title: Cost-effectiveness of using a social franchise network to increase uptake of oral rehydration salts and zinc for childhood diarrhea in rural Myanmar.
abstract: BACKGROUND
  This paper examines the cost-effectiveness of achieving increases in the use of oral rehydration solution and zinc supplementation in the management of acute diarrhea in children under 5 years through social franchising. The study uses cost and outcome data from an initiative by Population Services International (PSI) in 3 townships of Myanmar in 2010 to promote an ORS-Zinc product called ORASEL.
  
  
  BACKGROUND
  The objective of this study was to determine the incremental cost-effectiveness of a strategy to promote ORS-Z use through private sector franchising compared to standard government and private sector practices.
  
  
  METHODS
  Costing from a societal perspective included program, provider, and household costs for the 2010 calendar year. Program costs including ORASEL program launch, distribution, and administration costs were obtained through a retrospective review of financial records and key informant interviews with staff in the central Yangon office. Household out of pocket payments for diarrheal episodes were obtained from a household survey conducted in the study area and additional estimates of household income lost due to parental care-giving time for a sick child were estimated. Incremental cost-effectiveness relative to status quo conditions was calculated per child death and DALY averted in 2010. Health effects included deaths and DALYs averted; the former modeled based on coverage estimates from a household survey that were entered into the Lives Saved Tool (LiST). Uncertainty was modeled with Monte Carlo methods.
  
  
  RESULTS
  Based on the model, the promotional strategy would translate to 2.85 (SD 0.29) deaths averted in a community population of 1 million where there would be 81,000 children under 5 expecting 48,373 cases of diarrhea. The incremental cost effectiveness of the franchised approach to improving ORASEL coverage is estimated at a median $5,955 (IQR: $3437-$7589) per death averted and $214 (IQR: $127-$287) per discounted DALY averted.
  
  
  CONCLUSIONS
  Investing in developing a network of private sector providers and keeping them stocked with ORS-Z as is done in a social franchise can be a highly cost-effective in terms of dollars per DALY averted.
authors.affiliation: Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA.
authors.forename: David
authors.initials: D
authors.lastname: Bishai
authors.affiliation: Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA.
authors.forename: Karampreet
authors.initials: K
authors.lastname: Sachathep
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA.
authors.forename: Amnesty
authors.initials: A
authors.lastname: LeFevre
authors.affiliation: PSI-Myanmar, 16 West Shwe Gone Dine 4th Street, Bahan Township, Yangon, Myanmar.
authors.forename: Hnin New Nwe
authors.initials: HN
authors.lastname: Thant
authors.affiliation: PSI-Myanmar, 16 West Shwe Gone Dine 4th Street, Bahan Township, Yangon, Myanmar.
authors.forename: Min
authors.initials: M
authors.lastname: Zaw
authors.affiliation: PSI-Myanmar, 16 West Shwe Gone Dine 4th Street, Bahan Township, Yangon, Myanmar.
authors.forename: Tin
authors.initials: T
authors.lastname: Aung
authors.affiliation: Department of Epidemiology, University of California San Francisco, San Francisco, CA USA.
authors.forename: Willi
authors.initials: W
authors.lastname: McFarland
authors.affiliation: Department of Epidemiology, University of California San Francisco, San Francisco, CA USA.
authors.forename: Dominic
authors.initials: D
authors.lastname: Montagu
keywords: Burma; Cluster randomized trial; Costing; Myanmar; Oral rehydration; Private providers; Social franchise; Zinc