Enhancing diarrhea treatment services through community level zinc introduction in India, Mali, and Pakistan: Cost effectiveness and introduction at scale

Background. Diarrhea is the second leading cause of mortality in children under-5 and is responsible for more deaths in children than HIV/AIDS, tuberculosis, or malaria. Research has emerged demonstrating that therapeutic supplementation of zinc in addition to reduced osmolarity ORS significantly reduces morbidity and mortality due to diarrhea in children under 5.Objectives. Project activities sought to determine whether (a) community-based supplementation of zinc in addition to ORS is cost-effective in treating acute diarrhea in children 1-59 months (India and Pakistan) and (b) identify resource implications and activities associated with zinc introduction (Mali).Methods. In all sites, economic costs were collected from 2004-2007 from a societal perspective inclusive of program implementation costs, household out of pocket payments for care, and incremental government costs. Incremental cost-effectiveness between each study arm was calculated per death and DALY averted in India and Pakistan. In Mali resource implications were explored.Results. Findings across study sites affirm current global recommendations that zinc is a cost-effective intervention appropriate and feasible for delivery at scale. However, attention should be paid to factors related to achieving and sustaining product coverage. In Pakistan, despite the low cost of obtaining and delivering zinc and ORS, coverage remained low (<30%). As a result a statistically significant impact on diarrhea morbidity or mortality was not achieved. In India coverage reached 60%---a figure projected to rise to >80% following a year of implementation---and was associated with an 11% mortality reduction as well as significant improvements in health outcomes. The cost per DALY averted was USConclusions. Findings support the ascertain made by the Copenhagen Consensus 2008 that therapeutic provision of zinc in addition to ORS is the most cost-effective child health and public health intervention evaluated to date.