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The economic impact of childhood acute gastroenteritis on Malawian families and the healthcare system
  1. Nathaniel Hendrix1,2,
  2. Naor Bar-Zeev3,4,
  3. Deborah Atherly1,
  4. Jean Chikafa4,
  5. Hazzie Mvula5,6,
  6. Richard Wachepa4,
  7. Amelia C Crampin5,6,
  8. Themba Mhango7,
  9. Charles Mwansambo8,
  10. Robert S Heyderman4,9,
  11. Neil French3,4,
  12. Nigel A Cunliffe3,
  13. Clint Pecenka1
  14. for the VacSurv Consortium
  1. 1 Center for Vaccine Innovation and Access, PATH, Seattle, Washington, USA
  2. 2 Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, Washington, USA
  3. 3 The Centre for Global Vaccine Research, Institute of Infection & Global Health, University of Liverpool, Liverpool, Merseyside, UK
  4. 4 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
  5. 5 Karonga Prevention Study, Chilumba, Malawi
  6. 6 London School of Hygiene and Tropical Medicine, London, UK
  7. 7 Queen Elizabeth Central Hospital, Blantyre, Malawi
  8. 8 Ministry of Health, Lilongwe, Malawi
  9. 9 Division of Infection & Immunity, University College London, London, UK
  1. Correspondence to Dr Clint Pecenka; cpecenka{at}


Objectives This prospective cohort study sought to estimate health system and household costs for episodes of diarrhoeal illness in Malawi.

Setting Data were collected in two Malawian settings: a rural health centre in Chilumba and an urban tertiary care hospital in Blantyre.

Participants Children under 5 years of age presenting with diarrhoeal disease between 1 January 2013 and 21 November 2014 were eligible for inclusion. Illnesses attributed to other underlying causes were excluded, as were illnesses commencing more than 2 weeks prior to presentation. Complete data were collected on 514 cases at both the time of the initial visit to the participating healthcare facility and 6 weeks after discharge.

Primary and secondary outcome measures The primary outcome measure was the total cost of an episode of illness. Costs to the health system were gathered from chart review (drugs and diagnostics) and actual hospital expenditure (staff and facility costs). Household costs, including lost income, were obtained by interview with the parents/guardians of patients.

Results Total costs in 2014 US$ for rural inpatient, rural outpatient, urban inpatient and urban outpatient were $65.33, $8.89, $60.23 and $14.51, respectively (excluding lost income). Mean household contributions to these costs were 15.8%, 9.8%, 21.3% and 50.6%.

Conclusion This study found significant financial burden from childhood diarrhoeal disease to the healthcare system and to households. The latter face the risk of consequent impoverishment, as the study demonstrates how the costs of seeking treatment bring the income of the majority of families in all income strata below the national poverty line in the month of illness.

  • Malawi
  • gastroenteritis
  • diarrheal disease
  • low-income countries
  • burden of disease
  • medical impoverishment

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors NB-Z, DA and NAC designed the study with input from ACC, CM, RSH and NF. JC led data collection efforts. HM and TM contributed to data collection. NH, RW, NB-Z, CP and DA designed and performed the data analysis. NH wrote the first draft of the manuscript. All listed authors contributed to the interpretation of the data, contributed to the writing of the manuscript, reviewed the work prior to submission and have agreed to be responsible for its content.

  • Funding This work was supported by Wellcome Trust Programme Grant (WT091909), PATH and the Bill & Melinda Gates Foundation (OPP1053539).

  • Competing interests NB-Z, NAC and NF have received investigator-initiated research grants from GSK, and NB-Z and NAC from Takeda Pharmaceuticals. All other authors have no conflicts to declare.

  • Patient consent No identifiable medical information is included in this manuscript.

  • Ethics approval National Health Sciences Research Committee, Lilongwe, Malawi (1073), and by the Research Ethics Committee of the University of Liverpool, UK (000490).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data collected as part of this study is not available due to its not having been included in the approved protocol.

  • Collaborators James Beard (London School of Hygiene and Tropical Medicine, London, UK); Anthony Costello (WHO, Geneva, Switzerland; formerly University College London (UCL), London, UK); Miren Iturriza-Gomara (University of Liverpool (UoL), Liverpool, UK); Khuzwayo Jere (UoL) Carina King (UCL, London, UK); Sonia Lewycka (University of Auckland, Auckland, New Zealand; formerly UCL); Osamu Nakagomi (Nagasaki University, Japan); Umesh Parashar (Centers for Disease Control & Prevention (CDC), Atlanta, GA, USA); Tambosi Phiri (Mai Mwana Project, Mchinji, Malawi); Jacqueline E Tate (CDC); Jennifer R Verani (CDC); Cynthia G Whitney (CDC).

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