A CHILD HEALTH INTERVENTION IN POST-CONFLICT ANGOLA: A COST-EFFECTIVENESS ANALYSIS by Sylvia Blom An essay submitted to the Department of Economics in partial fulfillment of the requirements for the degree of Master of Arts Queen’s University Kingston, Ontario, Canada September 2011 Copyright © Sylvia Blom 2011 Acknowledgements I would first like to extend my gratitude to Professor Huw Lloyd-Ellis for his support and guidance throughout the writing of this essay and especially for his thoughtful and constructive commentary during the final stages. I would also like to express my appreciation for Professor George Kuo and his willingness to engage me in an insightful discussion pertaining to cost-effectiveness techniques and analysis, as well as to the Measure Demographic and Healthy Surveys project for the use of the Angolan Malaria Indicator Survey data. Lastly, I would like to thank the Queen’s University Department of Economics, and especially the graduate assistant, Rachel Ferreira, for her continued emotional and administrative support through out the entire program. © Sylvia Blom 2011 ii Table of Contents 1 Introduction………………………………………………………………………. 1 2 Motivation…………………………………………………………………........... 1 3 Background………………………………………………………………………. 4 3.1 Health and Poverty……………………………………………………….4 3.2 Child Health……………………………………………………………. 5 3.3 Returns to Education…………………………………………………… 6 4 The Intervention………………………………………………………………….. 7 4.1 Angola………………………………………………………………….. 7 4.2 Viva a Vida com Saúde (VaV): Enjoy a Healthy Life………………… 8 5 Methodology……………………………………………………………………... 9 5.1 Cost-Effectiveness Analysis…………………………………………… 9 5.2 Disability-Adjusted Life Years………………………………………… 9 6 Analysis…………………………………………………………………………... 10 6.1 Malaria…………………………………………………………………. 10 6.1.1 Malaria Introduction…………………………………………. 10 6.1.2 Malaria Methodology………………………………………… 12 6.2 Measles………………………………………………………………… 16 6.2.1 Measles Introduction…………………………………………. 16 6.2.3 Measles Methodology………………………………………... 19 6.3 Vitamin A Deficiency…………………………………………………. 21 6.3.1 Vitamin A Deficiency Introduction………………………….. 21 6.3.2 Vitamin A Deficiency Methodology………………………… 22 6.4 Poliomyelitis…………………………………………………………… 24 6.4.1 Poliomyelitis Introduction…………………………………… 24 6.4.2 Poliomyelitis Methodology………………………………….. 26 6.5 Helminth Infections……………………………………………………. 28 6.5.1 Helminth Infections Introduction……………………………. 28 6.5.2 Helminth Infections Methodology…………………………… 31 6.6 Indirect Effects…………………………………………………………. 33 6.6.1 Reduction of malaria cases and deaths due to Vitamin A supplementation……………………………………………………. 33 6.6.2 Reduction in all-cause mortality……………………………... 34 7 Results……………………………………………………………………………. 36 7.1 Health Outcomes……………………………………………………….. 36 7.2 Cost-Effectiveness……………………………………………………... 37 7.3 Ranking the interventions ……………………………………………… 37 7.4 Child Mortality…………………………………………………………. 38 7.5 Ranking the Interventions……………………………………………… 40 7.6 Long-term Benefits…………………………………………………….. 41 8 Limitations……………………………………………………………………….. 42 9 Discussion………………………………………………………………………... 42 10 References………………………………………………………………………. 45 11 Appendices……………………………………………………………………… 50 © Sylvia Blom 2011 iii 1 Introduction This paper quantifies the health outcomes of a multi-intervention child health campaign in Angola in 2006. The outcomes of interest are the number of cases averted, the number of disability-adjusted life years (DALYs) averted and the number of deaths averted. The cost-effectiveness of the campaign is assessed as per the World Health Organization’s (WHO) guidelines for assessing health programs and analyzed using methods from recent literature. Costs are expressed in 2006 USD, unless otherwise specified. The paper begins with the motivation behind this analysis, and then discusses the links between health and poverty and why child health in particular is so important, before introducing Angola and the campaign itself. The methodology section commences with an introduction to cost-effectiveness analysis and the use of DALYs and then analyzes each intervention in turn. Finally, the results are combined to determine the overall cost-effectiveness of the campaign and the discussion offers further analysis of expected educational returns, long-term health benefits and policy implications. 2 Motivation Numerous cost-effectiveness and cost-benefit analyses have been performed and compared to assess the payoffs to investing in health care, and in particular in preventative care. The WHO lists over 200 cost-effectiveness estimates of child health interventions in the AFR D1 sub-region, of which Angola is a member. However, there have been no known studies of such one-time intensive child health campaigns that combine five interventions, including both bed nets to prevent malaria and the poliovirus vaccine. 1 The WHO classifies countries into regions based on geographical and epidemiological criteria. © Sylvia Blom 2011 1 Much of the literature on the cost-effectiveness of malaria prevention tactics has been used to identify the ideal preventative tactic for various at-risk groups in regions with varying levels of endemicity. Furthermore, the lack of vaccine or pill to guarantee immunity from the disease has caused researchers to focus on identifying the incentives needed to encourage the adoption of practices to minimize the risk of contracting malaria. As such, it is difficult to evaluate malaria prevention programs for young children whose behaviour depends that of their parents. In this analysis, malaria cases and DALYs averted are calculated as a result of the distribution of bed nets in the campaign and the Vitamin A supplementation, which has been demonstrated to reduce both malaria morbidity and mortality. Additionally, the use of bed nets has been shown to reduce all-cause mortality, likely by reducing the incidence of malaria-induced anaemia thereby decreasing the burden on one’s immune system. Furthermore, the 2006-2007 Malaria Indicator Survey (MIS) indicated that the distributed bed nets are often used by up to three additional household members, thus extending the benefits of the bed net distribution beyond the under-five age group. Poliomyelitis is also rarely included in child health evaluations, and few studies have been done to evaluate the cost-effectiveness of vaccination campaigns. This is mainly due to the highly contagious nature of the virus and the difficulty in estimating the progression of the virus within a populace. Since the start of the polio eradication campaign in the 1980s, cost-benefit calculations have been continually updated as the struggle to eliminate the virus from the last four countries continues. As Angola has recently experienced the poliovirus both in an endemic state and as an outbreak due to the © Sylvia Blom 2011 2 virus being imported, the effects of this supplementary vaccination campaign can be easily extrapolated. The distribution of Vitamin A supplements during national vaccination campaigns is increasingly common as the cost per pill is quite low and the additional overhead is minimal. The effects of Vitamin A supplementation on malaria morbidity and its reduction in all-cause child mortality rates in combined intervention analyses has been estimated in previous studies, but not to the extent considered here. In this paper, the combined effect of malaria bed net use and Vitamin A supplementation in decreasing all- cause child mortality and the effect of Vitamin A on decreasing endemic malaria morbidity are novel additions to the cost-effectiveness literature. Furthermore, cost-effectiveness studies of child health campaigns are typically performed using a treatment and a control (or placebo) group, comparing the effect of a treatment to a do-nothing scenario. However, this is rarely a robust assumption, as all countries have some private or public health programs in place, minimal though they may be. Even Angola, with its civil conflict lasting almost three decades limiting access to health services and the destroying much of its infrastructure, demonstrated evidence of both prevention and treatment practices. This analysis attempts to quantify the marginal effect of a one-time child health intervention, controlling for the national health prevention practices already in place. The results of the cost-effectiveness of this type of supplementary campaign have policy implications for governments and public health organizations alike. © Sylvia Blom 2011 3 3 Background 3.1 Health and Poverty The correlation between health and poverty is undisputed. The causation goes both ways; insufficient funds to cover the costs of medical treatment results in fewer days worked and hence there is less income to buy nutritious food or preventative vaccines thereby perpetuating the downward spiral of the poverty trap. Childhood illness can accelerate this cycle, as sick children require additional care, leaving caregivers with less time to spend on income-generating activities. The high rate of infant and child mortality further induces families to have more children than desired, spending additional time and energy in child rearing (Sachs & Malaney, 2002). Furthermore, children who are too ill to attend school have little hope of landing higher paying jobs than their parents. It is this continuous cycle that justifies a one-time health intervention such as the Angolan campaign analyzed here, to give the poorest families an opportunity to break free of the health-induced poverty trap. Alleviating households of the financial burden