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. Table 2.

Household Costs Associated With Diarrheal Illness by Type and Setting (2011 US$) in Gambia, Kenya, and Mali

Of respondents reporting an episode of diarrhea in the previous 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, expenditure 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, medications (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. Figure 1.

Distribution of total household diarrhea costs by wealth 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.

We examined the effect of household economic status, maternal 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 incurring 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 each determinant. For many of the determinants, low sample size in the subcategories (Table 1) led to limited statistical power. Table 3.

Household Direct Medical Costs for Childhood Diarrhea by Socioeconomic, Demographic, and Illness Characteristic in Gambia, Kenya, and Mali

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 significant for Mali and Gambia. Table 4.

Household Total Costs for Childhood Diarrhea by Socioeconomic, Demographic, and Illness Characteristic in Gambia, Kenya, and Mali

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 significant. 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 associations 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.

Table 5 shows household reasons for not seeking care or hospitalization 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 believing their child needed care or that the costs were too high. Broken down further, 55.8% of Kenyan households seeking alternative forms of care did so because they felt hospital treatment 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%. Table 5.

Reasons for Not Seeking Treatment and Sources of Household Costs for Diarrhea Episodes—Kenya, Gambia, and Mali

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 households believed their child did not need care for his or her illness. Among Kenyan families, treatment and transportation 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 high.

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 children <5 years of age [25], 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 majority 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.

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 explanations 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 a constraint on what can be spent on treatment or transportation, resulting in less care seeking and less expenditure among poor households. However, we saw no differences in the proportion 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 intrahousehold 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 relationship 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 [30].

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 distribution of costs, the potential for impoverishment due to the costs, and the health burden of avoided costs. The cost distributions within each setting demonstrate that costs often substantially exceed the mean. In all countries, 10% of episodes 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 settings 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 fraction 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 economic 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 associated 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 study.

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 examination 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. Additional work must also be conducted to better understand how the complex interaction between direct medical, direct nonmedical, and indirect costs impact households' demand for and decisions to seek informal or formal care.