Determining the cost-effectiveness of managing acute diarrhoea through social franchising of ORASEL: a randomised controlled trial

Abstract

BackgroundOral rehydration solutions (ORS) along with zinc supplementation (ORS-Z) can reduce mortality more so than plain ORS if properly prepared and administered. Because ORS-Z is still infrequently used in many rural settings, health planners are looking for strategies to increase coverage wherever children can be reached. Given the high number of children seeking care for diarrhoea in the private sector, this study examined the cost-effectiveness of a strategy to introduce a Population Services International (PSI)-developed ORS-Z product, an ORASEL Kit, into a network of private providers. The cost-effectiveness analysis was conducted in the context of data on programme impact from a community-level, cluster randomised trial of the introduction of ORASEL through a social franchising programme. MethodsEconomic costs were obtained from a societal perspective inclusive of programme, provider, and household costs for the 2010 calendar year. Data were gathered during key informant interviews with staff in the central Yangon, Myanmar (Burma) office as well as through PSI payroll and cost data. We also estimated providers' retail costs as well as patients' opportunity costs of care seeking. Incremental cost-effectiveness relative to status quo conditions was calculated per child death and disability-adjusted life-year (DALY) averted in 2010. Health effects included deaths and DALYs averted with a 3% discount rate; the former modelled based on coverage estimates obtained through a cross-sectional household survey and inputted into the lives saved tool. Uncertainty was tested with acceptability curves and other sensitivity analyses. FindingsThe children in the treatment arm of the trial had a 13·7% (95% CI 7·3–20·2) point increase in probability of using ORASEL for a case of diarrhoea compared with no treatment or plain ORS. Based on the model, this would translate to 3·12 deaths averted in a population of 10 000 person-years. The incremental cost-effectiveness of the franchised approach to improving ORASEL coverage is estimated at US$2557 (2457–2568) per death averted and $94·50 (94·13–94·89) per discounted DALY averted. InterpretationDistribution of ORASEL through private sector franchising is highly cost effective according to the thresholds set forth by the Commission for Macroeconomics and Health. Results are comparable to other priority interventions recommended for adoption in south Asia by the Disease Control Priorities Project and are anticipated to contribute to the discourse on achieving the fourth Millennium Development Goal. Further work is recommended to assess the cost-effectiveness of this delivery modality in other settings. FundingBill & Melinda Gates Foundation.