In the past few decades, the world has seen a significant decline in the prevalence of pediatric diarrhoeal diseases. However, it still remains one of the major public health concerns, especially in LMICs.[23] It has been reported that children are more susceptible to the disease with an average incidence of 3.2 to 12 episodes per year per child, although most of these episodes are self-limiting.[23] Apart from the obvious physical toll it exerts on the child, the economic strain of diarrhoeal disease on the household is by no means negligible.[2] In this study, we analyzed the data from the GEMS study. It was a multicentered study considering U5C as the participants. The study collected household cost related data from the caregivers. We found that the median total indirect cost was higher than the total direct cost (10.2 I$ vs 8.4 I$). This finding signifies the often-neglected effect of diarrhoeal diseases, i.e., the economic strain it puts on the family due to loss of productivity. Koopmanschap and Rutten have indicated that if any healthcare program produce health benefits quickly, then the impact of that particular program is more impactful.[24] Unfortunately, programs that aims to reduce diarrhoeal burden, often fails to consider this point. Our study found some significant differences regarding the independent variables between the two continents (South Asia and Sub-Saharan Africa). This indicates that although the economic situation between the countries of these two continents are often similar, there are marked differences in the culture and social dynamics.[25] The TDC was significantly higher in Sub-Saharan Africa (12.9 I$) than South Asia (7.6 I$). TIC was also higher in Sub-Saharan Africa, although the difference was not statistically significant. In their study, Asante et al., presents various findings that can account for this fact.[26] Although the region bears a disproportionate share of global disease burden, the allocation of resources to healthcare is quite low. Additionally, in 2016, the per capita health spending in Africa was more than 50 times lower compared to the Organisation for Economic Co-operation and Development countries.[26] Furthermore, the financing systems for healthcare in SSA is largely dependent on high OOP payment with very low government spending.[26]

However, when compared between countries, Bangladesh reported the highest TDC and TIC. When we consider the Per capita total expenditure on health in I$, this finding becomes understandable. During 2011-12, i.e., the period of the GEMS study, Bangladesh spend 66.8 and 67.8 I$ respectively which was the second lowest among all 7 participating countries.[27] It has been reported that OOP payments by the households are responsible for nearly 67% of the total health expenditure.[28] Several reasons like poorly designed health financing system, lack of proper health insurance measures, hidden charges, understaffing etc. are often cited as the root cause of this high OOP rate.[28]

Our study found that the highest proportion of TDC was due to medication while diagnostic cost was the minimum. In developed countries, the government usually provides subsidy for pharmaceuticals. As the cost of medicines are subsidized, the direct cost is not much impacted. On the other hand, in LMICs like Pakistan, the prices of drugs are usually controlled at the level of retail pharmacy.[29] As such, the higher proportion of medication is understandable.

We found that no. of family members and no. of U5C increased the median TDC. The effect of number of family members and other U5C is most likely to be indirect. Several studies have reported family size to be a significant influencer of diarrhoea among U5C.[30,31] One possible reason is the low level of care by the parents and increased risk of transmission.[30]

Residence was an important predictor of TDC where urban households are more likely to have higher cost. The living cost in urban areas is significantly higher when compared to rural areas. Additionally, the cost of care at tertiary level hospitals, which are more prevalent in the urban areas, are significantly higher.[32]

Diarrhoeal diseases can be categorized as less severe disease and moderate to severe disease (MSD) based on level of dehydration, presence of blood in stool and hospital admission.[15] U5C with MSD are usually provided in-patient care. Thobari et al. conducted Health facilities and community survey to estimate the economic burden of U5C in Indonesia where they found that DTC for in-patient cost was significantly higher than out-patient care. Our study reports similar findings. It has been reported that patients with in-patient care requires higher professional fees, diagnostic and medication costs. Additionally, the cost become higher due to the presence of several specialty and subspecialty medical professionals.[32] Another study conducted in Bangladesh reported similar findings were MSD was associated with direct medical and direct non-medical cost.[5] As ORS or IV is used as the rehydration method for MSD, the positive association between rehydration method and TDC found in our study is also understandable.

We found that, children with mothers who completed primary education reported lower cost. However, when the maternal educational level is post-secondary, the cost increases. In LMICs, mothers are usually considered as the primary caregivers. Education is known to have significant impact on the maternal care-seeking behavior for their child’s illness.[5] Reports suggest that when the mother is highly educated, their tendency to more frequent care-seeking also increases, leading to higher expenditure.[5]

Diarrhoea is a water-borne disease, which is reported to be linked with the quality of the drinking water.[23,33] In a cluster randomized controlled trial, Solomon et al. reported that treating drinking water considerably decreases the diarrhoeal episodes.[34] According the WHO, 94.0% of diarrhoeal incidence can be prevented simply by modifying the environment, improving hygiene and sanitation, and making clean water more available.[34] We also found that consuming treated drinking water negatively impacted TDC.

When the child’s condition does not improve, mothers often seek additional consultations. In LMICs, the population often seek care from informal caregivers rather than professional doctors.[35] However, this causes multiple negative impact on patient. These informal caregivers doesn’t have formal care or education which exacerbates the disease leading to increased direct and indirect cost. Moreover, seeking care from multiple sources puts additional financial strain. Our findings also indicate that seeking previous care has caused increased TDC and TIC.

It has been suggested by multiple studies that malnutrition can increased the frequency and duration of diarrhoeal illness.[36,37] Specially wasting is reported to be a strong predictor for prolonged illness.[37] Several mechanisms are suggested for explaining this phenomenon like poor appetite, malabsorption of nutrients, hastening of intestinal transit time etc. Our study has also reported a positive association between wasting, underweight and TDC.

In this study, we utilized data from a large, multicenter study conducted in multiple LMICs. As such, the results of the study can be considered as generalizable. We also considered non-zero cost for both direct and indirect cost to gain valuable insights considering the overall picture. The costs were adjusted for inflation and converted into I$ for better comparability. However, there were several limitations also. As the GEMS data was collected in 2011-2012, it may fail to capture the current trends. Additionally, cost data was reported by the caregivers which may have caused recall bias. Differences in healthcare systems, currencies, and purchasing power across regions may have complicated the direct comparisons of costs.