1,474). In high-income countries, the cost of hospitalized cases averaged US$2,800 in primary or secondary hospitals and more than US$7,000 in tertiary hospitals. Note that in most of these studies, only direct medical costs were included and thus total costs – including non-medical costs and lost wages – would be considerably higher.
Key Evidence: In rural Malawi, where medical care for cholera is free-of-charge, cholera still cost households, on average, US$66 in lost wages of the patient or caregiver and direct, non-medical costs, such as food and transportation. The direct cost to health facilities was $60 per case, twice as much as the 2016 per capita health budget for Malawi that year.
From the VoICE editors: Data on per capita health expenditures by country can be found in the WHO Health Expenditures database here: http://apps.who.int/nha/database/Select/Indicators/en
Key Evidence: In a study in The Gambia – a setting where healthcare is free of charge to patients – pneumococcal disease nonetheless placed a heavy financial burden on families seeking treatment before arrival at the hospital, with families paying for transportation costs, drugs, diagnostic tests and even burial in the case of death. 50-80% of the cost of treating an episode of pneumococcal disease was born by the health system, which still left families to cover a cost up to 10 times their average daily household budget. In addition the estimated treatment cost for inpatient pneumonia of US$109 is nearly 4 times the annual per capita expenditure for health in The Gambia.
Key Evidence: In Malawi, in 17% of cases where children were admitted to the hospital, and in 9% of cases where children were treated as outpatients for diarrhea, household costs associated with treating that episode, exceeded monthly income in a significant number of cases. The costs were significant enough to push families from each income level below the national poverty line for the month in which the illness occurred.