ECONOMIC EVALUATION OF THE COSTS AND COST-EFFECTIVENESS OF THE DIARRHEA ALLEVIATION THROUGH ZINC AND ORAL REHYDRATION THERAPY PROGRAM AT SCALE IN GUJARAT, INDIA
Shillcutt, Samuel Dedman
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Problem: Diarrhea is the third leading killer of young children, with India bearing the largest national burden. Effective and low-cost treatment is available through oral rehydration salts and zinc supplementation, and trial based literature suggests that these interventions are cost-effective. However, coverage of these interventions remains low, and strategies are being developed for scaling them up. It is less certain whether this health systems strategy is cost-effective at scale, or what economic impact it will have on caregivers. This dissertation evaluates the Diarrhea Alleviation through Zinc and ORS Treatment (DAZT) program in rural Gujarat India in terms of impact on caregiver costs, cost-effectiveness, and cost-effectiveness of different bundles of diarrhea and pneumonia prevention and treatment interventions. Methods: The influence of factors on the odds and amount of economic costs to caregivers was evaluated with a two part model. Due to the non-randomized study design, a net-benefit regression approach was used to evaluate cost-effectiveness while controlling for covariates. Cost-effectiveness of bundled services was evaluated with a mathematical model using probabilistic sensitivity analysis to evaluate uncertainty, and the Lives Saved Tool to project the number of deaths averted over five years. Results: The DAZT program was not associated with a change in odds of incurring an economic cost, although was associated with a $2.12 lower amount spent controlling for covariates. While a 14% to 11% reduction in diarrhea prevalence was observed, it is difficult to infer causality due to study design limitations. Estimates of cost-effectiveness were highly dependent on covariates included, never achieving 95% certainty in the fully specified model. The cost-effectiveness of the program bundled with other services was favorable relative to a ceiling ratio of per capita Gross National Income. Conclusions: It is inconclusive whether the DAZT intervention is a good investment in rural Gujarat based on its impact on diarrhea outcomes, although was cost saving to caregivers. With investment decisions based on expected values of the data taken at face value, the program is recommended in terms of cost-effectiveness. Zinc and oral rehydration salts may be bundled with other services, while maintaining cost-effectiveness.