Socioeconomic Impact of Hospitalization Expenditure for Treatment of Noncommunicable Diseases in India: A Repeated Cross-Sectional Analysis of National Sample Survey Data, 2004 to 2018

Measurement of Catastrophic Health Expenditure in India: A Systematic Review and Meta-Analysis

INTRODUCTION

The escalating burden of catastrophic health expenditure (CHE) poses a significant threat to individuals and households in India, where out-of-pocket expenditure (OOP) constitutes a substantial portion of healthcare financing. With rising OOP in India, a proper measurement to track and monitor CHE due to health expenditure is of utmost important. This study focuses on synthesizing findings, understanding measurement variations, and estimating the pooled incidence of CHE by health services, reported diseases, and survey types.

METHOD

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a thorough search strategy was employed across multiple databases, between 2010 and 2023. Inclusion criteria encompassed observational or interventional studies reporting CHE incidence, while exclusion criteria screened out studies with unclear definitions, pharmacy revenue-based spending, or non-representative health facility surveys. A meta-analysis, utilizing a random-effects model, assessed the pooled CHE incidence. Sensitivity analysis and subgroup analyses were conducted to explore heterogeneity.

RESULTS

Out of 501 initially relevant articles, 36 studies met inclusion criteria. The review identified significant variations in CHE measurements, with incidence ranging from 5.1% to 69.9%. Meta-analysis indicated the estimated incidence of CHE at a 10% threshold is 0.30 [0.25-0.35], indicating a significant prevalence of financial hardship due to health expenses. The pooled incidence is estimated by considering different sub-groups. No statistical differences were found between inpatient and outpatient CHE. However, disease-specific estimates were significantly higher (52%) compared to combined diseases (21%). Notably, surveys focusing on health reported higher CHE (33%) than consumption surveys (14%).

DISCUSSION

The study highlights the intricate challenges in measuring CHE, emphasizing variations in recall periods, components considered in out-of-pocket expenditure, and diverse methods for defining capacity to pay. Notably, the findings underscore the need for standardized definitions and measurements across studies. The lack of uniformity in reporting exacerbates the challenge of comparing and comprehensively understanding the financial burden on households.

The Short-Term Cost-Effectiveness of a Fixed-Ratio Combination of Insulin Degludec and Aspart: A Cost of Control Analysis in Australia and India

OBJECTIVES

The real-world ARISE study demonstrated initiation of fixed-ratio combination insulin degludec and aspart (IDegAsp) led to improvements in people achieving key glycemic control targets compared with prior therapies in Australia and India. This study evaluated the short-term cost-effectiveness of IDegAsp in these countries, in terms of the cost per patient achieving these targets.

METHODS

A model was developed to evaluate the cost of control (treatment costs divided by the proportion of patients achieving each target) of IDegAsp versus prior therapies received in ARISE for 2 endpoints: glycated hemoglobin (HbA1c) <7.0%, and HbA1c less than a predefined individual treatment target. Costs, expressed from a healthcare payer perspective, were captured in 2022 Australian dollars (AUD) and 2022 Indian rupees (INR).

RESULTS

The number of patients needed to treat to bring one to endpoints of HbA1c <7.0% and less than an individualized target with IDegAsp was 51% and 87% lower, respectively, than with prior therapies in Australia, and 52% and 66% lower, respectively, versus prior therapies in India. Cost of control was AUD 2449 higher and AUD 64 863 lower with IDegAsp versus prior therapies for endpoints of HbA1c <7.0% and less than an individualized target, respectively, in Australia and INR 211 142 and INR 537 490 lower with IDegAsp compared with prior therapies in India.

CONCLUSIONS

IDegAsp was estimated to be cost-effective versus prior therapies when considering an individualized HbA1c target in Australia, and when considering an individualized HbA1c target and HbA1c <7.0% in India.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

A comprehensive examination of the economic impact of out-of-pocket health expenditures in India

More than 50% of health expenditure is financed through out-of-pocket payments in India, imposing a colossal financial burden on households. Amidst the rising incidence of non-communicable diseases, injuries, and an unfinished agenda of infectious diseases, this study examines comprehensively the economic impact of out-of-pocket health expenditure (OOPE) across 17 disease categories in India. Data from the latest round of the National Sample Survey (2017-18), titled 'Household Social Consumption: Health', were employed. Outcomes, namely, catastrophic health expenditure (CHE), poverty headcount ratio, distressed financing, foregone care, and loss of household earnings, were estimated. Results showed that 49% of households that sought hospitalization and/or outpatient care experienced CHE and 15% of households fell below the poverty line due to OOPE. Notably, outpatient care was more burdensome (CHE: 47.8% and impoverishment: 15.0%) than hospitalization (CHE: 43.1% and impoverishment: 10.7%). Nearly 16% of households used distressed sources to finance hospitalization-related OOPE. Cancer, genitourinary disorders, psychiatric and neurological disorders, obstetric conditions, and injuries imposed a substantial economic burden on households. OOPE and associated financial burden were higher among households where members sought care in private healthcare facilities compared with those treated in public facilities across most disease categories. The high burden of OOPE necessitates the need to increase health insurance uptake and consider outpatient services under the purview of health insurance. Concerted efforts to strengthen the public health sector, improved regulation of private healthcare providers, and prioritizing health promotion and disease prevention strategies are crucial to augment financial risk protection.

The Economic Cost of Rising Non-communicable Diseases in India: A Systematic Literature Review of Methods and Estimates

BACKGROUND AND OBJECTIVES

India has one of the world's highest proportions of out-of-pocket expenditure (OOPE) payments. The low share of public health expenditure coupled with the double burden of disease (communicable and non-communicable) has a direct financial impact on individual OOPE and an indirect impact in the form of decreasing life expectancy, reduced productivity, and hence a negative impact on economic growth. This systematic review aims to compare and assess the estimated economic cost of non-communicable diseases (NCDs) in India and ascertain the methods used to derive these estimates.

METHODS

This paper reviews the past 12-year (2010-22) literature on the economic impact of health shocks due to NCDs. Three databases were searched for the literature: PubMed, Scopus, and Google Scholar. Thematic analysis has been performed to analyse the findings of the study.

RESULTS

The OOPE was very high for NCDs. The increasing cost was high and unaffordable, pushing many people into financial distress measured by catastrophic payments and rising impoverishment.

CONCLUSION

The results indicate both the direct and indirect impact of NCDs, but the indirect burden of loss of employment and productivity, despite its relevance, has been less studied in the literature. A robust economic analysis will allow an evidence-based policy decision perspective to reduce the rising burden of NCDs.

Nonfatal drowning-related hospitalizations and associated healthcare expenditure in India: An analysis of nationally representative survey data

BACKGROUND

Drowning is a global public health challenge, with significant burden in low- and middle-income countries. There are few studies exploring nonfatal drowning, including the economic and social impacts. This study aimed to quantify unintentional drowning-related hospitalization in India and associated healthcare expenditure.

METHOD

Unit level data on unintentional drowning-related hospitalization were obtained from the 75th rounds of the National Sample Survey of Indian households conducted in 2018. The outcome variables were indices of health care cost such as out of pocket expenditure (OOPE), health care burden (HCB), catastrophic health expenditure (CHE), impoverishment, and hardship financing. Descriptive statistics and multivariate analysis were conducted after adjusting for inflation using the pharmaceutical price index for December 2020. The association of socio-demographic characteristics with the outcome variable was reported as relative risk with 95% CI and expenditure reported in Indian Rupees (INR) and United States dollars (USD).

RESULTS

174 respondents reported drowning-related hospitalization (a crude rate of 15.91-31.34 hospitalizations per 100,000 population). Proportionately, more males (63.4%), persons aged 21-50 years (44.9%) and rural dwelling respondents (69.9%) were hospitalized. Drowning-related hospitalization costs on average INR25,421 ($345.11USD) per person per drowning incident. Costs were higher among older respondents, females, urban respondents, and longer lengths of hospital stays. About 14.4% of respondents reported hardship financing as a result of treatment costs and 9.0% of households reported pushed below the poverty line when reporting drowning-related hospitalization.

CONCLUSIONS

Drowning can be an economically catastrophic injury, especially for those already impacted by poverty. Drowning is a significant public health problem in India. Investment in drowning prevention program will reduce hospitalization and economic burden.

PRACTICAL APPLICATIONS

This study provides support for investment in drowning prevention in India, including a need to ensure drowning prevention interventions address the determinants of health across the lifespan.

Financial risk protection from out-of-pocket health spending in low- and middle-income countries: a scoping review of the literature

Background

Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.

Results

The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.

Conclusion

The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00886-3.

Unmet need for treatment-seeking from public health facilities in India: An analysis of sociodemographic, regional and disease-wise variations

Treatment-seeking behaviour is closely associated with the health status of individuals and countries. About 800 million people have no access to health services in the developing world. Though the situation has been improving, the inequalities across geographical regions, socioeconomic status, and disease types continued to persist. The available literature suggests research gaps in examining the unmet need for treatment-seeking from public health facilities across sociodemographic characteristics, regions, and specific diseases. Data for this study comes from the three rounds of National Sample Survey (NSS) (2004, 2014, 2018). We applied descriptive, bivariate, and multivariable analysis to investigate the unmet need for treatment-seeking for public health facilities across sociodemographic characteristics, regions, and specific diseases between 2004 and 2018. The unmet need for treatment-seeking from public health facilities remained high at 60% in 2004 to 62% in 2018. However, the proportion of respondents who did not seek treatment has reduced 12% to 3% from 2004 to 2018. In states like Andhra Pradesh, Madhya Pradesh, Maharashtra, Punjab, Telangana, Uttar Pradesh, and West Bengal, the unmet need for treatment-seeking from public health facilities was more than 60% in 2018. For 2018, the quality of services at public health facilities was the main reason for showing a higher unmet need for treatment-seeking in the richer MPCE quintiles. On the other hand, the ailment not considered serious as the main reason for the unmet need for treatment-seeking from any sources has got nearly doubled from 36% in 2004 to 71% in 2018. This study concludes that improving the availability of various kinds of services at public health facilities should be a priority under India's universal health coverage program. Education plays a vital role in treatment-seeking. Thus, there is an urgent need for increasing awareness among people for treatment-seeking. Ensuring a minimum quality of health care services and reducing long waiting timing would reduce the apathy to receive services from the public health facilities.

Rising healthcare expenditure on tuberculosis: Can India achieve the End TB goal?

OBJECTIVE

To examine the out-of-pocket expenditure (OOPE), healthcare burden, catastrophic health expenditure, hardship financing and impoverishment effects of TB treatment in India.

METHODS

Data of three rounds of National Statistic Surveys 60th 2004-05, 71st 2013-14 and 75th 2017-18. Descriptive statistics, bivariate estimates and multivariate models were performed to calculate the OOPE, healthcare burden, catastrophic health expenditure, hardship financing and impoverishment using standard definitions at December 2019 price values.

RESULTS

More than two-thirds of the TB cases are seen in the economically productive age group (14-59 years). Illiterate patients had a higher healthcare burden and OOPE. The healthcare burden, hardship financing and catastrophic health expenditure are considerably higher for those utilising private hospitals. Male patients have a higher exposure to hardship financing than female patients. Impoverishment effects are higher among Hindus and illiterate populations due to utilisation of hospitalisation services.

CONCLUSION

The present analysis helps to understand the trends in the financial burden of TB on households over last 15 years, thus providing evidence to policymakers for more effective channelling of resources in order to achieve a TB-free India by 2025.