In the developing world, acute gastroenteritis presents an enormous public health threat to children under five years of age, with an incidence of one billion episodes and 1.9 to 3.2 million deaths per year . Pediatric diarrhea incidence has been shown to be inversely related to socioeconomic status, with children in poverty much more vulnerable to acute diarrheal episodes .
Bolivia (per capita GDP of $4,700 ) is one of the lowest-ranking countries in the Americas region in terms of the Human Development Index (taking into account measures of health, education, and income) according to the United Nations Human Development Report  and suffers from high rates of diarrhea-related infant mortality. Out of every 1,000 live births, 54 children die before the age of five, with an estimated 15% of these deaths attributable to diarrheal illness . The costs of these diarrheal episodes can have severe financial consequences in a setting where 15.6% of the population lives on less than $1.25 per day (2008 estimate) .
Acute gastroenteritis presents an economic burden to both healthcare systems and patient families [6–8]. Although there is a universal insurance program that benefits Bolivian children under the age of five, not all medications or diagnostic tests are covered. Further, if medications are out of stock at the hospital, the family may have to pay out-of-pocket at a non-hospital pharmacy. Thus, Bolivian patient families may still face substantial out-of-pocket expenses and productivity losses associated with pediatric gastroenteritis-related hospitalizations and outpatient visits. Direct (“out-of-pocket”) expenditures include all costs paid directly by the family, encompassing medical costs (such as medications, tests, or consult fees) as well as non-medical costs (such as transportation or extra diapers) . Indirect costs are defined as the value of the time lost by a caregiver and their spouse from income-generating activities during the acute episode of diarrhea .
Incurred familial costs due to pediatric diarrheal episodes have been quantified in several different studies. In Kenya (GDP per capita US$1,800 ) and Kyrgyzstan (GDP per capita US$2,400 ), two countries with a relatively similar economic situation to Bolivia, the estimated average per-episode total familial costs (direct and indirect) ranged from US$19.86 (Kenya ) to US$47.90 (Kyrgyzstan ) for hospitalized children. In Vietnam (GDP per capita US$3,400 ) direct costs alone were found to amount to US$31.83 per case in one study . Findings in somewhat wealthier countries included total incurred costs of US$215.88  for hospitalized children in Mexico (GDP per capita US$14,800 ) and direct costs of US$12.89  per case in Brazil (GDP per capita US$11,900 ).
In a low-resource setting like Bolivia, incurred costs may sometimes represent a large proportion of a family’s overall economy. This ratio, the total incurred costs for a single diarrheal episode to the annual family income, can be termed the “cost burden” . While absolute costs associated with pediatric diarrhea have been quantified in various settings, few studies specifically examine the relative measure of cost burden as it relates to pediatric gastroenteritis. A review of the literature identified only two studies in low- and medium-income countries (LMIC) that addressed cost burden using a similar methodology as the present study. In a study set in India (GDP per capita US$3,700), Mendelssohn et al. found that direct costs incurred per diarrheal episode ranged from 2.2% to 5.8% of the household’s annual income . In the aforementioned study in Kyrgyzstan, Flem et al. found that family-incurred costs (including direct and indirect) totaled 2.5% of the mean annual household income . Several studies have shown that incurred familial costs can be difficult for families to pay, causing some (particularly the already-impoverished) to resort to borrowing money to cover these expenses [20, 21]. In the aforementioned study in India, more than 80% of lower-income households reported borrowing money to cover direct costs, as compared to only 35.7% of higher-income households .
Factors that may affect familial direct and indirect costs include treatment setting (e.g. rural primary care facilities versus urban referral hospitals) and appointment type (outpatient versus inpatient), though limited studies have specifically sought to quantify the potential effects of these characteristics. In the above-discussed study by Mendelssohn et al., direct familial costs for hospitalized patients in India were found to be significantly higher at an urban referral hospital as compared to a rural community hospital (p<0.001); direct costs were also higher for outpatients, but not significantly so (p=0.06) . However, the proportion of direct familial cost to annual family income for one episode of diarrhea was high in both urban (5.8%) and rural (2.2%) hospitals . Two other studies conducted in China, one in rural areas and one in urban hospitals, also showed higher mean direct familial costs for diarrhea inpatients compared to diarrhea outpatients (statistical significance not reported) [20, 22, 23]. In three cities studied in Brazil, direct familial costs associated with diarrhea outpatient visits represented the largest proportion of overall direct familial costs associated with diarrheal episodes (including hospitalizations), likely reflecting the greater number of outpatient visits compared to hospitalizations .
Pediatric diarrhea can cause not only financial difficulties, but also emotional distress for caregivers: Parents may feel frustrated that they cannot help their sick child, frightened by the severity of the illness, and fatigued by caring for their child . In one analysis from European countries, parents whose children were hospitalized for rotavirus-associated diarrhea reported higher levels of stress as compared to those whose children were seen in an outpatient or emergency room setting . Perceptions of financial stress differed in the above two studies (both in developed settings) [24, 25], but were not explicitly compared with actual incurred financial difficulty. A review of the literature did not find any studies directly comparing financial stress or perceived cost burden to actual incurred cost burden.
The aim of this report is to describe total incurred costs and cost burden associated with caregivers seeking treatment for pediatric gastroenteritis across six Bolivian hospitals. The first objective is to quantify these costs. The second objective is to better understand the relationships among costs, treatment setting, and appointment type. An additional objective is to understand the relationships among perceptions of cost and actual incurred cost burden. These results should further complement a study from 2011, where the impact of pediatric gastroenteritis to the entire Bolivian health care system was estimated, and helped provide the rationale for introduction of the rotavirus vaccination program in 2008 .