Environmental Health and Child Survival in Nepal: Health Equity, Cost-Effectiveness, and Priority-Setting
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Children in the developing world continue to face an onslaught of disease and death from largely preventable factors. These children are especially susceptible to poor environmental conditions, which put them at risk of developing illnesses in early life. In many developing countries, programs to improve child health have typically focused on improved feeding practices, micronutrient supplementation, national immunization campaigns, and measures to strengthen health systems (improving the availability of drugs, ensuring better treatment of cases, and hiring more trained personnel). However, with continued exposure to contaminated water, inadequate sanitation, smoke and dust, and mosquitoes, children in developing countries are still falling sick, imposing a sustained and heavy burden on the health system. Recognizing the environment’s contribution to overall child survival, there is an urgent need to broaden the spectrum of interventions beyond the health sector. Yet, environmental health interventions (which are defined as those aimed at environmental risks such as inadequate water and sanitation, and indoor air pollution) remain relatively neglected in the process of devising and implementing child survival intervention packages in most developing countries. In this thesis, only environmental health risks associated with sanitation coverage is addressed. In developing countries like Nepal, sanitation coverage (defined as access to improved sanitary facilities)–an important contributor to child health – has been overlooked (JMP 2012). Politically, attention to provide access to water, especially piped water, has received much more attention, and strategies to expand access to water have often focused on urban areas. This neglect of sanitation becomes even more stark when one looks at it through the lens of health equity – with lower socio-economic sections (as measured by wealth quintiles) of the population being disproportionately impacted. This dissertation, through three related papers, employs different types of analyses to investigate the importance and relevance of including environmental health interventions such as sanitation to address child health. These three papers focus on Nepal – where poor environmental conditions and malnutrition together continue to threaten child survival and development. The first paper highlights how expanding sanitation coverage may have the potential to differentially impact the poor, and may contribute to reducing health inequities across wealth quintiles in Nepal. The second paper investigates if cost-effectiveness of environmental health interventions to address diarrhea in children under five years old in Nepal varies across wealth quintiles. The third paper studies how environmental health interventions are prioritized among child health interventions by public health decision-makers in Nepal. The first paper involves an estimation of the lives saved under two scale-up scenarios for improved sanitation in Nepal at the national level and across the 5 wealth quintiles using the Lives Saved Tool (LiST). This paper attempts to demonstrate the differential impact on child mortality and diarrheal incidence of scaling up sanitation coverage across wealth quintiles, through the use of the LiST model. The results suggest that many more lives of children under five are saved when sanitation scale-up is targeted to the lowest quintiles. It is important to note that welfare improvements made by sanitation clearly may go beyond child mortality; providing a healthier environment to children is likely to not only affect their short-term, but also their long-term physical and mental development, labor-force productivity, and lifetime earnings (Alderman et al 2006; Grantham-McGregor et al 2007; Lorntz et al 2006; Maluccio, Hoddinott, and Behrman 2006). The second paper estimates how cost-effectiveness of sanitation scale-up may vary across wealth quintiles in Nepal. Results suggest that incremental cost-effectiveness ratios (ICERs) associated with scaling up sanitation are relatively low across all wealth quintiles in Nepal, and may be comparable to other child health interventions such as vaccines. Between the equal scale-up and pro-poor scale-up scenarios, there are no real differences in the ICERs for each quintile. This demonstrates that for Nepal, from a cost-effectiveness (efficiency) perspective, there is no advantage of a pro-poor scale-up approach (however, for equity reasons, this may still be valid). A sensitivity analysis showed that while the scaling up of sanitation can be cost-effective, the degree of cost-effectiveness is sensitive to the intervention costs, diarrhea incidence, and effectiveness ratios. The absence of information/ research on differences in sanitation effectiveness across wealth quintiles, as well as the poor information of sanitation costs disaggregated by wealth quintile and type of technology, limits the interpretation of these results. The first two papers present the equity and efficiency (cost-effectiveness) perspective when looking at scaling up sanitation. In health systems around the world policymakers share the common concern on how to find the right balance between these objectives. Ultimately, decisions on such programs to address child health involve prioritization of interventions across health and non-health sectors. The third paper uses a multi-criteria decision making approach to better understand how environmental health interventions might be prioritized relative to other interventions relevant for child health in Nepal. For this a discrete choice experiment survey was conducted in Kathmandu, with responses received from forty-six sanitation and public health decision-makers. This explorative analysis suggested that non-health benefits may be relevant in priority setting in child health while including a larger range of relevant criteria for priority setting. Environmental health interventions (both water and sanitation – which help reduce diarrheal incidence, as well as rural clean energy solutions –which help reduce incidence of acute respiratory infections) may be ranked as the highest priority in the context of child health in Nepal. Together, these papers help investigate the attractiveness and potential for the inclusion of environmental health interventions within the scope of broader child health programs in developing countries like Nepal. More generally, this thesis illustrates the potential benefits of building on and extending various existing tools and methodologies to a range of environmental health interventions which lie outside the health sector. It also specifically applies these methodologies at a disaggregated level (by wealth quintiles) to explore the differences across the socioeconomic sub-groups. There are still need for more customized and country-specific research needed on intervention effectiveness and costs, including specifically in programmatic settings to gather evidence on scalability and sustainability. Uncertainty in several parameters and the lack of data at a disaggregated level limit the generalizability of the findings. But the economics of sanitation –from an equity-efficiency perspective –as shown in this thesis can help to inform the policy dialog on scaling up sanitation for better child health. This is an important step towards addressing the unfinished health agenda among the most vulnerable groups—children less than five years of age and in poorer households, who are disproportionately exposed to and affected by health risks from environmental hazards.