CHOLERA OUTBREAKS IN GREATER ACCRA REGION, GHANA: THE ECONOMIC COSTS TO THE HEALTH FACILITY AND AFFECTED HOUSEHOLDS BY AWALIME KWESI DZIEDZOM (10444083) THIS THESIS IS SUMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FILFILMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL ECONOMICS DEGREE JULY, 2015 University of Ghana http://ugspace.ug.edu.gh i DECLARATION This is to certify that this thesis is the result of research undertaken by Dziedzom Kwesi Awalime towards the award of the Master of Philosophy (M.PHIL) degree in Economics at the Department of Economics, University of Ghana. ………………………………………………………………………………….. DZIEDZOM KWESI AWALIME (10444083) ……………………………….. ………..…………………………… DR. NKECHI S. OWOO DR. EDWARD NKETIAH AMPONSAH University of Ghana http://ugspace.ug.edu.gh ii DEDICATION I dedicate this work to my brother Mr. Walter Awalime and sister Mrs. Cynthia Boateng whose love and support is without measure. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT Special recognition and thanks to my Father and Lord Jesus Christ for health, strength and insight to reach this height in my life. The completion of my thesis would have been with much difficulty without His constant provision. My sincere gratitude goes to my supervisors, Dr. Mrs. Nkechi S. Owoo and Dr. Edward Nketiah-Amponsah for their immense support and constant encouragement till the completion of this work. I could not have done it without their valuable contributions and great supervision, for which I am grateful. Special thanks also to my family; Mr. Cephas Kofi Awalime, Mrs. Grace Emefa Kanda-Awalime, Mr. Walter Awalime and Mrs. Cynthia Addo-Boateng for their constant prayers, encouragement and financial investments in my education thus far. God bless you all. I wish to express my heartfelt gratitude to Mrs. Patience Bedu of the La General Hospital and Mr. Alfred Manyeh of the Dodowa Health Research Centre for their immense support from start to finish of this work. Also, I am grateful to the Noguchi Memorial Institute, Post-Doctoral Office for awarding me a thesis grant to undertake my field work. It would have been an uphill without their support. Finally, I wish to appreciate all my colleagues and friends in the department who have made this journey very fulfilling and worthwhile. May God Almighty bless you all. University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Ghana experienced its worst cholera outbreak in the last three decades in 2014. However, evidence of the economic costs of the disease on the health system and affected households has not been fully documented. This study therefore sought to determine economic cost associated with recent outbreak the disease. Two districts which were high and low incidence areas (HIA and LIA) were selected for comparative cost studies. A total of 418 (282 HIA and 136 LIA) households which experienced at least one case of cholera infection were interviewed. The Cost of Illness (COI) method was adopted to identify and cost the disease at household and health facility levels. The Tobit Regression model was employed to determine the correlates of cholera incidence. STATA 13 software was used for analysis. The average direct cost to households in the HIA amounted to GH¢342.00 (USD 106.88), almost 2 folds higher than in the LIA GH¢198.47 (USD 62.02). Total cost saving of the episode of cholera was GH¢317,444.10 (USD 99,201.28) in the LIA but rose to almost 8 folds more in the HIA (GH¢2,504,357.12; USD 782,611.60). Total cost of treatment in health facilities were above 10 folds more in the HIA (GH¢66,745.00; USD 20,862.58) compared with LIA (GH¢6,300 USD 1,968.75). Households with the lowest income category had the greatest incidence of cholera (0.073) compared to other categories and drinking water sources such as from neighbouring homes as well as marital status of individuals were significant in the incidence of cholera. University of Ghana http://ugspace.ug.edu.gh v Table of Contents Page DECLARATION.................................................................................................... i DEDICATIOIN ..................................................................................................... ii ACKNOWLEDGEMENTS ................................................................................ iii ABSTRACT .......................................................................................................... iv List of Tables ...................................................................................................... viii List of Figures ....................................................................................................... ix List of Abbreviations .............................................................................................x CHAPTER ONE ....................................................................................................1 INTRODUCTION..................................................................................................1 1.0 Background of Study .......................................................................................... 1 1.1 Problem Statement .............................................................................................. 6 1.2 Objectives of the Study ..................................................................................... 10 1.3 Relevance of the Study ..................................................................................... 10 1.4 Organization of the Study ................................................................................. 12 CHAPTER TWO .................................................................................................14 OVERVIEW OF CHOLERA IN GHANA ........................................................14 2.0 Introduction ....................................................................................................... 14 2.1 History of Cholera............................................................................................. 15 2.2 Clinical Features of Cholera ............................................................................ 16 2.3 Transmission of Cholera ................................................................................... 17 2.4 Cholera Treatment ............................................................................................ 18 2.5 Prevention of Cholera ....................................................................................... 19 2.6 Cholera Epidemic and Outbreak ....................................................................... 19 2.7 Cholera in Ghana .............................................................................................. 20 2.7.1 Historical Trends ...................................................................................... 21 University of Ghana http://ugspace.ug.edu.gh vi CHAPTER THERE .............................................................................................27 LITERATURE REVIEW ...................................................................................27 3.0 Introduction ....................................................................................................... 27 3.1 Theoretical Foundation ..................................................................................... 27 3.1.1 Economic Consequences of Illness on Households .................................. 29 3.1.2 Health as component of Human Capital ................................................... 32 3.1.3 Application of Grossman Model to Study ................................................. 33 3.2 Cost of Illness Approach (COI) ........................................................................ 34 3.2.1 Costs Definitions ....................................................................................... 36 3.2.2 Healthcare evaluation costs concepts ....................................................... 37 3.3 Theoretical Framework ..................................................................................... 41 3.3.1 Direct Cost ................................................................................................ 43 3.3.2 Indirect Cost.............................................................................................. 44 3.3.3 Intangible Cost .......................................................................................... 48 3.4 Empirical Review.............................................................................................. 48 3.4.1 Costs Methods in the measurement of Cholera ........................................ 50 3.5 Cholera, Portable Water, Sanitation and Poverty linkages ............................... 56 3.6 Summary of Chapter ......................................................................................... 59 CHAPTER FOUR ................................................................................................60 METHODOLOGY ..............................................................................................60 4.0 Introduction ....................................................................................................... 60 4.1 Characteristics of Study Area ........................................................................... 60 4.1.1 Study Sites ................................................................................................. 62 4.2 Data and Sampling ............................................................................................ 63 4.3 Data Collection Procedure ................................................................................ 64 4.4 Ethical Considerations ...................................................................................... 64 4.5 Theoretical Framework ..................................................................................... 65 4.6 Methods of Analysis ......................................................................................... 68 4.6.1 Direct Costs .............................................................................................. 69 4.6.2 Indirect Costs ............................................................................................ 70 4.6.3 Model Specification (Objective 1)............................................................. 73 4.6.4 Model Specification (Objective 2)............................................................. 76 4.6.5 Marginal Effects and Cross Tabulations .................................................. 78 University of Ghana http://ugspace.ug.edu.gh vii 4.6.6 Selection of Variables ............................................................................... 79 4.7 Methodological Limitations .............................................................................. 84 CHAPTER FIVE .................................................................................................85 PRESENTATION AND DISCUSSION OF RESULTS ...................................85 5.0 Introduction ...................................................................................................... 85 5.1 Demographic Characteristics ............................................................................ 85 5.1.1 Cholera Infection ...................................................................................... 86 5.1.2 Infection; Household heads, Sex, Age, Education and Income level ........ 87 5.1.3 Infection; Location, Access to portable water sources and Access to Toilet facility 88 5.2 Direct and Indirect Costs of Cholera to Household .......................................... 89 5.2.1 Direct Cost of Cholera within Higher and Lower Incidence Areas .......... 90 5.2.2 Indirect Cost of Cholera within Higher and Lower Incidence Areas ....... 94 5.3 Facility Costs in High and High and Low Incidence areas ............................... 99 5.4 Correlates of Cholera incidence using Tobit Regression Model .................... 100 5.5 Summary of Chapter ....................................................................................... 105 CHAPTER SIX ..................................................................................................107 SUMMARY, CONCLUSION AND POLICY RECOMMENDATIONS .....107 6.0 Introduction ..................................................................................................... 107 6.1 Main findings of study .................................................................................... 107 6.2 Contributions of the Study and Policy Recommendations ............................. 108 6.3 Limitations of the study and areas for further research................................... 110 References ...........................................................................................................111 APPENDICES ....................................................................................................126 APPENDIX A: Sample Size Calculation ................................................................... 126 APPENDIX B: Test for Multicolinearity ................................................................... 127 APPENDIX C: Descriptive Statistics ......................................................................... 127 APPENDIX D: Cholera Infection Cross Tabulations ................................................. 132 APPENDIX E: Health Facility Questionnaire ............................................................ 133 APPENDIX F: Household Questionnaire ................................................................... 136 University of Ghana http://ugspace.ug.edu.gh viii List of Tables Page Table 1.1 Cholera Cases in Ghana by Region by Week, 2014 ................................6 Table 2.1 Cholera cases and deaths by region, Ghana 2014 ..................................23 Table 3.1 Illustrative health policy questions addressed by economic impact studies. ...................................................................................................................32 Table 4.1 Variables and their expected signs .........................................................83 Table 5.1 Descriptive Statistics of dummy and continuous variables ...................86 Table 5.2 Direct Costs in High and Low Cholera Incidence area .........................91 Table 5.3 Individual and Household Direct Average Costs for HIA .....................92 Table 5.4 Days missed by Patients and Caregivers with Indirect Costs in High and Low incidence areas ...............................................................................................96 Table 5.5 Tobit Regression Output showing coefficients, marginal effects for censored sample, standard errors and p-values. ...................................................102 University of Ghana http://ugspace.ug.edu.gh ix List of Figures Page Figure 1.1 & 1.2 Overview of Cholera cases and deaths in WHO African sub- region .......................................................................................................................4 Figure 2.1Cholera cases within 16 districts of the Greater Accra between 2012 and 2014. ................................................................................................................22 Figure 2. 2 Cholera in Ghana: 1980 to 2014 ..........................................................25 Figure 2.2 Distributions of Cholera Cases by Region, Ghana 2014. .....................26 Figure 3.1 Conceptual Framework for Costs of Cholera. ......................................42 Figure 5.1 Household Direct Average Costs in High and Low Incidence Areas ..94 Figure 5.5 Total Costs in High and Low cholera incidence areas. ........................97 Figure 5.6 Per capita cost in High and Low incidence area. ..................................98 Figure 5.1 Total Cost of 2014’s Cholera Outbreak in High and Low Incidence Area. .......................................................................................................................99 University of Ghana http://ugspace.ug.edu.gh x List of Abbreviations CFR Case Fatality Rate COI Cost of Illness GHS Ghana Health Service GSS Ghana Statistical Service HIA High Incidence Area LIA Low Incidence Area UNEP United Nations Environmental Programme WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background of Study Economic measurements of disease complement clinical and epidemiological approaches in assessment of disease burden. Economic analysis seeks to address a number of policy questions on consequences of disease or injury (WHO, 2009). Such questions normally fall within either microeconomic or macroeconomic remit of a study. Under microeconomic analysis, impact of illness is measured on household income or a firm’s profit while the macroeconomic analysis aggregates impact of the disease on the country’s Gross Domestic Product (GDP) or its future growth prospects. Such estimates for diminished health status due to specific illnesses can usefully inform decision makers about the overall magnitude of economic losses and their distribution across a number of key drivers or categories of costs. These costs can ultimately be viewed as benefits from health improvements in the form of avoiding adverse health effects. Morbidity and mortality measures provide key features in estimating disease burden but such considerations are limited in accounting for health ‘shocks’ such as unexpected increases in health expenditure, reduced functional capacity and lost income and productivity which are primary risk factors for impoverishment (WHO, 1999; Xu et al., 2003). Ultimately, economic burden studies may help identify possible strategies for reducing the cost of disease via appropriate action, prevention or treatment strategies. University of Ghana http://ugspace.ug.edu.gh 2 Cholera still remains a major public health concern in many parts of the world but especially in developing countries. However, it seems to receive attention only with the on-set of an outbreak where large populations are affected. In 2014, there were 58 public health events within the World Health Organization (WHO) African Region and out of these, infectious diseases formed 95% of all these events with Cholera being the most frequently reported (31%), ahead of Ebola (13%) which has seen its biggest epidemic in history recently (WHO, 2014). According to the WHO, there were 101,987 cholera cases of which 1,881 resulted in deaths giving rise to a Case Fatality Rate (CFR) of 1.8% within the African Sub region (WHO, 2014). These reported cases were more than double that of the previous year 2013. In total, 16 countries reported cholera cases of which Ghana was the second most affected country only topped by Nigeria. Ghana, Nigeria plus DR Congo accounted for 85% of all cases reported in 2014. Figures 1 and 2 give details of distribution of cholera cases across the African sub-region during the 2014 outbreak. Worldwide, there have been many advances in methods and development of new drugs and vaccines before the turn of the 20th century, despite this, there has been an apparent increase in the emergence of many new as well as more ancient infectious diseases throughout the world of which cholera is one (Smith et al., 2005). Cholera was eradicated from the developed world well over five decades now but in Africa, poor sanitation as well as unsafe drinking water sources driven by poverty creates huge causal linkages between the frequent incidences and easy spread of the disease. According to United Nations Environmental Programme University of Ghana http://ugspace.ug.edu.gh 3 (UNEP, 2005), Cholera though an ancient disease, is at present, one of the most important resurgent diseases plaguing the world. Cholera is an acute intestinal infection caused by the ingestion of food or water contaminated with the bacterium Vibrio Cholera serogroups O1 or O139. It has a short incubation period and produces watery diarrhea in patients that can quickly lead to severe dehydration. The disease condition is nearly unrivaled in terms of the speed with which it kills. Healthy adults can die in as little as three to twelve hours after the first showings of symptoms if treatment is not promptly administered (Briggs, 2002). University of Ghana http://ugspace.ug.edu.gh 4 Figure 1.1 & 1.2 Overview of Cholera cases and deaths in WHO African sub- region Source: WHO, 2014 Outbreak Bulletin Vol. 6 Cholera remains a serious public health disease because outbreaks can spread easily over large regions and quickly overwhelm the health services system. Despite these facts, approximately 80 percent of all persons infected with the cholera never develop symptoms. However, the bacterium stays in their fecal matter for 7 to 14 days, leaving others at risk of infection when proper fecal Fig1. Geographic distribution of cholera cases in the WHO African Region, 2014 Fig2. Distribution of cholera cases and deaths by country, January – September 2014 35996 28944 22203 6421 3355 2059 832 582 485 309 262 235 213 44 35 11 755 243 372 167 185 80 12 9 13 9 11 12 3 0 9 2 0 5000 10000 15000 20000 25000 30000 35000 40000 Nigeria Ghana DR Congo South Sudan Cameroon Niger Benin Burundi Namibia Uganda Togo Cot d'Ivoire Angola Liberia Kenya Guinea-Bissau Deaths Cases University of Ghana http://ugspace.ug.edu.gh 5 matter disposal and personal hygienic practiced are not observed. Also, of all those who develop symptoms, up to 80 percent only develop mild to moderate watery diarrhea while between 10 and 20 percent develop severe watery diarrhea. Case fatality quickly rises to as high as 50 percent if symptoms are left untreated (WHO, 2014). “Cholera represents an estimated burden of 1.4 to 4.3 million cases, and 28,000 to 142,000 deaths per year worldwide” (WHO, 2015). However, WHO claims that there could be as much as 100,000 to 120,000 deaths due to cholera every year but countries normally fail to report actual numbers because of fear of external implications on their economics in sectors like trade and tourism. Coupled with this are poor surveillance systems and weak public health systems in most developing countries which are normally the worst hit regions. Such estimates are supported by Ali et al. (2012) who has reported the same case numbers annually worldwide. In addition to human suffering caused by Cholera, outbreaks of the disease cause panic, disrupt social and economic structures of families and can impede development in affected communities. In some instances, it may result in panic- induced reactions by other countries that curtails or restricts trade and travel from countries where the outbreak is occurring. For example, in 1991 the outbreak in Peru cost the country US$ 770 million due to food embargoes and adverse effects on tourism (WHO, 2014). University of Ghana http://ugspace.ug.edu.gh 6 Outbreaks may also result in catastrophic health expenditures by affected households in addition to over-stretching health system services with the rapid spreading of the disease. In Ghana, this was particularly evident in the 2014 outbreak where some health facilities reported overwhelming number of cases daily. In some of these facilities like the La General Hospital, the Out-Patient- Department (OPD) had to be converted into a makeshift ward for cholera patients. Table 1.1 Cholera Cases in Ghana by Region by Week, 2014 Source; WHO Country Office Ghana: Situation Report on Cholera Outbreak in Ghana as of 05 October (Week 40) and 28 December, 2014 (Week 52). 1.1 Problem Statement In parts of Ghana, cholera has now become endemic and the country has been experiencing outbreaks of the disease about every five years since 1970 (Amankwah, 2011). In June 2014, the country reported its first 6 cases of the disease in the Greater Accra region. Within two weeks the number of reported cases had risen above 250 and began spreading to other regions. Impoverished 1-Jan to 13-Jul 20-Jul 27-Jul 3-Aug 10-Aug 17-Aug 24-Aug 31-Aug 7-Sep 14-Sep 21-Sep 28-Sep 5-Oct 1-Jan to 5 Oct 1-Jan to 28-Dec W1-28 W29 W30 W31 W32 W33 W34 W35 W36 W37 W38 W39 W40 W1-40 W1-W52 Ashanti 0 0 0 0 0 0 30 0 0 130 13 173 287 Brong Ahafo 0 0 0 1 4 1 4 19 20 17 27 16 67 176 1056 Central 0 6 2 22 148 155 160 262 306 487 163 1711 3846 Eastern 0 16 50 92 107 154 117 125 180 145 165 180 27 1358 1875 Greater Accra 99 251 436 947 1873 1640 2188 2386 2044 1745 1425 1099 837 16970 20199 Northern 0 0 0 0 0 0 0 0 0 0 0 0 0 0 282 Upper East 0 0 0 0 0 0 0 0 3 0 2 5 22 32 294 Upper West 0 0 0 0 0 0 0 0 0 1 1 5 7 36 Volta 0 0 0 33 6 57 39 69 33 32 16 72 357 651 Western 0 0 4 2 8 7 13 17 12 47 28 31 2 171 429 Ghana 99 273 492 1097 2146 2014 2551 2878 2598 2604 1840 1408 955 20955 28955 Cases Region University of Ghana http://ugspace.ug.edu.gh 7 communities within the capital city of Accra which lack adequate plumbing and where open defecation is normally rampant appeared to be the epicenter of the country’s outbreak of Cholera. By the close of 2014, a cumulative total of 28,955 cases with 243 deaths and a CFR of 0.8% were recorded. All ten regions in Ghana reported cases with 70% of all the cases from the Greater Accra region alone. The economics surrounding Cholera have always shown poverty, social amenities like portable water and poor sanitation plus personal hygiene nexus. A desk study carried out by the Water and Sanitation Program (WSP) estimated that poor sanitation costs Ghana GH¢420 million (USD 290 million) each year. This sum is equivalent of USD 12 per person per year and forms 1.6% of the national GDP (WSP, 2012). Usually, the highest economic burden falls disproportionately on the poorest and costs of poor sanitation are inequitably distributed. For example, the average cost associated with poor sanitation, constitutes a much greater proportion of a poor person’s income than that of a wealthier person. The Water and Sanitation report on the economic impact of sanitation also reports that the poorest 20% of the population are 22 times more likely to practice open defecation than the wealthiest 20% of the population. For the poorest therefore, poverty cuts in two ways; not only are they more likely to have poor sanitation but they have to pay proportionately more for the negative effects that are resultant from these practices. “An efficient and hygienic method of human waste disposal available in a dwelling unit is a critical indicator of the sanitary condition of the unit and is an indirect measure of the socio-economic status of a household” (GSS, 2013 p.388). University of Ghana http://ugspace.ug.edu.gh 8 In 2010, public toilet was the highest reported facility in urban localities while in rural areas the highest was the use of bushes, fields and beaches which are all forms of open defecation. Public toilets were used by 38.4 percent of urban dwelling units and 29.8 percent in rural localities (GSS, 2013). These statistics are not entirely reflective of the cholera incidence situation in Ghana; because the largest numbers of cases are normally reported in urban areas which equally lack sanitation facilities as rural areas and unhygienic practices such as open defecation are also common. One intractable challenge of both urban and rural areas in Ghana is adopting modern and hygienic solid waste disposal systems. People are stuck to traditional ways of disposing off refuse such as burying and burning. A modern method such as collection by waste management companies is normally shorn especially by poor communities because of cost implications. Appropriate waste management helps to prevent the spread of infections including cholera and improves the quality of the environment. Poor sanitation however undercuts households and communities economically causing sanitation-related diseases burden, force adults out of work, children out of school, lowering productivity and household incomes. The burden of Cholera during an outbreak is easily noticeable with increases in diarrheal related cases at health facilities, increased deaths of patients presenting symptoms and a rapid spread of the disease to other localities. Despite these observable features, without estimation of real costs, the disease burden of Cholera will remain mostly observatory without much ‘teeth’ to show actual University of Ghana http://ugspace.ug.edu.gh 9 impact of the disease. Costs of the disease normally comprise epidemiological costs where government health systems and other agencies must respond quickly in curbing the outbreak. WASH response to Ghana’s cholera outbreak is estimated to be USD 1.2 million each year (WSP, 2012). Productivity losses are also significant due to either debilitating impact or premature death of patients as well as losses attributed to their caregivers. Outbreaks also lead to the diversion of expenditures from other essential sectors which have more direct impact on the economic development of communities rather than outbreak management. Trade and tourism is normally hampered by Cholera because it is a disease associated with flirt plus being communicable. Hence, the government experiences revenue losses due to reductions in both trade and tourism. The economic costs of Cholera in Ghana; direct, indirect or intangible have received very little attention despite the fact that the government, households and health facilities are all impacted at various levels and in various degree by the disease. Though most facilities have data on costs incurred, these usually cover only direct costs and in most instances these costs are shared costs for all services rendered at the facility without conscious effort in segmenting them for various disease impact. Additionally, costs borne by households in seeking care are completely missed and in this situation, the true cost of the disease is lost or underestimated because these key components are excluded. University of Ghana http://ugspace.ug.edu.gh 10 Additionally, the suddenness of Cholera’s emergence and its ease of spread can quickly drive both households and the whole health system into catastrophic expenditure. This situation is a cause for concern to all stakeholders involved. 1.2 Objectives of the Study The study is to generally assess the economic costs of 2014’s outbreak of Cholera on households and health facilities in the Greater Accra region of Ghana. Specifically the study seeks; • To estimate comparative costs in one low and one high cholera incidence area. • To determine correlates of cholera affected households with key interest on income quintiles plus other characteristics. 1.3 Relevance of the Study The relationship between socioeconomic status and health indicators has been widely studied, and it is recognized as a cause-effect relationship and access to social services such as education, housing, food, as well as equitable income distribution are important determinants of individual health conditions. Research on cholera in Ghana has focused more on determinants and risk factors of outbreaks, without much attention to economic costs of such outbreaks. Some of these studies include; (de Magny et al. (2006) who observe the relationship between disease’s temporal patterns and climate; Osei et al. (2010) studied spatial dependency of cholera prevalence on potential cholera reservoirs in Kumasi. These two studies reviewed the environmental factors influencing cholera University of Ghana http://ugspace.ug.edu.gh 11 incidence in particular locations. Thompson et al. (2011) sought to understand the evolution of the cholera epidemic in Ghana by analyzing a collection of Cholera strains from the beginning of the seventh cholera pandemic in Ghana. To the best of my knowledge and literature searches done, there is no known research on Ghana measuring economic costs of cholera outbreaks even though outbreaks have now become nearly perennial during every rainy season. The closest study of this kind was one done by Aikins et al. (2010) which measure health care costs of diarrheal disease in Northern Ghana. Studies of this nature however, lack the specificity needed in assessing disease-specific interventions which normally is the central focus of most costing studies. In addition, studies such as this that mainly present a provider based perspective greatly limit the study by ignoring the burden that disease pose to families. These all buttress the point of an existence of an important gap in the literature on Ghana especially with the regard of economic perspective on cholera. On the African front, Kirigia et al. (2009) proposed the urgent need for further studies to determine localized- level economic burden of cholera. The present study aims to fill the gap and increase global knowledge on costing of cholera in Ghana. This shall highlight a number of relevant policy implications and applications; • Cholera is an acute disease and can quickly lead to death within hours when left untreated. But up to 80% of cases can be successfully treated with Oral Rehydration Salts (ORS) (WHO, 2014). Most cases of deaths result from late arrival of patients at the health facilities to seek care. University of Ghana http://ugspace.ug.edu.gh 12 Knowledge in household’s cost drivers and importance of economics in early healthcare seeking is immensely critical in reducing CFR. • Households’ economic status can have an important influence on lifestyle, prevention and treatment of cholera. The a-priori expectation is for households that are relatively wealthier to live healthier life-styles and hence having lesser infection rates or faster recoveries from the disease. Having knowledge on the distributional effects of cholera on various income quintiles can guide policy makers in using targeted approaches to alleviate the burden of the disease where it is heaviest felt. • During emergencies like a cholera outbreak, there is increased collaboration between health agencies like the Ghana Health Service (GHS), Ministry of Health (MOH), WHO, UNICEF, the Red Cross, etc. In these collaborative efforts it is important that such organizations know the severity of the disease not just in human suffering but economic consequence within affected localities. This guides the channeling of collaborative efforts in combating such outbreaks. 1.4 Organization of the Study The study is structured into six chapters. Chapter one gives a general introduction, statement of problem, objectives, relevance, methodology and the organization of the study. Chapter two looks at cost of illness study, the history of the disease and its implications. Chapter three reviews existing literature on the both theoretical and empirical studies done on cholera. Chapter four profiles the two districts being studied, the theoretical framework and the empirical model that underpin University of Ghana http://ugspace.ug.edu.gh 13 analysis of data. Chapter five presents analysis and discussions of the data collected and entered from the field. Finally chapter six deals with summary of findings, recommendation and policy implications of the study. University of Ghana http://ugspace.ug.edu.gh 14 CHAPTER TWO OVERVIEW OF CHOLERA IN GHANA 2.0 Introduction Industrialization and development is lessens poverty and makes access to basic social amenities such as safe drinking water and sanitation improvements a reality. Sanitation and water are two key features in in the fight against infectious diseases such as Cholera. Due to these same features resulting from development, cholera has been eradicated from the developed world for over half a century now. Sadly, the situation seems to be worsening in the developing world and has been aided by proliferation of urban slumps, poor housing conditions, poor sanitary practices like open defecation among other factors. Cholera has been evidently predominant in communities or countries where poverty levels are still quite high. A study done by Talavera & Pérez (2009) showed that countries with low Gross National Income per capita reported the highest numbers of cholera cases in contrast with middle and high income per capita countries that reported 34% folds lower incidence. This underscored the statement that “cholera is a disease of poverty”. Cholera reached Africa in the 1970’s, and since then has become endemic in many African countries especially causing many deadly, multinational epidemics in many sub-Saharan countries. The incidence has also shown a growing seasonal pattern with onset of rainy seasons where poor sanitary conditions within these countries are exposed including large prevalence in refugee camp situations within the region which are plagued by many wars displaced persons. University of Ghana http://ugspace.ug.edu.gh 15 In 2005, 31 (78%) of the 40 countries that reported indigenous cases of cholera to WHO was in sub-Saharan Africa. The reported incidence of indigenous cholera in sub-Saharan Africa in 2005 (166 cases/million population) was 95 times higher than the reported incidence in Asia (1.74 cases/million population) and 16,600 times higher than the reported incidence in Latin America (0.01 cases/million population). In that same year, the cholera case fatality rate in sub-Saharan Africa (1.8%) was 3 times higher than that in Asia (0.6%); no cholera deaths were reported in Latin America. 2.1 History of Cholera There have been records of cholera-like diseases as far back as in the time of Hippocrates (460-377 BC) and Galen (129-216 AD) and numerous cholera-like maladies were also known in the plains of the Ganges River since antiquity. However, modern knowledge about cholera dates only from the beginning of the 19th century when researchers such as John Snow began to make progress towards a better understanding of the causes of the disease and its appropriate treatment. But since that period great advances have been made in identifying root causes, spread, treatment and prevention of the disease. So far, throughout history there have been 7 cholera pandemics starting from 1817 and which have always originated from Asia and spreading to the rest of the world. The first six pandemics all seem to have originated from Ganges in Bangladesh, and are thought to be caused by infection of the Classical O1 biotype strain of the disease (Laws, 2006). In 1961 the current cholera pandemic started and unlike the previous six which began in Bangladesh this began in Indonesia University of Ghana http://ugspace.ug.edu.gh 16 spreading through Asia to Africa, Europe and finally to Latin America and resulting in large number of cholera cases and deaths per year since that time (Colwell, 2002). Currently, the disease affects 3 to 5 million people every year predominantly in Africa and Asia (WHO, 2010). The pandemic reached sub-Saharan Africa in 1970 and has remained entrenched ever since. Latin America recorded its first cases in 1991 and within 3 years the number of recorded cases had risen to nearly 1 million. Though there was a great explosion of the disease within the first few years of it reaching that region, in contrast to Africa, cholera was largely eliminated from Latin America within a decade but in Africa it remains a persisting problem. 2.2 Clinical Features of Cholera Cholera is an acute diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae serogroup O1 or O139. Infection can be asymptomatic, mild, or severe: approximately 1 in 20 infected persons have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these persons, rapid loss of body fluids leads to dehydration, electrolyte disturbances, and hypovolemic shock. Without treatment, death can occur within hours but treatment is simple and inexpensive for most cases. In severe cases, vigorous oral or intravenous fluid and electrolyte replacement is key to recovery and overall mortality can be reduced from as much as 50% to less than 1%, even in makeshift rural treatment centers. University of Ghana http://ugspace.ug.edu.gh 17 2.3 Transmission of Cholera Two routes of transmission of cholera have been recognized; the first one occurs from aquatic reservoirs in the environment (primary transmission) and the second occurs from previously infected individuals (secondary transmission); once the primary transmission has initiated an outbreak, secondary transmission depends the problem by causing epidemics in the endemic areas (Ruiz-Moreno et al. 2010). Patients infected who have no symptoms will generally shed-off the organism for only a few days; however, patients who are symptomatic shed-off the organism between 2 days and 2 weeks (Nelson et al. 2009; Weil et al. 2009). Transmission of cholera within households has been documented (Weil et al. 2009) this increases the risk of infection among household members. Vibrio cholerae are present in human stool and when proper fecal disposal is not practiced there is the likelihood of pollution of water sources which are used by poeple (Nelson et al. 2007; Faruque et al. 2006). In environmental water, organisms convert to conditionally viable environmental cells within 24 hours (Nelson et. al. 2008). These organisms are infectious upon reintroduction into humans, although the infectious dose in this form is not known. Thus, the major source of Vibrio cholerae is feces of persons acutely infected with the organism that reaches water most often through sewage. Individuals with reduced gastric acidity and blood group O are more susceptible to the infection, and in situations where poor environmental sanitation is coupled with poor domestic and personal hygiene, transmission results from ingestion of faecally contaminated water (as well as University of Ghana http://ugspace.ug.edu.gh 18 food), and hence it is usually a disease of developing countries or areas where improved water and adequate sanitation are lacking. In endemic areas, water is usually the main vehicle of transmission, although this may occur through food, and thus infection due to Vibrio cholerae begins with the ingestion of contaminated water or food. Transmission of cholera in non-endemic areas is more commonly associated with consumption of foods, such as raw or undercooked seafood, imported from cholera-endemic regions and also due to migration of persons from affected regions. 2.4 Cholera Treatment Without treatment the case-fatality rate for severe cholera is about 50%. However, treatment is very effective and simple and is based on the concept of replacing fluids as fast as they are being lost. It is required that replacement fluids be similar to electrolyte composition of the fluids being lost. Initially, the fluids must be given sufficiently and rapidly to make up for the volume that has already been lost so that blood circulating volume can be restored. Additionally, maintenance fluids are given to replace continuing losses as they occur this will forestall any deaths when fluids are given promptly and efficiently. Normally, signs of dehydration are not clinically apparent until the patient has already lost about 5% of his or her bodyweight. A patient with severe dehydration requires emergency intravenous polyelectrolyte solution for rehydration followed by oral rehydration solution (ORS) for maintenance hydration. In milder cases, ORS can be used for both rehydration and maintenance. Patients who are severely University of Ghana http://ugspace.ug.edu.gh 19 dehydrated are assumed to have lost 10% of their bodyweight, and this is the volume that needs to be replaced. There are cases where patients have no pulse but in such situations patients are to be given fluids as rapidly as possible and more than one intravenous line may be needed to infuse the fluid rapidly enough to restore the pulse. In patients with lesser degrees of dehydration, the simple use of ORS is effective for rehydration. 2.5 Prevention of Cholera Contaminated food and water are normally the main routes for infection and much can be done to keep transmission rates to a minimum. The measures include ensuring a safe water supply, improving sanitation, making food safe for consumption by thorough cooking, and health education through mass media. Some important messages for the media during outbreaks include the importance of purifying water and seafood, washing hands after defecation and before food preparation, recognition of the signs of cholera, and locations where treatment can be obtained to avoid delays in case of illness. Filtration of water through sari cloth is quite effective and reduces cholera transmission by nearly 50% (Colwell et al. 2003). The long-term prevention of cholera will require improved water and sanitation facilities, but these improvements are not happening rapidly in most regions where cholera is prevalent because many needs usually ‘juggle’ for the same limited resources. 2.6 Cholera Epidemic and Outbreak Epidemics or explosive outbreaks generally occur in underdeveloped areas with inadequate sanitation, poor hygiene, and limited access to safe water supplies, University of Ghana http://ugspace.ug.edu.gh 20 whereas in some countries, a seasonal relation for cholera epidemics has been observed (Koelle et al. 2005; Faruque et al. 2005). WHO described a dramatic increase in the number of cholera cases and outbreaks, in new communities and in communities where the disease had been absent for emerging disease. 2.7 Cholera in Ghana In West Africa, Guinea was the first country to report cases of cholera and though the government initially denied it, the WHO had to break protocol and establish for the first time that “the health of the world's people is more important than the sovereignty of member countries” (Ofori-Adjei & Koram, 2014). The first case of cholera in Ghana occurred on September 1, 1970 when a Togolese national in transit from Guinea collapsed at the Kotoka International Airport and was later diagnosed with cholera (Pobee & Grant 1970). Two of the worst hit sites in Ghana, subsequently, were the fishing villages of Akplabanya (in the then Ada District) and Nyanyano (Winneba District). Cholera in these areas appeared to have been “smuggled in” by relatives of dead Ghanaian fishermen from Togo and Guinea, respectively, for burial despite a sanitary cordon on Ghana's borders. By July 1971, the Ashanti region began to report cases, indicating that cholera had spread across the country (Ashitey, 1994). Since then there has been focal outbreaks every 4 to 6 years. In recent years outbreaks have become more frequent and protracted and now believed to be endemic in Greater Accra, Central and Western Regions. A pilot study by GHS (2014) within Accra Metropolis found that 3 out of every 10 University of Ghana http://ugspace.ug.edu.gh 21 diarrhea cases proved positive for Vibrio cholera stamping rife of the disease. Attempts at controlling cholera have not been successful because needed long term approaches, such as potable water supply, proper disposal of solid waste etc. have been grossly inadequate and inequitably distributed to capture disadvantaged populations. Cholera is now endemic parts of Ghana with cyclical epidemics. These epidemics are now predictable but sanitary reforms have been inactive, ineffective and local authorities have failed in applying necessary bye-laws on food hygiene, sanitation, environmental health and waste disposal. Cholera in Ghana is mainly an urban problem with high impact on the urban poor. The unprecedented unregulated growth of urban slums has resulted in poor environmental conditions, lack of access to clean potable water and extreme challenges in waste disposal. Hence, the routes of cholera problem Ghana is well- known. 2.7.1 Historical Trends With the current outbreak inclusive, there have been 5 major outbreaks in Ghana since 1980 and the current outbreak being the worst ever to affect the country. Figure 2.1 below shows incidences of outbreaks from 1980 to 2014 giving a picture of its resurgence every 4 to 6 years. Most of the outbreaks have normally shown a steady rise of the outbreak from the previous year but the 2014 outbreak had a sudden trend rising from an almost zero cases in the previous year to become the worst outbreak in 30 years in a short span of six months. Out of the 5 major outbreaks, 3 recorded over 10,000 cases of the disease. The years between 1985 and 1989 was the longest period recorded with less than 200 cases. University of Ghana http://ugspace.ug.edu.gh 22 However, the years 1988, 1998 and 2013 had the lowest number of cases in the history of the disease in Ghana, reporting less than 20 cases. Finally, apart from the year 1998, which had zero cases of the disease, all other years have reported cases of the disease. The Greater Accra region has consistently reported the largest number of cases in the country and within the region Accra Metro, Ga West, Ga South and Ledzokuku Krowor districts have recorded the highest number of cases over the past 3 years. In the recent outbreak, the region recorded 70% of all reported cases and 50% of deaths. Figure 2.1Cholera cases within 16 districts of the Greater Accra between 2012 and 2014. Source: Author’s computation Data Source: GHS, 2015. Regional Disease Control Unit. 10,504 103 1 19 68 152 190 2,082 1,286 280 1,907 770 1,398 32 315 1,092 20,199 0 5,000 10,000 15,000 20,000 25,000 ACCRA METRO ADA EAST ADA WEST ADENTAN ASHAIMAN GA CENTRAL GA EAST GA SOUTH GA WEST KPONE KATAMANSO LA DADEKOTOPON LA NKWANTANANG LEDZOKUKU KROWOR NINGO PRAMPRAM SHAI OSUDOKU TEMA TOTAL 2014 2013 2012 University of Ghana http://ugspace.ug.edu.gh 23 Table 2.1 Cholera cases and deaths by region, Ghana 2014 Cholera Cases and Deaths by Region, Ghana 2014 Region Cases Deaths CFR (%) Ashanti 287 3 1.05 Brong-Ahafo 1056 26 2.46 Central 3868 64 1.65 Eastern 1875 6 0.32 Greater Accra 20199 121 0.6 Northern 282 2 0.71 Upper East 294 9 3.06 Upper West 36 1 2.78 Volta 651 8 1.23 Western 429 7 1.63 Source: GHS, 2015. Regional Disease Control Unit. Table 2.2 shows the distribution of cases in the recent 2014 cholera outbreak by region. Apart from Greater Accra, Central region had the second highest number of cases recording over 3800 cases over the period. Though Greater Accra reported the largest number of deaths over the entire period, it reported the least CFR (0.6) and the Upper East Region which recorded 294 cases had the highest CFR (3.06) in the country. This might be attributable to the relative ease in accessing health facilities, proximity of health facilities and education on the disease which might all be better in Greater Accra compared to the other regions. The cholera outbreak in 2014 recorded 28,975 cases 243 deaths (CFR=0.8%) with all the 10 regions of the country reporting cases. Some triggering factored identified by the GHS as the cause of the cholera outbreak include; Shortage of potable water supply, Breakdown of waste management systems, Poor personal hygiene and poor food hygiene. Accra was the epicenter of the outbreak and all University of Ghana http://ugspace.ug.edu.gh 24 cases reported within the country were due to internal migration. Identifiable challenges in dealing with the outbreak were due to persistence of risk factors (personal and environmental), slow response by stakeholder agencies, overwhelming large number of cases during outbreak and inadequate cholera logistics and treatment centers. Between December 2010 and 2012 nine out of the ten regions of Ghana experienced a protracted outbreak and though very few cases were reported in 2013, 2014 saw an unprecedented surge in cases giving a clear indication that the situation is far from being abated. University of Ghana http://ugspace.ug.edu.gh 25 Figure 2. 2 Cholera in Ghana: 1980 to 2014 Source: Author’s computation Data Source: GHS, 2015. Regional Disease Control Unit. 261 940 11086 15032 1015 62 25 58 17 119 3464 13743 273 1470 2387 4443 1118 64 0 9463 3431 5483 3763 239 517 4387 3353 179 1126 1272 438 9370 9562 18 28975 0 5000 10000 15000 20000 25000 30000 35000 19 80 19 81 19 82 19 83 19 84 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 Fig 2.2 Cholera in Ghana: 1980 to 2014 NO. OF CASES University of Ghana http://ugspace.ug.edu.gh 26 Figure 2.2 Distributions of Cholera Cases by Region, Ghana 2014. Source: GHS, report on cholera outbreak in Ghana, 2014. University of Ghana http://ugspace.ug.edu.gh 27 CHAPTER THERE LITERATURE REVIEW 3.0 Introduction In this chapter, the theoretical foundations of economics of ill-health and its impact on households is presented. The concept of economic cost is defined and the different methods recommended by WHO guidelines to identifying the economic consequences of disease are expounded. The Cost of Illness (COI) method as developed by Rice (1966) and modifications by Shepard et al. (1991) is reviewed and its application to identifying cost components and its estimation. Also, Grossman’s (1972, 2000) model on the demand for health including its application as human capital is discussed. Finally, an empirical review is done in two parts. The first part reviews studies using different cost approaches in measuring costs of cholera and the second part delves into the linkages of poverty, sanitation, access to portable water and the incidence of cholera. 3.1 Theoretical Foundation Health care utilization and health seeking behaviour modeled by Andersen (1995) has been widely used in public health circles. It is assumed by the model that health seeking behavior results from interaction of individual’s characteristics, population and his environment, and that the use of medical service is dependent on three main factors namely; predisposing, enabling and need factors. Predisposing factors are features that influence an individual’s health as a result of certain peculiar behaviour patterns which include demography (sex, marital University of Ghana http://ugspace.ug.edu.gh 28 status, household headship and past ailments); social structure (education, race, occupation and religion); and lastly, belief systems (such as culture). Enabling factors are related to issues of availability, equity, accessibility, quality and costs. These tend to promote, inhibit or limit the use of health services. The third factor; need, encompasses the individual’s health use that is necessitated by disease or impairment such as intensity of illness measured by the number of sick days. Thus, Andersen’s model estimates the use of health care services as a function of these three factors. However, economic theories on the use of health services focus on the how individuals make decisions in consuming health care to produce health as in the case of Grossman (1972) and with further simplifications by Wagstaff (1986). “The theory develops a conceptual apparatus for analyzing the interaction of socioeconomic determinants of health and indicates how this can be used to shed light on a variety of policy issues such as socioeconomic inequalities in health and the design of prevention policies” (Wagstaff, 1986, p.1). Wagstaff hinges his theory on three basic economic concepts; the indifference map, the health production function and the budget constraint. An individual’s indifference map is made up of several indifference curves of which these curves are formed from the individual’s combination of commodities that gives him or her a certain amount of utility. Under the theory, the individual views ‘good health’ as a desirable commodity in addition to other commodities from which utility is derived but the individual does not place an overriding value on ‘health’ relative to the other commodities. The individual will therefore end up with an indifference curve University of Ghana http://ugspace.ug.edu.gh 29 showing a combination of health consumption as well as other goods that brings him or her maximum satisfaction. In the ‘health production function’, it is postulated that an individual produces an output ‘health’ by combing health inputs. These inputs include; education, medical care, food, exercise etc. and the interaction between these inputs in producing the output forms the ‘health production function’. Thirdly, the theory assumes the existence of a budget constraint resulting from costs of health inputs and its consumption process. Meaning the consumption of health inputs is not limitless and the quantity that can be accessed by an individual will be dependent on his or her income and the prices of the inputs. Deducing from these three principles, it can be assumed that an individual’s production of health will depend on factors such as his utility, technical know- how (education) and income. 3.1.1 Economic Consequences of Illness on Households Welfare economic theory suggests that individuals seek to maximize their utility or economic welfare subject to some constraints which include income and time. This is achieved by combining a range of goods and services; some of which can be bought or sold (including health care) and some of which cannot but still have value. Health, unlike other economic goods and services that yield direct utility, has an indirect utility, because consumers of health would have preferred not to incur University of Ghana http://ugspace.ug.edu.gh 30 these expenses in terms of money and or time. Therefore, health contributes to the individual’s utility in three ways. One, people prefer more healthier days to less healthier days. Two, the level of health partly influences the consumption of other goods and services. Three, poor health inhibits economic objectives like making income that allows people to consume market goods. Poor communities normally have high proportion of out-of-pocket health expenditure and ill-health drives up household’s consumption of health goods whilst lowering that of their basic needs such as food, clothing, housing and children’s education. For example, in Germany where per capita GDP is US$ 32,860, households bear 11.3% of all medical expenses and the rest by a social health insurance or by the government. In contrast, in DR. Congo where GDP per capita is only US$120, households bear about 90% of health care costs directly. This situation creates the tendency of deterring poorer people from seeking orthodox health services, truncating treatments or resorting to other unorthodox methods of treatment which sometimes leaves fatal results. Time spent seeking care further inhibits work and lowers financial earnings. Financing healthcare might transcend current income into households’ savings if available or if not, through a loan or sale of family assets. Reduced income, savings and assets will deplete investment and eventually affect future consumption possibilities. Xu et al. (2003, 2007) estimate that 44 million households worldwide are plunged into catastrophic health expenditures (40% of a household’s none-subsistence income on healthcare payments as defined by Xu et al. (2003) and about 25 million pushed into poverty each year. Clearly defined, University of Ghana http://ugspace.ug.edu.gh 31 Xu et al. (2003) states that health expenditure as being catastrophic if a household’s financial contributions to the health system exceed 40% of its income remaining after subsistence needs have been met. Wyszewianski (1986) alludes to the fact that, high medical costs were not necessary synonymous to catastrophic expenditures to households especially when there is the existence of medical insurance policy to cover either all or large portions of the costs. But conversely, small medical bills for common diseases could become financially dangerous to poor households with no insurance cover. A recent WHO report also noted that the likelihood of financial catastrophe is negligible if 15-20% of household’s total health expenditure is out-of-pocket (OOP). However, the average OOP is 40% for African countries, indicating the higher possibility and plausibility of financial catastrophe and resultant poverty. From the aforementioned, Cost of Illness studies try to answer a number of health policy questions under macro or micro levels of the economy. Table 3.1 captures questions at their respective levels and the economic unit these questions apply to. University of Ghana http://ugspace.ug.edu.gh 32 Table 3.1 Illustrative health policy questions addressed by economic impact studies. Source: WHO guide to identifying the economic consequences of disease and injury (2009). 3.1.2 Health as component of Human Capital In the broadest definition of the term asset, economists define an asset as a resource with economic value that an individual, corporation or country owns or controls with the expectation that it will provide future benefit. This asset can either become depleted with time or produce gains. In this sense, health can be viewed as economic asset capable of either depletion with time and other factors like high risk behaviour or enhanced through investments like healthy dietary practices and exercise. Hence health has the capacity to be produced through investments and also viewed as capital consumption due to aging and lifestyle. Health investment can also be seen through either curative or preventive methods. LEVEL QUESTION MACRO 1. What impact does ill-health have on gross domestic product or its rate of growth? Society 2. How much does society pay for medical and other expenses because of illness? 3. What is the impact on social product (i.e., both market and non-market consumption lost opportunities), or on social welfare more generally? MICRO Households 1. What impact does ill-health have on a household's income or consumption patterns (over a single year, or for a longer period of time)? 2. How much do households pay for medical or other expenses because of illness (for an episode, over a year, or over a lifetime)? Firms 1. What impact does ill-health have on a firm's operating costs, output or profit? 2. What is the impact of ill-health on productivity in the work place (including impaired performance while still at work, as well as absenteeism) ? Government 1. What proportion of government expenditure could have been saved and directed to an alternative use in the absence of illness? (e.g. what social security payments could be avoided by the prevention of or cure for disease?) 2. What impact does ill-health have on the government workforce and on the government's ability to provide services? University of Ghana http://ugspace.ug.edu.gh 33 Curative is where upon the onset of ailment, medical services are purchased to ensure the return to good health and preventive in the form of one introducing exercise to lifestyle and healthier eating habits that reduces the risk of certain disease conditions. The return on these health investments is lesser time spent in bad health. The healthy time gained can in-turn increase labour income and thus increase consumption or leisure. In economic theory rational beings prefer more utility to disutility and will seek to maximize this utility. This model is theorized by Grossman (1972) which suggest that given an individual’s initial stock of health inherited from their parents and their environment, the individual will make informed choices regarding their health improvements over their life cycle. The individual does so by investing in healthcare and practicing health enhancing behaviours to maximize utility but will be constrained by a budget. 3.1.3 Application of Grossman Model to Study According to Grossman (2000), the demand for health is split into two based on either for ‘Pure Consumption’ or ‘Pure Investment’ purposes. With pure consumption purpose, the return is mainly ‘psychic’ granted that it reduces disutility in terms of fewer sick days. On the other hand, pure investment in health is mainly for the purposes of increasing healthy days to participate in market and non-market activities. This study assumes based on this model that wealthier persons have greater positive returns on health and will hence face a lesser burden when an outbreak of cholera occurs. Grossman further postulates that price of medical goods have a negative effect on both consumption and investment into health. This is directly linked to factors of affordability and access. Wealthier University of Ghana http://ugspace.ug.edu.gh 34 homes are able to utilize and make investments into their health better than their less wealthy counterparts due to these factors and hence poorer homes continually face greatest burden of diseases. On education, similar arguments are put forward by the model. Stating that with improved education, individuals are more efficient in producing health, that is; more educated people are better off following instructions for medications and or are more knowledgeable about what is bad for their health. It has been empirically observed that population level (local-level) risk factors of cholera include poverty, lack of development, high population density, low education, and lack of previous exposure (Ackers et al., 1998; Ali et al., 2002). Penrose et al. (2010) also suggest that global urbanization plus urban poverty are associated with high risk of infectious diseases such as cholera among other studies. This study hinges on these assumptions and tries to determine the impact of the cholera outbreak based on the costs that result from treatment of the disease and its predisposing factors resulting from the income strata of cholera affected households. The COI method is used to identify costs and a Tobit model in determining the correlates of cholera for these households. 3.2 Cost of Illness Approach (COI) Cost of illness (COI) studies is a type of economic study common in medical literature, particularly in specialist clinical journals (Byford et. al., 2000). It is most usual to these studies when the economics of health is being observed. COI studies seek to identify and measure all costs of a particular disease; direct and University of Ghana http://ugspace.ug.edu.gh 35 indirect as well as intangible dimension in some cases. The determination of total cost of an illness provides two critical useful pieces of information. One, it tells us how much society is spending on a particular disease, and by implication the amount that would be saved if the disease were curtailed. Two, it identifies the different components of cost and the size of the contribution of each sector in society. Such information, it is argued, can help to determine research and funding priorities by highlighting areas where inefficiencies may exist and savings may be made (Rice, 1994; Ament & Evers, 1993). COI was formulated by Dorothy Rice and colleagues in the late 1960’s and subsequently revised (Rice, 1966, 1967; Cooper and Rice, 1976; Rice et al., 1985). A bulk of economic impact studies in health use some version of COI approach and it remains the most common measurement of illness approach. In its original form, measurements of costs associated with pain or suffering were not considered though they were described as ‘intangible costs’. The traditional COI approach estimates the societal impact of disease and injury combining ‘direct costs’ (medical diagnosis, treatment, transportation, follow-ups care, etc.) and ‘indirect costs’ (the value of lost production because of reduced working time). Two methods of COI have evolved; Prevalence and Incidence approaches. The commonest is the prevalence method and it estimates the total cost of a disease incurred in a given year. Incidence approach calculates the lifetime costs of cases first diagnosed in a particular year (Rice, 1994). In this study a prevalence University of Ghana http://ugspace.ug.edu.gh 36 approach is applied for the costs associated with the incidence of cholera within the 2014 outbreak. An important factor for consideration in estimating households’ direct and indirect costs in seeking healthcare is households’ ‘coping strategies’ in mitigating the impact of ‘shocks’. These strategies include adjustments of labour supply within the household to preserve production and income flows, drawing on savings, borrowing, social or health insurance and disposal of assets (Sauerborn et al., 1996). On the other hand, Russell (2004) shows that most of these coping strategies come with future repercussions and might in the long-run be more costly to the household’s livelihood. For this reason, coping strategies though might mitigate impact of disease burden in the short term, have long term effects which are equally problematic for households. Hence coping strategies are concluded as having little to no effect in the long-run. 3.2.1 Costs Definitions Economists define costs as opportunity cost. That is, a forgone benefit in using resources in their next best alternative. This concept is fundamental in economics because resources are scarce and choices need to be made among alternative uses. For example, during the 2014 cholera outbreak, the Out-Patient-Department (OPD) of the La General Hospital became a mid-shift admission ward and all other medical services suspended except emergencies. Hence, the opportunity cost of the outbreak was all other unattended health cases which were less acute. Therefore, opportunity cost presents a picture of competing needs and scaling of priorities. University of Ghana http://ugspace.ug.edu.gh 37 On the other hand, accountants’ costs comprise of only physical expenditure on goods and services such as payments for medical supplies, staff salaries, equipment etc. But accountants’ costs tend to underestimate costs because it does not capture costs of resources being used in other capacities as well as costs such as volunteers’ time and auxiliary services like free treatment of medical staff. Therefore economic costs capture both financial monetary costs as well as non- monetary costs. Costs studies are crucially dependent on the viewpoint of the measurements of interest. As in Table 3.1, economic impact on the whole economy might differ from that on a firm or a household. For example, the effect of disease or injury on a household's income or consumption opportunities (household question 1 in Table 3.1) could be interpreted to include only market production and cash purchases, in which case the quantity of interest is the value of market consumption opportunities foregone because of illness. On the other hand, the quantity of interest could be redefined to include the economic losses associated with both market and non-market production or consumption opportunities. Finally, it could be defined even more broadly to include the value of the lost welfare associated with illness, which would include not just the lost production and consumption, but the value of the changes in leisure and the decrement in welfare. Each of the questions measure different quantities of interest and estimates derived from each are normally viewed separately. 3.2.2 Healthcare evaluation costs concepts • Cost analysis University of Ghana http://ugspace.ug.edu.gh 38 Cost analysis break down a cost summary into its various constituents and investigate the parts of the whole and their relations in making up the whole. It focuses on assessing the costs of providing or consuming a service or intervention. It is useful for assessing the affordability of a programme and for guiding budgetary planning. It also provides useful understanding of incremental costs of interventions and the total resource needed to support current and future strategies. Cost analysis does not consider the effectiveness of an intervention or service. In its application in health economics, it identifies the key drivers of costs for particular diseases and measures its impact at the individual, household, firm, government or the entire society level. It is also relevant to conduct when a new intervention is sort to be introduced like a vaccine to deal with a health related problem. It provides useful information on where costs are heaviest felt and therefore needs policy focus. • Cost-minimization analysis (CMA) Cost-minimization analysis is used when identifying the least cost among alternative choices that produce similar outcomes in terms of benefits or effectiveness. It is a comparison of two or more strategies which have the same effectiveness but which are assumed to have different costs. It aims at achieving ‘value for money’ either through a desire to achieve a predetermined objective at least cost or a desire to maximize the benefit to the population of patients served from a limited amount of resources. It is a useful tool when benefits from alternative measures are considered to be equal. It becomes however challenging especially among human rights activists when priority of ‘value for money’ is placed above saving lives. This aside, this method seeks to achieve the best use of University of Ghana http://ugspace.ug.edu.gh 39 resources in producing maximum outcomes without compromising quality of healthcare. • Cost-effectiveness analysis (CEA) A cost-effectiveness analysis compares relative costs and outcomes/effects of two or more courses of action. The aim is to identify the strategy with the lowest cost per unit of output, or alternatively the strategy that delivers the highest output for a given fixed budget. In the health services field, it is normally useful in situations where it may be inappropriate to monetize health effect. It is expressed in terms of a ratio where the denominator is a gain in health such as years of life, sight years, premature births averted etc. and the numerator, the cost associated with the health gain. The effectiveness indicator is the same for each strategy being compared, and consists of a health outcome measure. • Cost-utility analysis (CUA) Cost-utility analysis is relevant when the aim of the study is to compare alternative health services or interventions that are associated with different costs and different outcomes especially with procurement decisions. In health economics it estimates the ratio between the costs of a health related intervention and the benefits it produces in terms of the number of years lived in full health by beneficiaries. The main distinguishing feature of cost-utility analysis from cost- effectiveness analysis is that it involves measurement of the “utilities” associated with different interventions. This estimation technique is based on “expected utility theory”, also referred to as von Neumann-Morgenstern utility theory, which is a theory of rational decision-making under uncertainty. The existence of University of Ghana http://ugspace.ug.edu.gh 40 uncertainty in the analysis captures the extent to which individuals are risk averse, risk-seeking or risk-neutral. This procedure allows for comparison across different health programmes and policies by using a common unit of measure and it also takes into account the quality of life of the individual has. • Cost-benefit analysis (CBA) Cost-benefit analysis is credited to the French Economist Jules Dupuit. He theorized this analysis by comparing the total expected costs of alternative intervention programmes against its benefits to see whether the benefits outweighed the costs. This technique determines the option that provides the best approach for adoption in terms of benefits or effectiveness. CBA assigns monetary value to health improvements which differ from other cost analysis like Cost Effective Analysis and Cost-Utility Analysis which mostly assigns Quality Adjusted Life Years (QALYs) as the unity of analysis. Cost analysis procedure is most suitable for this study because the study attempts to identify all cost components associated with of an episode of cholera outbreak and how each component contributes towards the overall costs of treatment to households and health facilities in dealing with the disease. Though direct costs are important and shows an obvious impact of illnesses on the unit under study, some studies such as Akazili et al. (2007), Poulos et al. (2012), Sachaetti et al. (2012) & Sarker et al. (2013) all found indirect costs to be higher than direct costs. Specially, Akazili et al. (2007) found indirect cost to be as high as 71% of the total cost of treatment of malaria within households in Northern Ghana. University of Ghana http://ugspace.ug.edu.gh 41 Cost analysis also measures the amount society spends in total upon an episode of the disease and in effect the cost-savings of the eradication or minimizing of infections of the disease. Other cost analyses don’t make conscious effort breaking down the costs into its base components to check its impact on specific units for example, CBA will weigh the costs and benefits of a programme to choose the programme but not consciously seeking to find impact on various cost components. CMA seeks the least cost in undertaking a venture while CEA seeks to maximize a given budget. But because this study seeks to identify the impact of costs on households especially identifying other none-direct costs which might play a significant role in impacting these households Cost analysis is the best method for analysis. Finally, this study does not examine the impact of an intervention like the introduction of a Cholera vaccine or interaction of various interventions such as combination of water source improvements with either a vaccination programme which all the other cost analysis might be suitable in providing relevant measures, they are not used here. 3.3 Theoretical Framework Mortality, morbidity and debility are costs associated with cholera but this study focuses on the impact of morbidity and to a lesser extent mortality (burial cost). Debility which deals with the impact of an inability to engage in work due to physical weakness is not investigated separately in this study but captured under morbidity. This is peculiar with cholera studies as the idiosyncrasies of the disease make all cases admission cases. Shephard et al. (1991) categorize various University of Ghana http://ugspace.ug.edu.gh 42 costs components borne by the individual, the household, the health facility, the government and or the economy into direct, indirect and intangible. Malaney, (2003) further comprehensively expressed by as: COI = Private Medical Cost + Non Private Medical Cost + Labour Loss + Risk Related Behavior Modification + Investment Lost + Non Economic Personal Burden Figure 3.1 shows the COI due to cholera is conceptualized in a framework adopted from Asante & Asenso-Okyere’s (2003) Economic Burden of Malaria in Ghana but with modifications to suite this study. These modifications exclude intangible costs and other direct costs to institutions such as Non-Governmental Organizations because they don’t fall within the scope of this particular study. Figure 3.1 Conceptual Framework for Costs of Cholera. Mortality Morbidity Costs of Illness Direct Costs • Household Treatment, Transportation & burial. • Facility Treatment Indirect Costs • Treatment time, waiting & travel time • Income & Production losses Household / Individual Costs Health Institute Costs Reduced Productivity • Loss of Labour hours • Absenteeism Cholera Effect University of Ghana http://ugspace.ug.edu.gh 43 Source: Asante & Asenso-Okyere (2003) with modifications by Author. 3.3.1 Direct Cost Direct costs are costs that can easily be identified and completely attributed to specific items in the production of specific goods or services but in this study it is seen as in the production of health by households and health facilities. The process of seeking treatment involves cost to the individual and his household. In addition, facilities giving out treatment also bear costs in providing such services to its consumers and these are also captured under the direct cost. Cash expenditures made by households in seeking care form the root of most direct costs in health economics and these costs normally include; medical expenses, cash expenditures on special foods, transportation and provisions for burials in event of deaths. On the other hand, facilities bear direct cost through both medical and non-medical supplies and services. Both households and facilities costs constitute resource consumption costs for the seeking and provision of healthcare. Direct costs to households can easily be obtained through recalls but that of health facilities become more complex due to how health systems are setup. Costs within such establishments are mostly shared among several activities which are not easily distinguishable. For the purposes of this study, only costs that went directly into logistical supplies in dealing with the outbreak at the facility level were considered. These supplies were items used directly in addressing the problem of the cholera outbreak in the facility. University of Ghana http://ugspace.ug.edu.gh 44 3.3.2 Indirect Cost There is a usual debate about the inclusion of indirect costs in costing procedures since it is not mostly tangible or directly associated with an event. But when included in studies they show the bigger view and truest costs because they mostly comprise opportunity costs which are fundamental costs to economists. Indirect costs are very significant with the incidence of cholera. Cholera unlike other diseases leaves the patient acutely dehydrated and unable to partake in any meaningful work, school or social activity. Additionally, caregiving for patients is crucial towards the full recovery of patients because patients are critically weak and need constant attention and sometimes special feeding. These characteristics of the disease condition make both patient and caregiver loose valuable hours which hitherto could have be engaged in participating in productive venture. Oxfam’s Cholera outbreak guidelines (2012) suggests that children under the age of five are among the three most vulnerable groups during an outbreak and these children mostly will require constant caregiving for the entire duration of their ailment until recovery. Indirect costs hence include costs incurred not for its own sake but as a result of another item or activity. These costs sometimes go beyond monetary expense to include productivity and time losses. Therefore, they are difficult to assign to or identify with a specific cost objects. In definition, indirect costs are ‘…costs associated with lost or impaired ability to work or to engage in leisure activities due to morbidity and lost economic productivity due to death’ (Gold et. al, 1996. University of Ghana http://ugspace.ug.edu.gh 45 p.181). It is simply defined as the value of time lost due to illness or death. These productivity loses will differ according to the age and occupation of an individual. During the period of sickness patients and their caregivers incur an opportunity cost in time spent on treatment, waiting and travel. This is not an out-of-pocket expenditure but productive time loss that could otherwise be used for attaining both economic and non-economic goods. Such productivity losses result from incapacitation, occupational disability, caregiving and premature death. Indirect costs are made up of basically three components; absence from paid work, reduced productivity at paid work and unpaid production such as reduced possibilities of performing usual activities at home. The first two components apply to the adult productive group normally between the ages of 15 years (age for employment under the Ghana Children’s Act 1998) and 60 years (retirement age in Ghana). Indirect costs become importantly crucial when the sick household member is the bread-winner or contributes substantially to the household income and his or her incapacitation results in huge financial strains on the family. The commonest measure of indirect cost is through the human capital approach based on the Neo-classical viewpoint that wage rate is equivalent to the value of marginal productivity of labour. Concluding that incomes earned can be equated to monetary value of production lost and therefore calculates the indirect cost using the individual’s gross wage that would have been earned except for the onset of disease multiplied by the duration of absence. University of Ghana http://ugspace.ug.edu.gh 46 A more recent approach is the friction method. This came in response to the assumption of full employment adopted by the human capital approach which did not take into account certain realities. A more societal view is to look at the gap between unemployment and frictional unemployment. In this case, an absentee worker is replaced by a previously unemployed person and hence his lost income transferred to the newly employed. On a societal level, there is no loss of income or productivity, the only loss of productivity is the period it takes to replace the sick individual and this is called the ‘friction cost’. This makes the friction method provide a less exaggerated production cost compared to the human capital approach. A second recent method recommended by the Washington Panel’s guidelines incorporates indirect non-medical cost as health effects rather the traditional methods of productivity losses due to ailment. It jumps a step further ahead of the friction approach by supplementing a friction effect with health effect. It recommends that productivity losses be measured through its impact on quality of life in terms of health effects plus friction costs. Unlike the human capital approach and the Friction methods which both capture in monetary terms indirect costs through productivity losses and income reduction, the Panel method further breaks into two the impact of reduced productivity; one, impairment in role functioning and two, reduced income conditioned by disease effect. The Panel’s method theorizes that quality of life of an individual is in part dependent on their role functionality in society or specifically on the job they are involved in. Therefore, the impact of role functioning is measured as health related quality of University of Ghana http://ugspace.ug.edu.gh 47 life-effects and the relationship between productivity and quality of life runs partially through the patient’s income. The Panel concludes that patients will base their estimation of quality of life reduction on their loss of income rather than directly on the loss of production. However, in response to this model, Brouwer et al. (1997) criticized the Panel’s method on three key issues; one, direct health effects might not be meaningful monetized on the quality of life and should only be considered as health effects and not productivity losses at the societal level. Two, the model does not take into account compensational facilities such as social security and private health insurance which can mitigate the impact of income losses. And finally, the model becomes most useful from the patient’s (individual or household) perspective when measuring the impact on quality of life and not for productivity costs from a societal viewpoint. From the above-mentioned, the traditional human capital approach has the greatest tendency of overestimating indirect costs because it assumes away many real life possibilities. The friction method deals with this potential overestimation by incorporating an augmenting factor of replacement of sick worker but is most useful in macro-level studies where a firm’s reduced productivity is being measured. Brouwer et al.’s third criticism of the Washington Panel’s method show this method has rather has advantages when doing micro level studies. Finally, other studies measure costs through a willingness-to-pay approach. This approach seeks to capture either the entire household by including adult University of Ghana http://ugspace.ug.edu.gh 48 household members who are not working and yet can incur some form of indirect cost. It normally focuses on individual’s own weighted perceived costs. Studies like Asante & Asenso-Okyere (2013) go further in using this approach in measuring intangible costs for burden of malaria in Ghana but this measure is clearly subjective and mostly criticized for not having any economic implication. WTP attaches monetary weights to costs which are not easily measurable such as psychological effects of ill-health and because it is subjective it can be influenced by many multiple factors. 3.3.3 Intangible Cost Intangible costs are costs which are not easily measured and associated with costs of pain, suffering, stigma and the fear of death as a result of a health condition. These costs are mostly subjective; limited to feelings and so might vary from person to person. In addition, there are difficulties in attaching real costs to them. Therefore, due to these measurement difficulties, this type of cost measurement is excluded from the study. 3.4 Empirical Review Literature on Cholera seems to lean towards its epidemiology, environmental, risk factors and socioeconomic correlates of the disease. This situation is no different for studies on Ghana, which have examined topics on cholera related to; climatic changes (global and regional) and its effects on cholera patterns observed in Ghana (de Magny et al. 2006). This study used cholera data from the WHO Weekly Epidemiological Record for Ghana from the years 1975 to 1995 and employed a wavelet analysis in running for its results. They found strong University of Ghana http://ugspace.ug.edu.gh 49 statistical coherence between cholera outbreak resurgence, temporal patterns of incidence and climatic parameters from the end of the 1980’s. The study revealed that there were two cyclical patterns of incidence every 4-5years and 7-8 years. However, this study just like others, presented only an environmental linkage with cholera incidence but recognizes in its literature review that other factors such as poverty and human density, may influence the spatial and temporal distribution of cholera cases. A similar work by Osei & Duker (2008), carried out a Geographic Information System based spatial analysis and statistical analysis to determine clustering of cholera in the Ashanti region of Ghana. Their study showed high cholera rates clustered around the Kumasi Metropolis (the central part of the region) showed direct relationship between cholera and urbanization as well as overcrowding but an inverse relationship with other neighborhood towns away from Kumasi. A later study by Osei et al. (2010) also did similar work on the relationship between cholera prevalence and environmental factors such as exposure of surface water to potential cholera reservoirs (like dump sites) in Kumasi the second largest city in the Ghana. This study set out to look for the impact of surface water contamination on cholera infection and spatial mapping of surface water to determine the relationship between cholera prevalence and proximity of upstream potential cholera reservoirs. Making use of statistical Ordinary Least Squares (OLS) and GIS spatial analysis they established that surface water pollution through run-offs from dump sites play significant role in cholera infection. It University of Ghana http://ugspace.ug.edu.gh 50 concluded that communities that were closer to dump site showed greater incidence of cholera compared with those further away. The closest attempt at observing an economic implication of cholera was a study by Davis-Teye et al. (2014) who looked at the socioeconomic factors associated with cholera outbreak in Southern Ghana. In their study, they conducted a descriptive and unmatched case-control study for persons who suffered from cholera during the 2012 outbreak within the Osu-Klottey district. Information on individual’s socio-economic, hygiene, food and water exposures were collected and used to determine the socioeconomic implication. They found that persons aged below 18 years, persons with educational level below tertiary, households that have exclusive toilet facility, the eating of cold or warm food either from home or outside home, eating food from home and access to pipe-borne water were associated all with cholera. But the study earns here and does not look at the impact in terms of the costs that households bore but only the socio and economic causal relationship of the disease within that district. This current study adds on to the thin number of studies of this nature by establishing an economic dimension of the disease in terms of its costs and going a step further to assessing its impact rather than only observing its causal routes. 3.4.1 Costs Methods in the measurement of Cholera From my literature search, I observed that studies focusing on the economic impact of the cholera is scant compared to that on other infectious diseases such as malaria. Most literature measuring economic impact of cholera has measured University of Ghana http://ugspace.ug.edu.gh 51 its impact at the macro level. These have mostly looked at the loss to Gross Domestic Product (GPD) or the impact on certain sectors of the economy like tourism, exports and domestic consumption. (Suarez & Bradford, 1993; Kimball et al., 2005; IVI, 2010). At the micro level, the impact are usually measured by either households’ or individuals’ expenditure during an outbreak (Sarker, 2013). Measurement of cholera’s economic impact have been done through different costing procedures including; Cost analysis, cost effectiveness analysis, cost benefit analysis and cost minimization analysis. A firth method of measurement; cost utility analysis, seems to be the rarely used as my literature search did not come across the use of this measure on assessing the impact of cholera. The earliest real attempt to measure cholera was a work done by Suarez and Brandford (1993) who conducted an extensive study of the costs on the Peruvian 1991 and 1992 cholera epidemic. They adopted a cost of illness approach in identifying the costs components of the outbreak at the macro level of the economy. They further calculated the impact on the supply channels and three demand effects: revenue from tourism, revenue from exports of goods and impact on domestic consumption. The total economic impact of the study was found to be about US$ 96.6 million; and when mortality costs are included the costs of illness increased to US$ 176.9 million. A drawback o