This study compared the crèche intervention to the status-quo in cost-effectiveness analysis from both a program and societal perspective. Results showed that for a typical Bangladeshi population of 100,000 children age 12 to 47 months who enrolled in crèches in rural areas the intervention would cost $1.6 million annually ($16 per child) from the program perspective and saved 92.26 children from fatal drownings (equivalent to 2,696.64 YLLs or DALYs averted). From the societal perspective, the intervention could generate approximately $15.9 million in cost savings to the community if parents freed up time is valued at the Bangladeshi minimum wage. This is equivalent to $172 thousand cost savings per live saved. From the program perspective alone, the creches’ ICER per DALY averted, $584, is very cost-effective, relative to a reference point of GDP per capita, which was $1,248 in Bangladesh 26 . Similarly, from the societal perspective excluding savings from parents freed up time, the creches’ ICER per DALY averted, $2,020, is cost-effective.
These results are in line with a prior CEA in Bangladesh which compared a package of drowning prevention interventions, including the crèches, with the status-quo 6 . Both studies found a similar effect size for reducing fatal drownings (88% vs. 89%) but the prior study’s effect was attributed to the creche and swimming lesson interventions implemented together, making the comparison of impact between both creche interventions inadequate 6,12 . Further, while both studies showed that about 80% of the program cost were wages, the cost per child estimate for that study was slightly higher than in this study ($51 in 2010 International USD, or $20–24 in 2015 USD, vs. $16). While both unit cost estimates produce cost-effective ICERs, the cost differences may be attributed to the costing methodology.
The creche’s intervention success in reducing child drowning can be explained by several child protective effects, including provision of a safe environment away from water and supervision with capable child care, particularly during peak drowning hours, and community education about drowning risk expanded by active community engagement strategies7,27,28. Specifically, the UIPCs and VIPCs played a major role in the sensitization of the community about both drowning prevention practices and dissemination of information about the creches and their safety. The UIPCs also focus on building local support among community leaders and the VIPCs provided a standard and regular platform available to parents and community members to provide feedback about the creche operations.
These CEA results are important to the fields of global health and injury prevention especially for countries like Bangladesh with high incidence of drowning. We make broad comparisons between our results and other cost-effectiveness analysis, but caution should be used in comparing our results to individual studies due to the variety of methodological approaches, costing perspectives and cost inputs used by each study. Overall, our results indicate that from a societal perspective the crèche’s cost-effectiveness ratio per DALY averted (including economic savings from parents free up time), $-5,899, is significantly more cost effective compared to other injury prevention interventions for which cost-effectiveness ratios per DALY averted range between $5 to $556 (or $7 to $744 in 2015 $US) 29 . Excluding economic savings from parents free up time the crèche cost per DALY averted, $2,020 is higher but cost-effective. These other interventions include speed bumps, use of helmets, and enforcement of traffic codes for road tariff injury prevention and childproof containers for poisoning prevention 29,30 . Compared to other child health interventions (e.g., treatment of febrile conditions, diarrheal disease, vaccines, severe acute malnutrition, platforms for delivery of interventions, etc.) with cost per DALY averted estimates ranging between $8 for treatment of severe malaria up to $50,000 for sanitation improvement interventions, our CEA shows the crèches to be an cost-effective alternative to improve child health 29,31 .
This CEA was limited using fatal drowning reduction estimates derived from a pre- and post-experimental design which may be biased by self-selected enrollment of children into creches. There also could have been secular trends (e.g., smaller family size or improved income) or other unobserved factors associated with higher or lower drowning rates (e.g., local interventions or policies, etc.). However, recent studies from Bangladesh show that while all-cause under-five mortality decreased over the last 10 years that drowning trends remained generally the same4,25, suggesting secular trends did not impact drowning rates. Similarly, the estimation attempted reducing self-selection bias by controlling for the drowning rate of the creche participant’s older sibling the year before the intervention. This control reduced the bias under the assumption that the reasons that parents chose to participate or not remained constant over time12. Our sensitivity analysis showed that the intervention would remain cost-effective even if the number of drowning deaths averted fell by 54%, from 92 to 42 deaths. Further, the positive results are conservative given that the ICER excludes both improvement in YLDs and long-term socio-economic benefits. For example, creches can offer protection against other child injuries8 and long-term economic benefits from improved childhood cognitive development and productivity in livelihood activities32,33.
This study also excluded healthcare costs associated with the medical treatment of drowning cases because likely there are few to no drowning survivors in rural Bangladesh. However, literature from high income countries where many more children survive near drowning, but suffer brain injury, suggests that the higher cost associated with drowning and other unintentional injuries are health care services and the lost productivity of survivors34. Other indirect costs that cannot be monetized in our study may include reduced quality of life from pain, suffering, and social isolation.
In conclusion, this paper shows the cost and cost-effectiveness of the large-scale implementation of the crèche intervention showing that crèches are cost-effective, even under scenarios of higher costs or lower effect sizes. Furthermore, the creches have the potential to improve parental economic status by freeing up their childcare time. More research is necessary to determine the extent to which parents use this freed-up time in ways that benefit the household and the economy. Our present findings provide strong empirical support for investing in the scale up of creches in communities burdened by high risk of child drowning.