Understanding the economic burden of diseases on households in Bangladesh

Economic burden estimates of diseases are increasingly reported and used to inform policy, programme, or intervention choices and funding decisions both by the private and public sectors in developed countries. Research on the cost of diseases is important to conduct in Bangladesh for providing correct and updated information on 1) the economic burden of a disease; (2) the comparison of cost burdens of different diseases (asthma versus diabetes); (3) the cost to be incorporated into cost-effectiveness, cost-benefit analysis (doctor visits, prescription costs); (4) the most important cost components of specific diseases warranting research on treatment options and prevention programmes; and (5) the trends in costs (change over the years) and projection of future costs (say, after 10 years).

Diseases and injuries often require emergency visits and hospitalisation. These cases have the highest potential of resulting in both short-term and long-term disability and are among the most costly of all diseases and injuries from an economic perspective. Many economic burden studies often exclude out-of-pocket costs borne by individual citizens and only take the perspective of the healthcare system, the employer or government, or the insurance company. For example, these estimates may not include food, meal, transportation, lost wages from work-time lost, etc. by the patients. Even if all people in Bangladesh would seek healthcare only in the public healthcare system, these costs would be borne by them. Without including these, economic burden studies will underestimate the real burden of an injury or illness.

The U.S. Centre for Medicare & Medicaid Services defines out-of-pocket as expenses for medical care that are not reimbursed by an insurance company. Out-of-pocket costs in the USA largely include deductibles, coinsurance, and copayments for covered services plus all costs for services that are not covered. U.S. National Cancer Institute defines it similarly "in medicine, the out-of-pocket cost is the amount of money a patient pays for medical expenses that are not covered by a health insurance plan."

In Bangladesh, in the absence of a functional health insurance market, and a lack of coverage by existing health insurance schemes (whatever is out there, provided only by a few large formal sector employers, and purchased by a few wealthy individuals), most costs people bear are out-of-pocket. A sudden onslaught of an illness or episode can create an enormous burden even for the middle class or well-to-do families and can damage the economic security of the family. Stories are abundant where a person was diagnosed with a continuing, costly illness like cancer, and that individual and his/her adult children had to spend their life savings to provide for the treatment of the patient. For villagers, it is often land or cattle they must sell or they must take loans for a chronic disease that afflicts them for years.

There are only a few research studies conducted in Bangladesh that attempted to understand and report the economic burden of disease on individuals or households. A few are summarized here.

One research studied household medicine expenditure and its associated determining factors. Out of 46,080 households, the poorest households were found to spend 10 per cent of their total household expenditure as out-of-pocket costs on medicines whereas the wealthiest households spent 6 per cent. The presence of chronic diseases, particularly cancer showed the most important correlation to high out-of-pocket expenditure on medicines.

Another study found that about 26 per cent of households incurred catastrophic health expenditures and 58 per cent faced distress financing to cover hospitalisation costs in Bangladesh. The highest catastrophic health expenditures were due to cancer (50 per cent), liver diseases (49.2 per cent), and paralysis (43.6 per cent). These hardships were more common among poor households; admission to private hospitals, affliction by a non-communicable disease, and the presence of patients with a chronic disease created more hardships for the households.

A cross-sectional research survey in 2019 from 3,100 randomly selected households in Dhaka, reported that acute illnesses such as fever or flu were more prevailing. Among the chronic illnesses, about 10 per cent of people had diabetes while 5 per cent had high/low blood pressure. The richest quintile only spent 5 per cent of household income on healthcare but the poorest households spent six times more.

Another study showed the overall out-of-pocket healthcare expenditure was 8 per cent  of the household monthly income and the poorer income group spent up to 35 per cent of their household income on healthcare. They showed that the poorest quintile spends a larger share of their income on healthcare services.

A community-based survey was conducted in 2014 to understand the determinants of hardship financing for healthcare seeking of under-five childhood illnesses in rural Bangladesh. A total of 7,039 children were reported to have suffered illness. Different financing mechanisms adopted by households to meet out-of-pocket payments are loans with interest, loans without interest, and financial help from relatives. The lowest quintile (19 per cent) needed assistance more than the highest wealth group (9 per cent).

Analysis of data from 12,400 patients who had paid to receive any type of healthcare services in the previous month showed the mean total out-of-pocket healthcare expenditures was US dollar  27.66 in Bangladesh and the cost of medicines (USD 16.98) was the largest component  (61per cent of out-of-pocket expenditure). The economic burden of diseases has been studied extensively within or across geographic regions by demographic or occupational groups, industries, and within the healthcare system in developed countries.

Little attention is paid in Bangladesh to understanding the comprehensive burden a disease or illness brings to the care recipients, particularly where the out-of-pocket component is known to be very high. Without such evidence, formulating policy and finding ways to develop a safety mechanism to help people from falling into poverty because of unexpected health expenses will never be a policy priority.

Dr. Hasnat M Alamgir is a Professor and Chair of Public Health at IUBAT (International University of Business Agriculture and Technology), Dhaka. [email protected]