S U P P L E M E N T A R T I C L E
Exploring Household Economic Impacts of
Childhood Diarrheal Illnesses in 3 African
Richard Rheingans,1Matt Kukla,1Richard A. Adegbola,2,3Debasish Saha,2Richard Omore,4,5Robert F. Breiman,6
Samba O. Sow,7Uma Onwuchekwa,7Dilruba Nasrin,8Tamer H. Farag,8Karen L. Kotloff,8and Myron M. Levine8
1Department of Environmental and Global Health, University of Florida, Gainesville;2Medical Research Council Unit, Fajara and Basse Stations, The
Gambia, West Africa;3GlaxoSmithKline Biologicals, Global Medical Affairs, Wavre, Belgium;4Kenya Medical Research Institute / Centers for Disease
Control and Prevention (KEMRI/CDC),5Centre for Global Health Research, Kenya Medical Research Institute, Kisumu,6Global Disease Detection
Division, Kenya Office of the US Centers for Disease Control and Prevention, Nairobi;7Center for Vaccine Development–Mali, Bamako; and8Center for
Vaccine Development, University of Maryland School of Medicine, Baltimore
Beyond the morbidity and mortality burden of childhood diarrhea in sub-Saharan African are significant
economic costs to affected households. Using survey data from 3 of the 4 sites in sub-Saharan Africa
(Gambia, Kenya, Mali) participating in the Global Enteric Multicenter Study (GEMS), we estimated the
direct medical, direct nonmedical, and indirect (productivity losses) costs borne by households due to diar-
rhea in young children. Mean cost per episode was $2.63 in Gambia, $6.24 in Kenya, and $4.11 in Mali.
Direct medical costs accounted for less than half of these costs. Mean costs understate the distribution of
costs, with 10% of cases exceeding $6.50, $11.05, and $13.84 in Gambia, Kenya, and Mali. In all countries
there was a trend toward lower costs among poorer households and in 2 of the countries for diarrheal illness
affecting girls. For poor children and girls, this may reflect reduced household investment in care, which may
result in increased risks of mortality.
As a leading cause of global child mortality, the
primary impact of diarrheal disease is the health
burden borne by children <5 years of age and their
families . However, there is also a growing aware-
ness of the economic burden created by diarrheal
disease. Several studies have attempted to estimate the
economic burden of illness, especially that portion as-
sociated with the healthcare system [2–6]. Estimating
these costs is critical for evaluating potential interven-
tions to reduce the health burden, whether through
vaccination, improved water and sanitation, or others
, given that these costs can partially offset the re-
quired investment. Less is understood about the
household economic burden associated with diarrhea.
Although this may be small in absolute terms, it may
be substantial relative to incomes of low-income
households, resulting in reduced care seeking and
Although most episodes of diarrheal illness can be
treated inexpensively with timely diagnosis , evidence
suggests that many low-income families lack access to
high-quality, low-cost treatments for diarrheal illnesses
or simply fail to utilize appropriate care [9, 10]. Reasons
for such access and utilization barriers range from a
lack of healthcare provision to poor transportation and
even climate conditions [11, 12]. There is also reason to
believe that access to and utilization of care for diarrheal
illness may be driven by household economic and cost
constraints [11, 13, 14, 15]. Conversely, reducing out-
of-pocket expenses stimulates greater demand and utili-
zation for healthcare [16,17].
aPresent affiliation: GlaxoSmithKline Biologicals, Global Medical Affairs,
Correspondence: Richard Rheingans, PhD, Department of Environmental and
Global Health, University of Florida, Box 100188, 101 S Newell Dr, Gainesville,
FL 32610 (email@example.com).
Clinical Infectious Diseases 2012;55(S4):S317–26
© The Author 2012. Published by Oxford University Press on behalf of the Infectious
Diseases Society of America. This is an Open Access article distributed under the
terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/3.0/), which permits unrestricted reuse, distribution, and reproduction in
any medium, provided the original work isproperly cited.
Household Costs of Diarrhea in Africa • CID 2012:55 (Suppl 4) • S317
Understanding these relationships is crucial for policy-
makers, particularly given health financing debates over user
fees and other cost-sharing mechanisms . For instance, al-
though user fees may be effective options for discretionary
care, they can have adverse impacts when applied to primary
care or preventive services like diarrheal illness care .
Studies in several African settings have shown that reductions
in user fees are more likely to stimulate demand for public
healthcare services and that revenue collected from user fees
are often not efficiently spent [17, 19–21]. Mwabu et al 
found that during a period of modest cost sharing in Kenyan
public clinics, demand dropped by nearly 50 percent.
This paper explores these issues using baseline survey data
collected from 3 of the 4 African sites (Kenya, Gambia, and
Mali) participating in the Global Enteric Multicenter Study
(GEMS) prior to the onset of the main GEMS case/control
study. The health economics substudy has 3 related objectives:
to (1) estimate and characterize household costs associated with
childhood diarrhea episodes by type and setting; (2) explore
how child and household characteristics alter cost patterns; and
(3) explore whether and how high costs can serve as a barrier to
care or contribute to impoverishment of the household.
This study uses data from the GEMS on acute diarrheal care
in 3 African countries—Kenya, Gambia, and Mali. These
countries were chosen in part owing to their relatively high
rates of diarrheal illnesses and early childhood mortality. The
sampling of households as part of the baseline Health Utiliza-
tion and Attitudes Survey (HUAS) that preceded onset of the
GEMS case/control study is described by Kotloff et al in this
supplement . Retrospective data were collected on house-
hold costs for children <5 years of age with diarrhea in the
previous 2 weeks. Data were collected using a standardized in-
terview from an age-stratified random sample of approximate-
ly 1000 households containing a child 0–59 months of age
within each study area (described in ). Analyses were
weighted on the basis of probability of selection. Each site
aimed to enroll 400 infants 0–11 months of age, 370 children
12–23 months of age, and 370 children 24–59 months of age.
Sample sizes varied among countries and are presented in
Table 1. The initial household sampling was expected to be
large enough to identify approximately 200 children with diar-
rhea during the previous 2 weeks and 150 children with
Table 1.Study Population Characteristics and Subsamples
None to primary
(69)183 131 108
All data are presented as No. (%).
S318 • CID 2012:55 (Suppl 4) • Rheingans et al
household costs associated with the episodes. Based on World
Health Organization methods for estimating diarrheal costs
, this was expected to be sufficient to produce estimates of
means with a confidence interval of ±10% of the true mean
with 80% power. The observed power in each country varies
based on the variance in costs within each and the actual
number of episodes. Sample sizes were not powered for sec-
ondary analyses to detect differences among subgroups.
We examined direct medical, direct nonmedical, and indi-
rect costs. Direct medical costs (eg, medications, visits, diag-
expenditures, with the former representing care provided by a
local healer or provider and the latter combining both outpa-
tient and inpatient care. Outpatient and inpatient facilities at
each site are described in more detail in Kotloff et al , but
outpatient facilities were primarily health centers and private
doctors’ offices, while inpatient facilities were primarily public
district hospitals. Direct nonmedical costs were broken down
by transportation and other costs, whereas indirect costs were
based on time lost from income-generating employment. For
both medical and total costs, some cases incur no costs and
the remainder of episodes typically produce a right-skewed
distribution. Descriptive statistics (means and standard errors)
for costs are provided for all cases, those incurring medical or
other costs, and the proportion incurring costs (Table 1).
Costs were collected in local currencies, converted to US$, and
adjusted to 2011 as the reference year.
We also examined how child, household, and episode char-
acteristics were associated with the costs incurred by house-
holds. This was analyzed separately for direct medical costs
and total costs. Analysis of variance was used to assess the
effect of household economic status, maternal education, child
sex, age, duration of illness, and illness severity. Multivariate
analysis was considered, but not presented owing to the
limited sample size. This analysis was conducted separately for
all episodes and those incurring medical or any costs. Logistic
regression was used to estimate the effect of these variables on
the likelihood of costs being incurred by the household.
Household economic status is based on an asset index calcu-
lated using principal components analysis using the full
household sample for each country . Maternal education
was broken down into 4 categories: none to some primary,
completed primary education, some secondary education, and
religious education only. Because of the limited sample size
and power, we considered P<.05 as statistically significant
and P values between .05 and .20 as marginally significant.
Given the empirical evidence citing costs as a significant
factor driving healthcare behavior and utilization, we exam-
ined the potential impact of costs on household impoverish-
ment and avoidance of care due to economic costs. This is
done by examining respondents’ self-reported reasons for not
seeking care and strategies for paying for the costs. We also
examined the distribution of costs to households and the pos-
sibility of large expenditures.
Expenditures by Type and Category
Table 2 displays costs of diarrheal episodes by type (direct
medical, direct nonmedical, and indirect), type of medical
(consultations, medications, and diagnostic), and setting of
care (formal and informal). Mean costs and standard errors
are calculated for all episodes and for those incurring a cost
and listed for each category.
Of respondents reporting an episode of diarrhea in the pre-
vious 2 weeks, 35%, 65%, and 68% incurred some costs in the
GEMS sites in Gambia, Kenya, and Mali, respectively. The
mean total household costs per episode ranged from $2.63 in
Gambia to $6.24 in Kenya, and the total cost among those
with nonzero costs ranged from $6.01 in Mali to $8.83 in
Kenya. Direct medical costs accounted for 11%, 27%, and 54%
of that total cost in Kenya, Gambia, and Mali, respectively.
Household indirect costs (productivity losses) accounted for
more than half of the total cost in Gambia and Kenya and
somewhat less (42%) in Mali. In Gambia and Kenya, expendi-
ture on care from informal providers was more than that of
formal providers. In Mali, expenditure on informal care was
even greater than in Gambia or Kenya, but only accounted for
24% of the direct medical expenditure. In all 3 countries, med-
ications (whether medically indicated or not) accounted for
the majority of the direct medical cost, ranging from 77% in
Gambia to 86% in Kenya.
In addition to mean costs, we examined the distribution of
costs to better understand how high-cost events might affect
households. The distributions of total costs by wealth quintile
for each country are shown in Figure 1. In Gambia, among all
children 25% of episodes resulted in costs over $1.73, in 10%
the cost was over $6.50, and in 5% it was over $15.27. In
Kenya the distribution was higher with 25% having costs over
$4.93, 10% having costs over $11.05, and 5% having costs over
$21.20. In Mali the costs were similar, with 25% over $4.26,
10% over $13.84, and 5% over $20.77.
Determinants of Costs
We examined the effect of household economic status, mater-
nal education, child sex, child age, disease severity, and disease
duration on the likelihood of incurring direct medical costs
and the mean household cost (for all episodes and those in-
curring costs) for each of the 3 countries (Table 3). For each
determinant the table shows the probability of incurring a cost
and the mean household cost. P values represent a bivariate
comparison of differences among the different subgroups for
Household Costs of Diarrhea in Africa • CID 2012:55 (Suppl 4) • S319
each determinant. For many of the determinants, low sample
size in the subcategories (Table 1) led to limited statistical
In all 3 countries, there was a trend toward differences by
economic status for both medical (Table 3) and total costs
(Table 4). For medical costs, there were increased expenditures
for children in high-wealth quintiles. For Gambia and Kenya
this was found for both mean costs among all episodes and
among episodes with nonzero costs. For Mali, direct medical
costs exhibit an inverted U-shaped curve with lowest costs
among the poorest quintile and highest costs among children
in the middle and upper wealth quintiles for both all episodes
and those with nonzero costs. These trends were statistically
significant (P<.05) or marginally significant (P<.20). In all 3
countries, medical costs per episode were 2–3 times greater in
the highest wealth quintile compared with the lowest. Trends
were similar for total household, but only statistically signifi-
cant for Mali and Gambia.
In Mali and Gambia there were significant or marginally
significant differences in household medical and total costs by
sex. For both countries, household direct medical and total
costs for boys were approximately twice that for girls;
however, the differences were only marginally statistically sig-
nificant. For Kenya there were no differences by sex.
Although there were country-level differences in medical
and total costs by maternal education, there were few clear
patterns within or among countries. There were no clear asso-
ciations between child age and household medical or total
costs within or across countries.
In Kenya and Mali, there were higher household medical
costs for moderate-to-severe episodes (all episodes and those
with nonzero costs). However, there was no such association for
Gambia. Total household costs were higher for moderate-to-
severe cases only in Mali. Duration of illness was also associated
with household medical and total costs in Gambia and Mali.
Costs as a Barrier and Cause of Impoverishment
Table 5 shows household reasons for not seeking care or hos-
pitalization and payment method for the expenses associated
with the episode. Across all 3 countries the main reasons for
not seeking hospital care when advised were either not believ-
ing their child needed care or that the costs were too high.
Broken down further, 55.8% of Kenyan households seeking al-
ternative forms of care did so because they felt hospital treat-
ment or transportation costs were too high; nearly 18% did
not think their child was sick enough to seek hospital care.
Among Gambian households, these figures are 22.2% and
48.1%, respectively. Among Malian households, they are
roughly 53% and 30%.
Similar results were found among those not seeking any
care. Among all 3 countries, the most common reasons for
not seeking any care was that, on average, 53.4% of all
Table 2.Household Costs Associated With Diarrheal Illness by Type and Setting (2011 US$) in Gambia, Kenya, and Mali
Cost by Type
Direct medical cost by setting
Direct medical cost by purpose
0.490.151.25 0.37 0.410.06 0.590.09 0.600.12 0.870.17
0.22 0.06 0.560.16 0.280.060.400.09 1.600.392.34 0.56
S320 • CID 2012:55 (Suppl 4) • Rheingans et al
households believed their child did not need care for his or
her illness. Among Kenyan families, treatment and transporta-
tion costs were close behind (41.2%), followed by a high
demand for traditional medicine (17.4%), too far a distance
(12.7%), and lack of transportation (9.5%). For Gambia, these
included treatment costs (22.5%), transportation costs (10%),
and preference for traditional medicine (10%). For Malian
households, treatment and transportation costs (26.6%) and
preference for traditional medicine (10%) were also common
reasons. The data indicate that households either believe their
child does not need care or, if he or she does, costs are too
The GEMS case/control study, the keystone of GEMS, is in-
tended to provide information on the etiology and burden of
moderate-to-severe diarrhea and its nutritional and mortality
consequences. However, as part of the rationale for undertak-
ing GEMS, we also wished to expand the assessment of
burden by gathering information on the direct and indirect
economic costs of diarrheal disease in sites where the case/
control study would be carried out. Our results document a
substantial economic burden stemming from diarrheal disease
and provide an additional reason to support interventions to
control the incidence and severity of diarrheal disease.
What Are the Costs and Where Do They Occur?
Our results suggest that households encounter a substantial
economic burden due to childhood diarrhea in the 3 settings.
For episodes with nonzero costs, the mean total cost ranged
from $6.01 in Mali to $8.83 in Kenya. When all episodes are
considered, the range was $2.63 in Gambia to $6.24 in Kenya.
Although these amounts may seem small in absolute terms,
these are settings where a substantial portion of households
live on <$1 per day. In addition, diarrhea is frequent in chil-
dren <5 years of age , implying that these expenses may
be incurred regularly.
Direct medical expenses only account for a fraction of these
total costs: 27% in Gambia, 11% in Kenya, and 53% in Mali.
Costs in informal settings ranged from $0.41 in Kenya to
$0.60 in Mali per episode, and accounted for more than half
of the household medical costs in both Gambia and Kenya. In
Mali, direct medical costs in formal settings accounted for a
larger fraction of household costs. For all 3 countries, the ma-
jority of household direct medical costs were for medications.
High nonmedical costs, whether for transportation or for lost
earnings, suggest that user fees for formal care may not be the
only financial barriers to treatment.
What Are the Determinants for Household Costs?
While the patterns vary among countries, wealth and sex
appear to be associated with direct medical and total household
diarrheal costs. Although there are a number of potential expla-
nations for this association, the relationship between household
wealth and diarrhea economic burden may reflect rationing of
care in poorer households. That is, household resources provide
quintile ($/episode) in Gambia (A), Kenya (B), and Mali (C). For each
group the box shows the 25th and 75th percentile and the bars show the
5th and 95th percentiles.
Distribution of total household diarrhea costs by wealth
Household Costs of Diarrhea in Africa • CID 2012:55 (Suppl 4) • S321
Table 3. Household Direct Medical Costs for Childhood Diarrhea by Socioeconomic, Demographic, and Illness Characteristic in Gambia, Kenya, and Mali
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
$ ANOVAP Value$ ANOVA$ ANOVAP Value$ ANOVA$ ANOVAP Value$ANOVA
None to primary
2.26P=.10.48P=.10P=.62 .67P=.87P=.15 .73P=.10
Abbreviation: ANOVA, analysis of variance.
S322 • CID 2012:55 (Suppl 4) • Rheingans et al
Table 4.Household Total Costs for Childhood Diarrhea by Socioeconomic, Demographic, and Illness Characteristic in Gambia, Kenya, and Mali
Gambia Kenya Mali
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
Mean Cost for
$ANOVAP Value$ANOVA$ANOVAP Value $ANOVA$ANOVAP Value $ANOVA
None to primary
P=.03P= .89 .40
4.07P=.16.65P=.25P= .40 .18P=.29 P=.09 .93P=.07
P=.17P= .21 .13
P=.70 P=.23 .84
7.39P=.93.59P=.97P= .98<.01 P=.38P=.02.06P=.09
Abbreviation: ANOVA, analysis of variance.
Household Costs of Diarrhea in Africa • CID 2012:55 (Suppl 4) • S323
a constraint on what can be spent on treatment or transporta-
tion, resulting in less care seeking and less expenditure among
poor households. However, we saw no differences in the propor-
tion of episodes incurring some costs among wealth quintiles,
suggesting that household wealth may not affect whether money
is spent, but rather how much is spent.
Sex was a second determinant of household diarrhea costs
in Gambia and Mali, but not in Kenya. There are 2 potential
explanations for this association. First, it is possible that this
reflects differences in diarrhea severity between boys and girls
that result in the need for greater care among boys. However,
there were no differences in the frequency of moderate-to-
severe diarrhea between boys and girls in either country. The
second interpretation is that cost differences reflect intrahou-
sehold resource allocation that disadvantages girls. Several
studies have documented reduced health expenditures for girls
in low-income settings [26–29]. If resources are limiting care
seeking for diarrhea, then it is plausible that girls will bear a
greater burden in terms of missed treatment and the resulting
negative outcomes. It is interesting to note that this relation-
ship only held for the 2 lower-income countries in the study.
It is also interesting to note that this relationship was not
observed in our related study in 3 Asian settings .
Is Household Economic Burden a Barrier to Appropriate Care?
Average costs per episode only provide one aspect of the
burden costs place on households in low-income settings.
Three other related factors must be considered: the distribu-
tion of costs, the potential for impoverishment due to the
costs, and the health burden of avoided costs. The cost
Table 5. Reasons for Not Seeking Treatment and Sources of Household Costs for Diarrhea Episodes—Kenya, Gambia, and Mali
QuestionKenya (n= 63)Gambia (n=49)Mali (n= 30)
Why did households not seek care for their child?
No need for care
Distance too far
Lack of transportation
No time off work
Local situation (political)
Leaving other children at home
Unhappy with clinical services
Preferred traditional medicine
Why did the household not seek hospital care when advised?
Hospital too far
Travel costs too high
No time off work
Needs of other children at home
Child not sick enough
Unhappy with clinical services
Where did the money come from?
Cutting other expenses
Relative or friend
Mali (n= 17)
Mali (n= 96)
Kenya (n= 34)
S324 • CID 2012:55 (Suppl 4) • Rheingans et al
distributions within each setting demonstrate that costs often
substantially exceed the mean. In all countries, 10% of epi-
sodes resulted in costs that were twice the mean and even
further above the median. In Kenya and Mali, this resulted in
10% of cases having costs of >$10, a substantial burden in set-
tings where households live on $1 per day. Figure 1 shows that
even the poorest households experience episodes with high
costs. Additionally, diarrhea is a frequent outcome among
children <5 years of age, implying that each episode brings a
chance of high costs when compared to earnings. In all 3
countries, households were most likely to get the funds from
reduced savings. Other common responses included incurring
debt and selling household assets. Our results do not allow us
to determine the long-term consequences of these costs on
household impoverishment. However, it is likely that reduced
savings, diminished assets, and increased debt would make it
harder for households to respond to adverse economic events
in the future, especially for the small but important fraction of
households that incur substantial costs.
Possibly the greatest economic burden is not the costs
themselves, but that they may encourage rationing of care for
children with diarrhea. The most common reasons for not
seeking care was related to a lack of resources or a perception
that the episode was not severe. These costs were not just the
formal costs of direct medical treatment but also the costs of
transportation, childcare, and missed work. Given that direct
medical costs in formal settings account for only a small frac-
tion of household costs, it is unclear whether reduced user
fees would have an impact on this barrier. Medication costs
(typically separate from user fees) are substantial, suggesting
that even with low costs for visits, households face other eco-
nomic costs that may impede access. Lower observed costs for
girls and children in poor households are likely symptoms of
this rationing of care, implying that the health burden associ-
ated with household economic costs falls primarily on these
children. The data analyzed here do not allow us to directly
address whether these household costs resulted in greater
adverse outcomes (eg, severe illness or mortality); however,
the results point to the importance of addressing these
questions empirical with the additional data being collected in
The current work suffers from several limitations. First, the
study sample size was designed to provide estimates of overall
costs within a margin of error but was not powered to
examine determinants of costs. As a result, differences among
subgroups are often not statistically significant and could be
addressed with larger samples in subsequent research. Second,
one-time cross-sectional data did not allow directly examina-
tion of the long-term consequences of incurred costs by
household for individual events or repeated episodes. Last, the
cross-sectional nature of the study makes it difficult to assess
whether low costs for specific subgroups are the result of
reduced severity, cheaper services, or rationing of care. Addi-
tional work must also be conducted to better understand how
the complex interaction between direct medical, direct non-
medical, and indirect costs impact households’ demand for
and decisions to seek informal or formal care.
Diarrheal episodes are common among children <5 years of
age in low-income settings, resulting in significant mortality
burden as well as substantial economic costs associated with
nonfatal events. These 2 aspects of burden—mortality and
household costs—may be closely connected. Costs may serve
as barriers that result in reduced healthcare seeking, especially
for poorer households and for girls. These costs may force
households to take other steps like borrowing and reducing
savings that may expose them to economic insecurity. While
the results here cannot prove this connection between house-
hold costs and mortality, it points to importance of further
study. The costs of diarrhea treatment to the healthcare system
are important and must be considered by national decision
makers choosing between health interventions.
Gates Foundation (grant number 38874). We wish to thank Ciara O'Reilly
and Eric Mintz of the US Centers for Disease Control and Prevention for
their contributions to study design and data collection.
The findings and conclusions in this report are those of
the authors and do not necessarily represent the views of the US Centers
for Disease Control and Prevention.
This article was published as part of the
supplement entitled “The Global Enteric Multicenter Study (GEMS),”
sponsored by the Bill & Melinda Gates Foundation.
Potential conflicts of interest.
All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
This work was supported by the Bill & Melinda
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