The financial burden from non-communicable diseases in low

Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of ... Skiptomaincontent Advertisement SearchallBMCarticles Search Thefinancialburdenfromnon-communicablediseasesinlow-andmiddle-incomecountries:aliteraturereview DownloadPDF DownloadePub DownloadPDF DownloadePub Review OpenAccess Published:16August2013 Thefinancialburdenfromnon-communicablediseasesinlow-andmiddle-incomecountries:aliteraturereview HyacintheTchewonpiKankeu1,PriyankaSaksena2,KeXu3&DavidBEvans4  HealthResearchPolicyandSystems volume 11,Article number: 31(2013) Citethisarticle 30kAccesses 196Citations 31Altmetric Metricsdetails AbstractNon-communicablediseases(NCDs)werepreviouslyconsideredtoonlyaffecthigh-incomecountries.However,theynowaccountforaverylargeburdenintermsofbothmortalityandmorbidityinlow-andmiddle-incomecountries(LMICs),althoughlittleisknownabouttheimpactthesediseaseshaveonhouseholdsinthesecountries.Inthispaper,wepresentaliteraturereviewonthecostsimposedbyNCDsonhouseholdsinLMICs.Weexamineboththecostsofobtainingmedicalcareandthecostsassociatedwithbeingunabletowork,whilediscussingthemethodologicalissuesofparticularstudies.TheresultssuggestthatNCDsposeaheavyfinancialburdenonmanyaffectedhouseholds;poorhouseholdsarethemostfinanciallyaffectedwhentheyseekcare.Medicinesareusuallythelargestcomponentofcostsandtheuseoforiginatorbrandmedicinesleadstohigherthannecessaryexpenses.Inparticular,inthetreatmentofdiabetes,insulin–whenrequired–representsanimportantsourceofspendingforpatientsandtheirfamilies.ThesefinancialcostsdetermanypeoplesufferingfromNCDsfromseekingthecaretheyneed.ThelimitedhealthinsurancecoverageforNCDsisreflectedinthelowproportionsofpatientsclaimingreimbursementandthelowreimbursementratesinexistinginsuranceschemes.Thecostsassociatedwithlostincome-earningopportunitiesarealsosignificantformanyhouseholds.Therefore,NCDsimposeasubstantialfinancialburdenonmanyhouseholds,includingthepoorinlow-incomecountries.Thefinancialcostsofobtainingcarealsoimposeinsurmountablebarrierstoaccessforsomepeople,whichillustratestheurgencyofimprovingfinancialriskprotectioninhealthinLMICsettingsandensuringthatNCDsaretakenintoaccountinthesesystems.Inthispaper,weidentifyareaswherefurtherresearchisneededtohaveabetterviewofthecostsincurredbyhouseholdsbecauseofNCDs;namely,theextensionofthegeographicalscope,theinclusionofcertaindiseaseshithertolittlestudied,theintroductionofatimedimension,andmorecomparisonswithacuteillnesses. PeerReviewreports BackgroundThe2010WHOGlobalStatusreportonnon-communicablediseases(NCDs)showedthattheyarenowthemostimportantcauseofmortalityworldwide.Indeed,morethan36millionpeoplediedfromNCDsin2008,mainlycardiovasculardiseases(48%),cancers(21%),chronicrespiratorydiseases(12%),anddiabetes(3%).Nearly80%ofthesedeathsoccurredinlow-andmiddle-incomecountries(LMICs),where,onaverage,theynowexceedcommunicablediseasesasthemajorcauseofdiseaseburden[1].Evenintheremainingcountrieswhereinfectiousdiseasesarethemainhealthproblem,NCDsaregrowingrapidly.NCDsareexpectedtoexceedcommunicable,puerperal,prenatalandfooddiseasesonthelistofleadingcausesofdeathinallcountriesby2020.TheincreasingimportanceofNCDshascausedthemtonolongerbeviewedsimplyasahealthissuebutratherasadevelopmentissueworthyofdiscussionataHigh-levelMeetingofthe66thGeneralAssemblyofUnitedNations[2].ConsiderableliteratureexistsontheimpactofNCDsonhouseholdsinhigh-incomecountries[3–7];researchersarenowbeginningtoexaminetheimplicationsofNCDsinlow-andmiddle-incomesettingsaswell[8].Indeed,theimpactisexpectedtodifferbecausethereislittlefinancialriskprotectioninmanyLMICsandthusfinancialcostsarelargelybornebyhouseholdsthemselvesratherthangovernmentsorinsuranceschemes[9].TheframeworkpresentedinFigure 1describesthechannelsthroughwhichNCDscanaffecttheeconomicwelfareofhouseholds.Figure1 FrameworkfortheanalysisofeconomicimpactsofNCDsonhouseholds(modifiedfromMcIntyreetal.[10]). Fullsizeimage WeconductedaliteraturereviewtopresentexistingevidenceonthefinancialburdenfromNCDsinlow-andmiddle-incomesettings,attheindividualandhouseholdlevel.Theaimistoprovideaccurateandrelevantinformationonthisimportantissuetopolicymakers,anddeterminewherefurtherresearchisneeded.MethodsWeperformedaliteraturesearchwithCabdirect,SciencedirectandWebofKnowledge,usingcombinationsofthefollowingkeywords:“Non-communicabledisease”,“chronicillness”,“diabetes”,“cardiovasculardisease”,“cancer”,and“chronicrespiratorydisease”with“cost”,“impoverish”,“financialburden”,“healthexpenditure”,“expense”,“out-of-pocket”,“healthspending”,“catastrophicexpenditure”,“catastrophicexpense”,and“catastrophicspending”.Atotalof8,966results(includingduplicates)wereobtained.Afterduplicateremoval,titlesandabstractsoftheremainingpaperswerereviewedtoassesstheirrelevanceaccordingtothefollowinginclusioncriteria:i)papersinEnglishorFrench;ii)from1990onwards;iii)coveringatleastonelow-,lower-middle-orupper-middle-incomecountrya[11];iv)measuringthehouseholdorindividualfinancialcosts;v)ofonecondition(ormore)fallingunderthedefinitionof“chronicdiseases”[12]orclassifiedin“GroupIIdiseases”accordingtotheICD-10code[8].Thisscreeningledtotheselection43articlesandasecondaryliteraturesearchwasperformedusingthereferencescitedintheseselectedpapers.Finally,atotalof49paperswereidentified,whosefull-lengthversionswereobtainedforthisreview.Eachofthesestudieswasexaminedforinformationondisease(s),studypopulation,analysismethodsandfindings.ThesedetailsarepresentedinAdditionalfile1:TableS1.ResultsOverviewofthemethodsusedintheliteratureThestudiesfoundintheliteraturereflectthediversityofmethodsusedtoassesshouseholdfinancialburdenfromNCDs.Themethodologicaldifferencesinthestudiesinherentlypreventaformalmeta-analysisfrombeingperformed.However,atthesametime,thesedifferencesofferopportunitiestoexploreresultsthroughthelensofdifferenttechniques.Inthissection,wepresentadiscussiononthemethodologiesused.SomestudieslookataspecificNCD(e.g.,diabetes,cancers,cardiovasculardiseases),whileamajorityconsiderNCDsingeneraloracombinationoftwoormorespecificNCDs.WefoundonlyonepreviousliteraturereviewwhichincludedstudiesonmultipleNCDs,butitincludesstudiesfromonlyafewcountriesanddidnotincludeanystudiesfromAfricaandLatinAmerica[13].Theoriginalstudiesfoundalsodifferedaccordingtodatasourcesandsamplesizes.Someauthorsconductedtheirownsurveysforthepurposeofthestudies,whileothersuseddatafromexistingsurveyscarriedoutbyanotherentity(e.g.,NationalInstituteofStatistics,MinistryofHealth,HealthInsurancePlans).Inthesesurveys,householdsandindividualsweregenerallychosenrandomly,throughsimple,stratifiedorclustersampling[14–22].However,manystudiesusedconvenientsamplesofpatientssufferingfromaspecificillnessinhealthcarefacilities,somethingthatwereportwhenpresentingtheresults[23–31].Additionally,studieslookingatspecificdiseasesgenerallyusedrelativelysmallsamples,whilethoseconsideringabroadsetofdiseasesusuallyreliedonbiggersamples.Fortheassessmentofdiabetescosts,forexample,somestudiesselectedasmallnumberofdiabeticpatients:50inNorthIndia,53inCapeTown(SouthAfrica)and77inGhana[23,25,32].Similarly,inastudyinEnugu(Nigeria),ObiandOzumbausedasampleof95patientssufferingfromcervicalcancer[27].Ontheotherhand,upto206,700individualsfrom48,600householdswereincludedinastudyonchronicdiseasesinMexico[33].Intermsofinternalvalidityoffindings,somestudiesusedhospitalregistriesorinsurancereimbursementrecordstoverifytheinformationreportedbypatientsand/ortheirrelativesduringface-to-faceinterviews[34–36];amajorityofstudies,however,simplyacceptedtheanswersoftherespondentsasbeingvalid.Finally,somestudiesusedatafromfocusgroupdiscussionsandkeyinformantinterviewstocomplementtheiranalyses[18,32,37–39].InthestudieslookingatNCDsingeneral,theterm“chronicdiseases”isfrequentlyused,andevenifthemajorNCDsareusuallytakenintoaccount,thedefinitionsvaryfromonestudytoanother.Forexample,Shietal.definedachronicailmentasanailmentthatlastsorisexpectedtolastforatleast12months,resultinginfunctionallimitationsortheneedforongoingmedicalservices,andincludesdisability[15].InKenya,Chumaetal.definedchronicillnessesasthosereportedtohavelastedthreemonthsormore[38],whileforGoudgeetal.,anyillnessthathadpersistedforlongerthanamonthwasdefinedaschronic[37].Mondaletal.consideredthatachronicillnessisaconditionthatlastsmorethanthreeweeks,whichneedstobemanagedonalong-termbasis[40].However,manyofthesestudiesprovidethelistofdiseasestheyconsideredaschronic,andthusitwaspossibletoknowwhetherNCDswereincludedalongwithsomecommunicablediseases(forexample,HIV/AIDS).Inthesecases,wereportresultsrelatedonlytochronicNCDs.Nevertheless,insomestudiesitwasnotpossibletobesurethatthefocuswaslimitedtoonlychronicNCDs.Irrespectiveofthediseasesconsidered,manystudiesassessingthedirectcostsincurredbyhouseholdsforthetreatmentofNCDsalsofocusonimpoverishmentandcatastrophichealthexpenditureduetotheseexpenses.Impoverishmentoccurswhenarespondentwouldhavehadanetincomeabovethepovertylineintheabsenceoftheexpenditureonthedisease,butbelowitafter.Differentpovertylinesareusedacrossstudies–US$1perday,US$1.08perday,US$1.25perdayandUS$2perday[28,35,39,41,42].Catastrophicheathexpenditureoccurswhenpeoplespendadisproportionateamountoftheirincome(sometimesnon-foodexpenditure)onthecondition,asdescribedinXuetal.[43].However,agreatvarietyofspecificdefinitionsforcatastrophichealthexpenditurewereusedinthestudiespresentedhere.Thethresholdsfordeterminingadisproportionatelevelofexpenditurevaryfrom10%to60%;somestudiesdeviatedfromthismorestandardapproach.Forexample,Mukherjeeetal.usedtheconceptof“highhealthcareexpenditure”insteadofcatastrophichealthpayments[44].Inthisstudy,ahouseholdwasidentifiedashavingincurredhighout-of-pocketexpenditureonhealthcareifitsannualhealthcareexpenditurewashighincomparisontothoseofotherhouseholdswithinthesamecastegroupinIndia[44].Theevidenceonthedirectcostsfromnon-communicableillnessesManyofthestudiesassesseddirectcosts,whichincludeallcostsincurredbyindividualsandhouseholdsforthetreatmentofNCDs.Intheory,thesecostsshouldbenetofanyreimbursementfrominsurance.Wepresentevidenceonthesedirectcostsorganizedbydisease.DiabetesDiabetesisaleadingNCDand16studiesincludedinthisreviewlookedatthedirectcostsincurredforbothoutpatientandinpatientservices.Allstudies,exceptone,reliedonconveniencesamples,sotheresultsneedtobeinterpretedcarefully.Overall,thestudiesfoundthatvaryingsharesofhouseholdincomeareallocatedtopayingfordiabetescare.Thisrangesfromaslowas5%ofincomeforarurallow-incomepopulationinIndiatoupto24.5%foralow-incomegroupinMadras(India)[34,36,45].Spendingcanalsodifferbetweenricherandpoorerhouseholdsandstudiesfoundthatpoorerhouseholdsspendahigherproportionoftheirincomeoncarefordiabetesthanricherhouseholds.Thesedifferencescanbequitestriking–onestudyfromIndiafoundthatinurbanareas,theshareofincomespentondiabetescareinthepooresthouseholdswasseventimesthatoftherichesthouseholds[45].Spendingondiabetescanalsobeaconsiderableshareofoverallhouseholdhealthspending.AstudyinSudanreportedthatonaverage65%ofhouseholdhealthexpenditurewasspentoncaringforachildwithdiabetes[46].Medicationsarefrequentlyfoundtobethelargestcomponentofexpenditureondiabetes[47].Spendingonmedicationsrepresentedfrom32%to62%oftotalexpenditureondiabetescareinvarioussettingsuchasIndia,Mexico,PakistanandSudan(Table 1).InruralGhana,spendingoninsulinalonerepresentsaround60%ofthemonthlyincomeofthoseontheminimumdailywage[32].Usingoriginator-brandmedicationresultedinmuchhigherspendingintheonlydiabetesstudythatusedrandomsamplingratherthanconveniencesamples.ThisstudyfoundthatinYemenandMali,purchasinganoriginatorbrandmedicineforglibenclamide(amedicineusedtotreattypeIIdiabetes)intheprivatesectorwasfoundtopotentiallyimpoverishanadditional22%and29%ofthepopulation,respectively,versus3%and19%,respectively,ifthelowestpricedgenericproductwaspurchased[41].Laboratoryandtransportationcostsweregenerallythesecondlargestcomponentofexpenditure.Somestudiesalsodocumentexpenditurerelatedtospecialdietaryregimes(upto20%ofthedirectcostsinNorthIndia[23]).Table1 Sharesofdiabetesexpenditurespentonmedications Fullsizetable Thepresenceofcomplicationsandthedurationoftheillnessareusuallyassociatedwithanincreaseofthedirectcosts.Forexample,Khowajaetal.foundthatinPakistan,thedirectcostforpatientswithco-morbiditieswas45%higherthanthedirectcostforpatientswithoutco-morbidities[50].Similarly,inIndia,thosewithoutcomplicationswerefoundtohavean18%lowercostcomparedtothemeanannualcostforoutpatientcareforallpatientswithdiabetes,whilethosewiththreeormorecomplicationshada48%highercost[51].SimilarresultswerefoundinIndia,China,ThailandandMalaysia[34,36,45,48].Thesestudiesalsohighlightthefactthattreatmentatanearlystageismuchcheaperforhouseholdsthantreatmentatalaterstagewithcomplications.Somestudieslookedatcopingstrategiesusedbyhouseholdstopayforthesedirectcosts.InIndia,themajorityofpatients(89%)usedtheirhouseholdincometofundthemonitoringandtreatmentoftheirdiabetes,whilehouseholdsavingswereusedby22%ofretiredpatientsandby19%ofthoseinthelowestincomebracket.Whenfacedwithhospitalization,56%ofpatientshadtodipintotheirsavingsorborrowinordertofundthecosts[51].Additionally,veryfewhouseholdsarereimbursedbyinsurance.InIndia,Kapurfoundthatonly1%ofpatientsclaimedthecostsoftreatmentoninsurance[51],whileRamachandranetal.observedthatmedicalreimbursementwasobtainedby14.2%ofurbanpatientsbutbyonly3.2%ofruralpatients[45].Moreover,Khowajaetal.foundthatinPakistan,noneofthepersonswithdiabetesindicatedthattheircostwasbornebyaninsurancecompanyortheiremployer[50].CardiovasculardiseasesFivestudiesexaminedspendingoncardiovasculardiseases.InastudyusingdatafromahouseholdsurveyinKazakhstan,peoplewithcardiacproblemswerefoundtopayonaverage24%moreforhealthcarethanpeoplewithotherhealthproblems[22].Aswithdiabetes,studiesfromCongoandUgandaalsofoundthattheuseoforiginatorbranddrugsincreasesspendingoncardiovasculardiseases[24,41].Onceagain,therewasonlyonecardiovasculardiseasestudythatdidnotuseaconveniencesample[41].Out-of-pocketpaymentsforthetreatmentofcardiovasculardiseasesalsoleadtosignificantcostsforhouseholds.Upto71%ofpatientswhohadexperiencedanacutestrokewerefoundtofacecatastrophichealthexpenditurebinChina,while37%ofthemfellbelowthepovertylineofUS$1perdayafterpayingfortheirhealthcare[35].ThestudyofHeeleyetal.alsofoundthatcatastrophicpaymentsandimpoverishmentduetocardiovasculardiseasesaremorecommoninpeoplewithnohealthinsurancethaninthosewithhealthinsurance[35].Inastudycovering35statesandunionterritoriesinIndia,Raoetal.investigatedthecopingstrategiesusedbyhouseholdstodealwithexpensesincurredforhospitalizationsduetocardiovasculardiseases[52];57%oftheseexpenseswerepaidfromhouseholdsavings,35%fromborrowings,and8%fromthesaleofassets.Inthepoorestgroup,upto55%ofout-of-pocketspendingwasfinancedthroughborrowings,andonly38%throughsavings[52].CancerCancersalsorepresentanemerginghealthprobleminLMICsandseekinghealthcareforthesediseasescanhaveasignificanteffectonfamilies’welfare.Wefoundthreepaperswhichfocusspecificallyonthedirectcostfromcancers.InastudyusingdatafromarandomizedhouseholdsurveyinPakistan,27.1%ofthosewhosoughtcareforcanceratprivatefacilitieswerefoundtofinancetheircarethroughunsecuredloans,while7.1%reliedonassistancefromothers[53].Twostudiesusingconveniencesamplesalsoshedsomelightoncomponentsofspendingoncancercare.Indeed,Zhouetal.foundthathealthinsurancefacilitatesthefinancialaccessoftreatmentforpatientssufferingfromoesophagealcancerinChina,particularlyforpurchasingdrugs[31].Meanwhile,transportation,multipleinvestigations,radiotherapyandchemotherapywerethemaincomponentsofdirectcostsforcervicalcancerinNigeria[27].Othernon-communicablediseasesThefinancialburdenfromotherNCDs,suchasepilepsy,cirrhosis,chronicobstructivepulmonarydisease(COPD),rhinitisanddepressivedisorders,isalsoestimatedinsomestudies.EveniftheyarenotasstudiedasthemajorNCDspresentedpreviously,thesetypesofillnessescanalsoexertaconsiderablepressureonhouseholdfinances.Forexample,astudyfromMumbai(India)basedonarandomsampleofhouseholdsfoundthattheshareoftheannualpersonalincomespentonoutpatientcareforallergicrhinitiswas1.7%whentreatmentwassoughtinpublicfacilities.Similarly,careforCOPDrepresented13.3%ofannualpersonalincomeamongthoseusingprivatefacilities.Withhospitalizationatpublicfacilities,out-of-pocketpaymentsforCOPDrepresentedupto62.3%oftheannualpersonalincomecomparedto50.7%forhospitalizationinprivatefacilities[54].Usingafocusgroup,RussellandGilsondocumentthecaseofanindividualsufferingfromasthma,whoincurredadirectcostrepresenting15%ofhismonthlywagewhenseekingcareforasorechestinaprivateclinicandpharmacy[39].MultiplelaboratorytestsandthepresenceofcomplicationswerealsofoundtocausehighexpensesforaconveniencesampleofpatientssufferingfromcirrhosisinBrazzaville(Congo)[26].CopingstrategiesusedtopayforcareassociatedwiththeseNCDsaresimilartothoseusedtocopewithmoredocumentedNCDs.InPakistanforexample,MahmoodandAliMubashirusingarandomsamplefoundthat22.9%ofpatientswithcirculatorydiseases(heartdiseases,rheumaticfeverandbloodpressure)whovisitedprivatedoctors/clinicsfortreatmentfinancedcarethroughunsecuredloans,while8.8%reliedonassistancefromothers[53].Amongthosewhodidnotvisitanyfacility,67.4%reportedfinancialconstraintsasthereasonfornotseekingcare.Non-communicablediseasescombinedWefoundalargenumberofstudies–allbasedonrandomizedhouseholdsurveys–lookingatNCDsingeneral,insteadoffocusingonspecificillnesses.Somestudieshighlighttheassociationofhavingahouseholdmembersufferingfromachronicdiseasewithasignificantincreaseinhealthcareexpenditureandahigherriskofimpoverishment.InRussia,forexample,eachadditionalcaseofchronicdiseaseinahouseholdwasfoundtoincreasetheprobabilityofincurringhealthcareexpenditureby8%andtheamountofhealthcareexpenditureby6.2%[19].Similarly,inUganda,householdswithamembersufferingfromachronicillnesswerefoundtobethreetimesmorelikelytoincurcostsforhealthcarethanotherhouseholds[18].InKazakhstan,peoplewithchronicillnesswerefoundtopayonaverage18%morethanpeoplewithotherhealthproblems,whileinGeorgia,themeancostforoutpatientcareincaseofchronicillnesswasalmosttwotimeshigherthanincaseofacuteillness[21,22].Ontheotherhand,astudyfromIndiafoundthattherelativeimportanceofchronicdiseasesforspendingmaybelower–themeanannualpercapitahealthexpenditureforachronicepisodewas11%lowerthanforanacuteone[44].Undeniably,expensesincurredwhenseekinghealthcareforchronicdiseasesrepresentanimportantfinancialburdenforhouseholdsaspresentedinTable 2.Infact,thecostsofhealthcareforchronicillnesseswerefoundtorepresentfrom5.0%ofhouseholdincomeinruralKenyatoupto30–50%ofmonthlyincomeforvulnerablehouseholdsinSouthAfrica,wherecarefortheseillnesseswereunaffordablewithoutgiftsfromsocialnetworks[37,38].Similarly,householdspendingonchronicillnessrepresented4.14%ofhousehold’stotalannualhealthcareexpenditureinurbanareasand5.73%inruralareasofWestBengalinIndia;however,itwasupto11%inVietnamand32%inMaharashtra,BiharandTamilNadustatesofIndia,withahighershareforhospitalizationanddrugs[20,40,55].Allthesestudiesusedarandomsample.Anotherproxyofhouseholds’capacitytopayusedintheliteratureistheirnon-foodexpenditure.Sunetal.foundthatinChina,theaverageproportionofchronicdiseaseexpendituretoannualnon-foodexpenditurewasabout27%inShandongProvinceand35%inNingxiaprovinceforpatientscoveredbyNewCooperativeMedicalScheme(NCMS),apublichealthinsuranceschemeforruralresidents[16].Fornon-NCMSmembers,theseproportionswere47%and42%,respectively.Table2 Expenditureonchronicdiseases Fullsizetable Inseveralstudies,thepresenceofhouseholdmemberswithchronicailmentswasalsofoundtoleadtocatastrophichealthexpenditureandimpoverishment.Theprobabilityofcatastrophicexpenditurewasthen4.4timeshigheramonghouseholdshavingincurredexpensesfortreatingchronicallyillpersonsinGeorgia,andupto7.8timeshigherinBurkina-Faso[17,56].SimilarresultswerefoundinWestBengal(India),inLebanonandinChina[15,40,57,58].Upto11.6%ofhouseholdsinWesternandCentralChinawerepushedundertheUS$1.08povertylineafterincurringoutpatientexpensesassociatedwithchronicdiseases[42].Moreover,Shietal.foundtheincidenceofmedicalimpoverishmenttoreach19.6%inhouseholdswheremorethan50%ofmembershadachronicillness[16].Aswithdiabetes,whenhouseholdsarecoveredbyhealthinsurance,thereimbursementratesforchronicdiseasesarerelativelylow.InShandongandNingxiainChina,forexample,only11.16%and8.67%,respectively,ofoverallmedicalexpenditureforchronicdiseaseswasreimbursedbytheNCMS[16].However,anotherstudyfromWesternChinafoundthathealthinsuranceprovidedprotectionagainstimpoverishmentduetoexpensesforchronicdiseases[42].GovernmentsubsidiesformedicineswerealsofoundtolowertheexpensesformanychronicdiseasesinVietnam[29].CopingstrategiesdocumentedintheliteraturecombiningchronicdiseasesaresimilartothosedescribedinthestudiesonspecificNCDs.InGeorgia,whenhouseholdswerelackingfinancialmeans,themostdominantstrategywastoborrowfromafriendorrelative(70%),followedbysellinghouseholdvaluables(10%)and/orhouseholdgoods/products(10%)[21].Literatureontheindirectcostsduetonon-communicablediseasesinlow-andmiddle-incomecountriesHouseholdsandindividualsalsobearindirectcostswhentheyareaffectedbyNCDs.Thesecostsmainlyincludetimeandproductivitylossbypatientsandcaregiversbecauseoftheillnessaswellasincomelostbypatientsandfamilymembers.Whereasthereisnodoubtthattheseindirectcostscanposeasubstantialburdenonhouseholds,therearenumerousmethodologicalchallengesinmeasuringthisburdenadequately;thesechallengeshavebeendiscussedindetailinapreviousstudy[59].Nonetheless,inthissection,wepresenttheavailableevidenceontheindirectcostsofNCDsasreportedintheliterature.Thisconstitutesfindingsfrom11studies,whichmainlyuseconveniencesamples,onlossofincome,lossoftimeandotherformsoffinanciallossrelatedtotheseillnesses.Wediscusspossiblelimitationsofthesefindingsinthediscussionsection.LossofincomeInIndia,onestudysuggeststhattheindirectcostfordiabetespatientsandtheircaregiverswas28.76%ofthetotaltreatmentcost.Itwasclaimedthatlossofincomeofthepatientcomprisedthegreatestportionofindirectcosts(60.54%),followedbylossofincomeofcaregivers(39.46%)[23].Rayappaetal.foundthatinBangalore(India),30.9%ofrespondentssufferingfromdiabetesreportedachangeinpersonalincome,andonaverage,theyfacedareductionof20.9%oftheirpersonalincome[48].Inaddition,20.8%oftherespondentsreportedachangeinfamilyincome,withameanreductionof17.4%.Similarly,Arrossietal.foundthatinArgentina,39%ofhouseholdswithamembersufferingfromcervicalcancerlostfamilyincome,partiallyortotally[28].Amonghouseholdsthatlostincome,47%lostlessthan25%offamilyincome,34%lost25–50%and19%lost50%ormoreoftheirincome.Asaresultofthereportedlossofincome,itwasestimatedthattheproportionofpatient’shouseholdslivinginpovertyincreasedfrom45%to53%.Likewise,ObiandOzumbafoundthatinNigeria,allpatientssufferingfromcervicalcancerandtheirrelativeslostincomefromworkplacesduetoabsenteeism,disengagementfromworkandmissingbusinessappointments[27].Inastudycovering19countries,oneofthetwostudiesusingrandomizedhouseholdsurveydatadocumentingindirectcosts,Levinsonetal.foundthatseriousmentalillnesswasassociatedwithapotentialreductioninearningsof10.9%ofaveragenationalearningsinLMICs[60].ThesecondstudyusingrandomizedhouseholdsurveydatawasfromRussiaandfoundthatlabourincomedecreasedby4.8%peradditionalcaseofchronicdiseaseinthehousehold[19].SomestudiesonlyestimatetheNCDs-relatedindirectcostsforpatientsandtheirfamiliesinabsolutevalue(localcurrenciesorUS$)[50,51,61].LossofworkingtimeThelossofincomebornebypatientssufferingfromNCDsismainlyduetoself-reportedabsenteeismfromusualeconomicactivity.Infact,thetreatmentofNCDsusuallyrequiresrepetitivevisitstohealthfacilitiesinadditiontotheinabilitytoworkduetotheirpoorhealth.Thiscanleadtoadditionallossesofworkingtimebothforpatientsandcaregivers.Intheliterature,themeanlossofworkingtimereportedbypatientswasfoundtovaryfrom2.8±1.7hourspervisitfordiabetesinPakistanto58±105daysperyearforepilepsyinIndia[30,50].EpisodesofrespiratorydiseasescanalsocauseimportantlossesofworkingtimeasshowninacasestudyinColombo(SriLanka)whereRussellandGilsonfoundapatientsufferingfromasthmatooktwodaysoffworkforasorechest,losing6%ofhismonthlywage[39].However,timecostsarenotlimitedtopatients,butalsoaffectcaregivers.InBuenosAires(Argentina)forexample,Arrossietal.foundthatin45%ofhouseholdswithamembersufferingfromcervicalcancer,atleastonememberreducedhis/herworkinghours[28].FordiabetespatientsinThailand,caregiverswerefoundtospendonaverage42.21±39.94hourspermonthonhealthcareactivities–e.g.,givingmedicines–and21.87±31.81hoursonactivitiesofdailyliving–e.g.,helpingwitheatinganddressing[61].OtherformsofindirectcostsSomeotherformsofindirectcostsduetoNCDswerefoundintheliterature;thesegenerallyconcernhouseholds’livelihoodandwelfare.ThestudyoncervicalcancerinBuenosAires(Argentina)byArrossietal.examinedtheseandalsofoundthatduetoalossofincome,thereweredelaysinpaymentsforessentialservicessuchastelephoneorelectricityandasaresult43%ofhouseholdshadtheservicecut[28].Therewerealsosignificanteffectsonself-reporteddailyfoodconsumption,whichwasreducedin37%ofhouseholds,while38%ofhouseholdsreportedthattheysoldpropertyorusedsavingstooffsetincomeloss.Someimpactsoneducationwerefoundandschoolabsencesweremoreprevalentin28%ofhouseholds.Therewerealsoproblemstopayforeducationin23%ofhouseholds.Furthermore,45%ofpatientswerecaredforbyoneormoreinformalcaregiversthatdidnotlivewiththemandone-thirdofthesecaregivers’householdsreducedtheirdailyconsumptionoffoodand26%haddelaysinpaymentsofessentialservicessuchaselectricityortelephoneservices.Itshouldbenotedthatthesearethetypesofwelfarelosseshaveshapedtheconceptofcatastrophichealthexpenditure.Therewerealsodirectimpactsonemploymentandatleastonememberstoppedworkingin28%ofhouseholdsaffectedbycervicalcancer.Severalintervieweeswhostoppedworkingexpressedthehopeofgoingbacktotheirjobsaftertreatment,fearingatthesametimethatthiswouldnolongerbepossible.Similarly,astudyfromBangalore(India)byRayappaetal.foundthatonly33.4%ofdiabetespatientsworkedandamongthoseworking,23%experiencedproblemsattheirjob,affectingtheirproductivityandattimesrequiringchangingworktoalessstrenuousjob(5.9%)orgivingupthejob(14.7%)[48].ConsideringNCDsingeneral,AbegundeandStanciolefoundthatinRussia,chronicillnesses,whichincludedNCDs,imposeareductionof5%inhouseholdconsumptionofnon-health-relateditems[19].DiscussionThisliteraturereviewhaspresentedtheavailableevidenceonthehouseholdfinancialburdenrelatedtoNCDsinLMICs.However,beforediscussingitsmostimportantresults,itisimportanttohighlightsomeofthemethodologicalissuesinmanyofthestudiesthatwereincluded.First,theheavyrelianceonconveniencesamplestakenfrompeoplewhoareseekingandobtainingtreatment,oftenathospitals,willalmostcertainlyresultinanupwardbiasincostsfortheaveragepersonwiththecondition.Thepeoplewhodonotseektreatmentorwhoseektreatmentatalowerlevelofcare,implyinglowercosts,havenochanceofbeingselected.Second,self-reportedcosts,evenfromrandomsamplesofpatients,arelikelytobebiasedupwardswhentherearenocontrols.Someofthepeoplewiththeconditionwouldhaveincurredsomehealthexpensesinanycaseandthiscanonlybecapturedbyincludingcontrolswithoutthecondition[59,62].Inotherwords,itislikelythatpartofthecostsreportedbypatientswithNCDswerenotdirectlyassociatedwiththoseconditions.Thisissueisparticularlyimportantwhenconsideringindirectcosts.Itisclearthatthemethodofaskingpeoplehowmanydaystheycouldnotworkoverestimatesthetruelossinworktimefromadiseasebecausemanyofthepeople,particularlyinlow-incomecountries,wouldnothavebeenworkingonthosedays,orforallofthosedays,intheabsenceofthedisease[59].Nordothestudiesconsiderwhetherabsentworkersarereplacedbyotherfamilymembersinfamilyenterprisesorfarms.Forexample,frequentlyotherfamilymembersfillinforasickpersonduringtheplantingseasoninagriculturesothatthesameareaoflandisplanteddespitetheillness[63].Thisdoesnot,ofcourse,meanthattherearenoopportunitycostsassociatedwiththeillness,butthatthemeasuredproductionfromthefamilyenterpriseisnotalteredasmuch.Ingeneral,therefore,weexpectthatthecostsfromstudieswithnocontrolstobeoverestimatesofbothdirectandindirectcosts.Thesubstantialvariationsinstudydesignsanddefinitionsdescribedearlieralsomakecomparisonstrickyandmeta-analysisinfeasible.Thereisconsiderableheterogeneityinobjectivesandthemethodologiesusedinthepapers.Whilewehavemoreconfidenceinthestudiesrelyingonrandomizedsamples,wepresentmoredetailsabouteachstudyinfile1:TableS1togivereadersfurtherinformationandtoallowthemtoconsiderpossiblegeneralizationsoftheresults.Takingintoconsiderationthemethodologicalissueshighlightedhereandinearliersections,wecanstillconcludethatNCDsalreadyimposesubstantialfinancialcostsonsomeoftheirsufferersinlower-incomecountries.Asaresult,thecostofobtainingtreatmentforNCDsisalsobecomingacauseofimpoverishmentandfinancialcatastropheinthesecountries.Whilethisisnotparticularlysurprisinggiventhegrowingburdenofdiseaseassociatedwiththeseconditions,ithasnotbeendocumentedbefore.Againnotsurprisingly,complicationsrelatedtotheseverityofillnesswerefoundtoincreasethehouseholdfinancialburden,bothforthepatientandforcaregivers.Healthpromotion,preventionandearlytreatmentwouldreducesomeofthesecostsalthougheachcountrywouldneedtochoosetheappropriatemixofpreventionandtreatmentaccordingtotheirrelativecostsandimpact.WealsofoundstrongevidencethatcostscouldbereducedbymorerationaluseofmedicationsforNCDs.ThecostsofmedicationforallthedifferenttypesofNCDsconsideredhereaccountedforthehighestproportionofthedirectcosts;whereaddressed,originatorbrandmedicineswerefrequentlyusedinsteadofavailablegenericsandcostswerethensubstantiallyhigherthantheyneededtobe.WhilemanyLMICsalreadyhavestrategiestopromotetherationaluseofmedicines,thereisstillsomewaytogoparticularlyinpromotingtheuseoflowercostgenerics.Theweaknessornon-existenceofmechanismstoprotecthouseholdsfinanciallyfromtheburdenofNCDsis,however,probablythemostimportantfindinginthisstudy.Inthestudiesthatconsideredinsuranceandprovidedinformationonreimbursementrates,NCD-relatedtreatmentisgenerallyuncommonandfrequentlypatientsandtheirrelativesdonotreportthattheyclaimedanyreimbursementfrominsuranceoremployers.Likewise,noneofthestudieswereviewedreportedasystemofsocialsecuritythatprovidescompensationforlossofincomeincurredbypatientsandtheirfamiliesbecauseofNCDs.Poorhouseholdsaremorelikelytosufferdisproportionallyfromthefinancialeffectsofthislackofsocialprotection.Tomeetthecosts,householdsreportedtakingunsecureloans,usingsavingsorsellinghouseholdassets,allofwhichcanleadtolonger-termproblemsforthehousehold.Forexample,thewiderliteraturesuggeststhatmanyoftheloanstakenbyhouseholdsforhealthexpensesareatveryhighinterestratesthatcantakegenerationstorepay[64].ThisispartofabiggerprobleminLMICs,manyofwhichrelyextensivelyondirectout-of-pocketpaymentstofundhealthservices.Recently,manyhaverecognizedtheneedtomodifythewaytheyraisefundsandmoregenerallytomodifytheirhealthfinancingsystemssoastoimprovefinancialriskprotectionandensuregreateraccesstoneededhealthservices[65];itisimportanttonotethatitwillbeincreasinglynecessarytoincludeNCDsinwhatevertypeoffinancialriskprotectionstrategyisdeveloped.ThisisparticularlyimportantforpoorfamiliesbecauseNCDsnolongeraffectonlythemoreaffluentpeopleinsociety[1,8,13,66,67].WhilewethinkthatthefinancialcostsreportedinthisreviewwilloverestimatethecostsofatypicalpatientwithNCDs,suchthatthenumberscannotbeusedtoextrapolatethecostsofNCDstoacountry,theyhighlighttheotherconsequencesofthelackoffinancialriskprotectioninLMICs.Intherandomsamplestudies,manypeoplewithNCDsreportedthattheydidnotseekcareatallbecauseoffinancialreasons(Additionalfile2).Manyoftheirconditionsarelikelytobecomemoresevereintheabsenceoftreatment,leadingtoearlydeathandgreaterproblemsforcaregiversandhouseholds.Theeffectsofnotseekingcareforpoorerhouseholdsisofparticularconcerngiventhattheabilitytoworkisoneofthemostimportantpovertyescaperoutes[68–72].Strategiestoimprovefinancialriskprotectionwillalsoleadtoincreasedfinancialaccesstohealthserviceswhiledemandsideresponses,suchascashtransfers,canhelpreducesomeofthefinancialbarrierstoseekingcare,suchastransportcosts.Nevertheless,demand-sideapproachesinLMICsare,toourknowledge,limitedlargelytomaternalandchildhealth(andeducation)andsomecommunicablediseases[73–77].Throughthisreview,wearealsoabletoidentifyareaswherefurtherresearchisneeded.AmongthefourmajorNCDs,thefinancialcostsfromchronicrespiratorydiseasesareverypoorlydocumented,althoughtheycausefourtimesmoredeathsthanforexamplediabetes,whichhasbeenresearchedmore[1,78].AccordingtotheWHO,almost90%ofCOPDdeathsoccurinLMICsandthehighestprevalenceofsmoking–theprimarycauseofCOPD–amongmenisinthesecountries[1,78,79].Itwouldthereforebeinterestingtohavemoreassessmentsofthefinancialcostsofthesediseasesinfuturestudies.Additionally,whileallstudiesreviewedhereusedcross-sectionaldata,paneldatawillbeveryusefulinassessingtheevolutionofcostsincurredbyhouseholdsbecauseofNCDs.ThecomparisonoftherelativeimportanceofthecostofNCDswiththatofacuteillnessesisalsoofagreatinteresthere,asaccordingtothepapersreviewed,thereisnocleartrend.Indeed,somestudiesshowthatNCDsaremorecostlyforhouseholds,whileothersobservetheopposite.Sometimesinthesamecountry,differentresultsarefounddependingonthearea(urbanvs.rural),thetypeofhealthcare(outpatientvs.inpatient)andhouseholdsocioeconomicstatus(poorvs.better-off)[17,21,38,39,44,55].Morestudies–introducingforexampleatimedimensionandadistinctionbetweenprivateandpublicproviders–arethereforeneededtoshedmorelightonthisissue.Itmayalsobeimportanttoexpandthegeographicaloutlookinfutureresearchtobemorerepresentativeofawidergroupofdevelopingcountries.Thisistrueevenafteraccountingfortheinfluenceofthelanguagesusedinthisreview.Ofthe49studiesfound,mostwerefromAsia,ascomparedtoonlyahandfulfromLatinAmericaorEasternEurope,and10studiesfromAfrica.ConclusionsTheliteratureonthesocial,financialandeconomicconsequencesofNCDsindevelopingcountrieshasnotkeptpacewiththeepidemiologicalevidence.IthasbeenknownforsometimethattheburdenofdiseaseassociatedwithNCDsandinjuriesisalreadyhigherthanthatassociatedwiththehealthconditionsincludedintheMillenniumDevelopmentGoals(HIV/AIDS,tuberculosis,malaria,andmaternal,childandreproductivehealth),evenindevelopingcountries.Moreover,ithasbeenwelldocumentedthattheshareofNCDsintheoveralldiseaseburdenwillcontinuetoincreaseglobally.Indeed,theUNs’2011conferenceonNCDsstressedtheimportanceofthesediseasesasadevelopmentissue.TheliteraturewereviewedshedssomelightonthefinancialconsequencesofNCDsonhouseholdsinLMICs.Nonetheless,therearelimitationstogeneralizationofthesefindingsduetomethodologicalchallenges.ValidestimatesoftheaveragecostsofNCDswillrequirerandomsampleswithcontrolstoaccountforpeoplewhohavecostlyandlesscostlytreatments,andwhatwouldhavehappenedintheabsenceofthediseases.Paneldatawouldbeidealalthoughthesestudiesaremoreexpensivethancross-sectionaldesigns.However,importantly,thisreviewsuggeststhatitisequallyasimportanttofocusonpeoplewhocouldnotseekcareforNCDsduetofinancialreasons.Littleisknownaboutthesubsequentdevelopmentofdisease,impactsonthesepeople’shealthandthefinancial,socialandotherconsequencesassociatedwithforegonetreatment.Thepushtodevelophealth-financingsystemsthatimprovefinancialriskprotectionandhelpachieveuniversalhealthcoverageinLMICsispromising.However,policymakersneedtoensurethatthehealthaswellasthefinancialburdenfromNCDsisadequatelyaddressedinfuturereforms,whileatthesametimeimproveaccessandfinancialprotectionforallotherhealthservicesneededbythepopulation.Endnotes aUS$995orless,US$996toUS$3,945,andUS$3,946toUS$12,195,respectively. bDefinedasout-of-pocketexpensesthataccountedfor≥30%ofthetotalannualhouseholdincomethatwasreportedatbaseline.Authors’informationTheviewsandopinionsexpressedinthisarticleareentirelythoseoftheauthorsandshouldnotbeattributedinanymannerwhatsoevertotheorganizationstheauthorsareaffiliatedto.HTKisPhDStudentatAix-MarseilleUniversity(Aix-MarseilleSchoolofEconomics),Marseille,France.PSisTechnicalOfficerattheDepartmentofHealthSystemsFinancing,WorldHealthOrganization,Geneva,Switzerland.KXisTeamLeader,HealthCareFinancingatWHORegionalOfficefortheWesternPacificRegioninManila,Philippines.DBEistheDirectoroftheDepartmentofHealthSystemsFinancing,WorldHealthOrganization,Geneva,Switzerland. 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PubMed GoogleScholarKeXuViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarDavidBEvansViewauthorpublicationsYoucanalsosearchforthisauthorin PubMed GoogleScholarCorrespondingauthorCorrespondenceto HyacintheTchewonpiKankeu.AdditionalinformationCompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.Authors’contributionsPSandKXconceivedtheprojectandthequestionstobestudied.HTKandPSconductedtheliteraturereview,producedthedraftofthepaperandproducedthefinalversionwiththeinputofotherauthors.DBEandKXcontributedtowritingthepaper.Allauthorsreadandapprovedthefinalmanuscript.Electronicsupplementarymaterial Additionalfile1:TableS1:Studiesreviewed.(DOC107KB)Additionalfile2:Financialdifficulties:amajorcausefornotseekingcareforNCDs.(DOC37KB)Authors’originalsubmittedfilesforimagesBelowarethelinkstotheauthors’originalsubmittedfilesforimages. 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HealthResPolicySys11,31(2013).https://doi.org/10.1186/1478-4505-11-31DownloadcitationReceived:26March2013Accepted:18July2013Published:16August2013DOI:https://doi.org/10.1186/1478-4505-11-31SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsFinancialburdenLow-andmiddle-incomecountriesNon-communicablediseasesReview DownloadPDF DownloadePub Advertisement HealthResearchPolicyandSystems ISSN:1478-4505 Contactus Submissionenquiries:AccesshereandclickContactUs Generalenquiries:[email protected]