Management of common childhood illnesses and child immunization programs in Haiti can help reduce under-five mortality. Expanding treatment of diarrhea, pneumonia and dysentery through primary healthcare with oral rehydration solution, zinc supplementation, and antibiotics could avert over 5,000 child deaths annually at an average annual cost of $61.5 million. Routine childhood vaccination programs for diseases like polio, measles and rotavirus could further reduce deaths and have benefit-cost ratios above 2.9 depending on vaccination package and discount rate. A combination approach of both expanding illness treatment and vaccination coverage could maximize health benefits by preventing over 325,000 healthy life years lost each year at an estimated combined cost of $100.

1. Child immunization and
management of common
childhood illness
Karin Stenberg (stenbergk@who.int), Organisation mondiale de la santé (OMS), Genève, Suisse
Ludovic Queuille (Queuillelm@paho.org), Organisation panaméricaine de de la santé (OPS/OMS), Port-au-Prince, Haïti
Rachel Sanders (RSanders@avenirhealth.org), Avenir Health, Washington DC, EUA
Marcus Cadet (marcuscade87@yahoo.fr), Ministère de la santé publique et le population (MSPP), Port-au-Prince, Haiti
Haiti Priorise conference (http://www.copenhagenconsensus.com/haiti-priorise)
Port-au-Prince - Haïti, du 29 avril au 2 mai 2017

2. Overview
1) Context - Rationale
2) Management of common childhood illness
- Management of diarrhea and acute respiratory illness /pneumonia (P3)
- Estimation of costs
- Estimation of benefits
- Benefit Cost Ratio
3) Child immunization
- Vaccination (P1 et P2)
- Estimation of costs
- Estimation of benefits
- Benefit Cost Ratio
4) Discussion

3. High rates of child mortality
• Progress has been made, but still 49 children under 5 years of age die every
day
• Under five Mortality Ratio (U5MR = deaths per 1000 live births) is 69 (source: UN
estimate)
• These deaths are largely preventable, and a big societal loss
• The intrinsic value of health and survival
• Societal effects
• Pneumonia and Diarrhea main causes of post-neonatal mortality
• Jointly account for 48% of child deaths (source for cause of death: UN)
• When considering death and disability combined, these two conditions are the second
and third largest causes of loss of healthy life in Haiti (IHME, 2016)

4. 1st analyzed solution*
Management of common childhood illnesses
Source: PAHO

5. Management of diarrhea and pneumonia
A package of interventions delivered through primary level health care:
• Oral antibiotics for pneumonia
• Management of diarrhea with Oral Rehydration Solution (ORS) and zinc
• Antibiotics for treatment of dysentery
Demonstrated cost-effectiveness: Edejer et al (2005), DCP2 (2006), DCP3 (2015)

6. Estimating costs
• Inputs-based costing, by year:
• Commodities: drugs, supplies *
• Supply chain costs and commodity waste
• Service delivery (inpatient & outpatient) operational costs*
• Programme support activities
*Cost assumptions based on WHO guidelines (UN-OneHealth Tool)
• Spectrum-GCEA/ UN-OneHealth Tool (LiST)
• Projected number of episodes of illness 2017-2036
• A comprehensive, country-tailored analysis

7. Estimated costs
Average annual additional cost to reach 95% coverage:
• Average annual cost: USD2014 61.5 million = HTG 2,781 million
• Cost per capita: USD2014 5.07 = HTG 229
• Equivalent to 8% of total health expenditure (2012/2013)

8. 0
10
20
30
40
50
60
70
80
U5MR IMR
Baseline (2015)
80% coverage
95% coverage
12%
Estimating benefits
• avert > 3,800 deaths/year (80% coverage)
• avert > 5,000 deaths/year (95% coverage)
• Healthy Life Years (HLYs) gained valued at
1, 3 and 8 x GDP/capita
Predicted reduction in under-five
mortality rate and infant mortality rate
• Interventions act on unique cause of death
10%
Spectrum-GCEA/ UN-OneHealth Tool (LiST)

9. Benefit-Cost Ratios
Benefits valued at 3x GDP
Discount
rate
Benefits
2018-2036
(HTG bn)
Costs
2018-2036
(HTG bn) BCR
Management of
common
childhood illness
(95% coverage)
3% 229.6 22.5 10.2
5% 129.0 18.9 6.8
12% 32.9 11.2 2.9

10. 2nd analyzed solution
Immunization
Source: PAHO

11. Package Vaccines:
Routine EPI
(P1)
BCG, Polio, Measles single dose, DTC/Penta,
Rotavirus
Routine EPI + PCV13
(P2)
BCG, Polio, Measles single dose, DTC/Penta,
Rotavirus
+ PCV13 (pneumococcal vaccine)
EPI = Expanded Programme on Immunization

12. Average annual additional cost (million USD )
Commodities
Service
Delivery
Supply
chain
Programme
costs
Total annual
cost
Average
HLYs
gained
/year
Cost (USD)
per HLY
Gained
Routine EPI (P1) 2.8 3.0 2.6 8.8 17.3 87,850 196
Routine EPI + PCV-13
(P2) 17.5 4.4 17.2 22.8 61.9 142,019 436
Mgt of common
childhood illness (P3) 3.3 25.8 1.1 31.3 61.5 244,065 252
Combination (P2 +
P3) 20.8 30.1 18.4 30.9 100.2 325,866 308

13. Benefit-Cost Ratios: including vaccines
95% coverage scale-up; Benefits valued at 3x GDP
0
2
4
6
8
10
12
Routine EPI
(P1)
Routine
EPI+PCV13
(P2)
Management
of childhood
illness (P3)
Combination
(P4)
Package Interventions
Routine EPI
(P1)
Vaccines: BCG, Polio, Measles
single dose, DTC/Penta, Rotavirus
Routine EPI +
PCV13 (P2)
Vaccines: BCG, Polio, Measles
single dose, DTC/Penta, Rotavirus
+ PCV13.
Management
of common
childhood
illness (P3)
Oral Rehydration Solution + zinc
Oral antibiotics for pneumonia +
Antibiotics for treatment of
dysentery
Combination
(P4) P2 + P3
10.4
3.7
6.8
4.5

14. Discussion
• High BCRs (very strong quality of evidence) – in particular for current
Immunization Schedule and management of common childhood illness
• Highlights the need for financial analysis concerning the introduction of PCV13
• Reduce direct (out of pocket) payments for common childhood illness
• Effective implementation of the Integrated Mgt of Childhood Illness (IMCI)
strategy
• Prioritization and rationalisation of available resources towards child health and
primary level
• Improve public health financing / address long term sustainability (vaccines)
• Improve health system performance
• Improve Maternal Health and reduce demographic pressure (family planning,
education and socio-economic development)