Cost-effectiveness of care environments for improving the mental health of orphaned and separated children and adolescents in kenya

Background: Institutionalization has shown contradictory effects on the mental health of orphaned and separated children and adolescents (OSCA) in sub-Saharan Africa. There is a paucity of data surrounding the cost-effectiveness of different care environments for improving OSCA's mental health. Aims of the Study: The goal of this analysis was to evaluate the cost-effectiveness of Charitable Children's Institutions (orphanages) compared to family-based settings serving OSCA in East Africa in terms of $/unit reduction in mental health diagnoses (depression, anxiety, post-traumatic stress disorder, suicidality) and $/qualityadjusted life-year (QALY) gained. Methods: This economic analysis was conducted from a societal perspective as part of the Orphaned and Separated Children's Assessments Related to their (OSCAR's) Health and Well-Being Project, a 10-year longitudinal cohort study evaluating the effects of different care environments on OSCA's physical and psychological health in western Kenya. Cost data were ascertained from 9 institutions and 225 family-based settings in the OSCAR cohort via survey assessments, budget reports, and expert interviews. Monthly per-child costs were calculated as the sum of recurrent and capital costs divided by the environment's maximum residential capacity, and cost differences between care environments were estimated using two-part models. Mental health effectiveness outcomes were derived from prior survival regression analyses conducted among the OSCAR cohort. We used Child Depression Inventory Short- Form scores at baseline and follow-up to calculate the number of depression-free days (DFDs) over the follow-up period, and translated DFDs into QALYs using established utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in monthly per-child cost divided by the difference in each mental health outcome, comparing institutions to family-based settings. Sampling uncertainty in the ICERs was handled using nonparametric bootstrapping with 1,000 replications. We assumed a willingness-to-pay threshold of three times Kenya's per capita gross domestic product. Results: Charitable Children's Institutions cost $123 more on average than family-based settings in terms of monthly per-child expenditures (p<0.001). Compared to family-based care, institutional care resulted in an ICER of $236, $280, $397, and $456 per unit reduction in depression, anxiety, PTSD, and suicidal diagnosis among OSCA, respectively. The incremental cost per additional QALY was $4,929 (95% CI: $3096 - $6740). The probability of Charitable Children's Institutions being more costeffective than family-based settings was greater than 90% for willingness-to-pay thresholds above $7,000/QALY. Discussion: Only a subset of institutions in the cohort were willing to provide budgetary information for this assessment, which potentially biased our cost estimates. However, institutions who did not provide budget data likely had lower expenditures than those for whom cost data were collected, leading to more conservative cost estimates. Furthermore, our QALY estimates were based solely on depression-free days such that OSCA in institutions may experience added mental health benefits for no additional costs. Implications for Health Policy: Compared to family-based settings, institutions may be more cost-effective for improving mental health outcomes among orphaned and separated children and adolescents. Our findings suggest that policy-makers should prioritize resources to strengthen family-based care but that formal institutions can offer cost-effective, mental health support as a last resort.