Estimating the distributional impact of improving access to snake antivenom in urban and rural Lao People’s Democratic Republic: An extended cost-effectiveness analysis

Introduction: Snakebite is a significant public health issue in the Lao People’s Democratic Republic (PDR), with victims often seeking traditional healers due to inadequate antivenom supply and high out-of-pocket (OOP) expenses, contributing to inequities between urban and rural populations. Methods: An extended cost-effectiveness analysis (ECEA) was conducted to evaluate the distributional impact of improving access to antivenom in urban and rural Lao PDR, where all victims with systemic envenoming clinically indicated for antivenom receive antivenom at conventional hospitals, on disease burdens (deaths and disability-adjusted life years [DALYs]) and economic burden (%household OOP expenditure per monthly income). Sensitivity analyses were performed. Results: Rural areas had higher mortality (3.14 vs. 0.35, +2.79 per 100,000 population), DALYs lost (78.97 vs. 8.86, +70.11 per 100,000 population), and household OOP expenses (39% vs. 38%, +1% of household monthly income) than urban areas. Full access to antivenom reduced health inequities in mortality (from +2.79 to +1.22 per 100,000 population) and DALYs (from +70.11 to +32.14 per 100,000 population) but increased inequities in household OOP expenses (from +1% to +39% of household monthly income). These differences had considerable uncertainties. Sensitivity analyses showed that free snakebite treatment and transportation costs with one caregiver reduced household OOP expenses in both areas (5% rural, 6% urban). Conclusions: While improving access to snake antivenom mitigates health inequities in disease burden, it exacerbates financial inequities between urban and rural areas. Policies targeting equitable access to care and financial protection are critical to achieving health equity for snakebites in the Lao PDR. Author summary: Snakebite is a significant public health issue in the Lao People’s Democratic Republic (PDR), with victims often seeking traditional healers due to inadequate antivenom supply and high out-of-pocket (OOP) healthcare expenses. These challenges contribute to health inequities between urban and rural populations. A previous cost-effectiveness analysis highlighted the substantial clinical and economic benefits of hypothetically treating all snakebite envenoming with clinical indications of receiving antivenoms in Lao PDR with antivenoms. However, the study did not examine the distributional impacts of antivenom access across urban and rural populations, nor did it evaluate the potential benefits of financial risk protection. An extended cost-effectiveness analysis (ECEA) was conducted to evaluate the distributional impact of improving access to antivenom in urban and rural Lao PDR, where all snakebite envenoming patients with clinical indications of receiving antivenoms could receive antivenom at conventional hospitals, on disease burdens and economic burden. Findings indicated that improving access to antivenom in Lao PDR is essential for reducing the significant burden of snakebite envenoming and addressing health inequities between urban and rural populations. While enhanced availability of antivenom can significantly reduce mortality, it may also impose considerable financial hardships on affected households, particularly in rural areas.