When health cost is a catastrophe for a family

How burdening can the medical bills be on a household with a cancer patient?

For the family of Sirajul Islam, a farmer from northern Rangpur district, it is unbearable. The Rangpur farmer had already sold his farmland and cattle, and is now in debt to pay for the chemotherapy and medicines for his wife's cancer treatment in the past three years.

Unable to avail a decent accommodation in the capital, the couple has taken shelter beside a garbage dump just outside of the National Institute of Cancer Research and Hospital.

"If I can borrow, my wife gets the chemo. If I cannot, we miss the chemo date," Sirajul told The Business Standard, adding the disease has cost him Tk9 lakh so far.

A recent study titled "Disease-specific distress healthcare financing and catastrophic out-of-pocket expenditure for hospitalization in Bangladesh" shows 26% of households in the country incurred catastrophic health expenditure (CHE) on hospitalisation in the past couple of years. The highest incidence of CHE was for cancer (50%), followed by liver diseases (49.2%), and paralysis (43.6%).

The World Health Organisation labels health expenditure as catastrophic when a family's medical bills account for 40% or more of their income available after buying food.

The study also shows the CHE incidence on hospitalisation in the country has been rising – from 14.2% (at 10% of total household consumption expenditure or THCE) in 2010 and 24.6% in 2016 to 26.1% in 2021.

The findings of the study were published in the British Medical Journal on 20 August, shedding light on rising out-of-pocket expenditure and a whopping 58% of the households facing distress financing on hospitalisation.

According to the study, out-of-pocket expenditure – the money spent by families for treatment in hospitals – has been on the rise for major diseases like cancer, putting more and more families in distress as poor health allocation in the national budget and the absence of insurance make patients bear most of the treatment cost.

Distress financing includes funding for out-of-pocket expenditure by selling or mortgaging household assets, lands, borrowing money and receiving assistance from friends and relatives.

The study comprised local and foreign researchers who analysed household survey data on 1,83,757 individuals from 45,423 households. The household survey data covers patients who got hospitalised and their hospitalisation expenditure including transport cost, informal tips, and other formal charges.

According to public health experts, there should be measures to reduce out-of-pocket expenditure, which eventually will protect families from distress financing or catastrophic health expenditure.

Dr Abdur Razzaque Sarker, health economist of Bangladesh Institute of Development Studies, also one of the researchers of the study, told The Business Standard, "To reduce out-of-pocket expenditure, medicine costs and unnecessary tests should be reduced. There should be prescribed guidelines for treatment. If medicine use is monitored, unnecessary medicine use will be reduced and financial pressure on people will also be lessened."

Currently, Bangladeshis have to pay 68.50% of their total treatment costs out of their own pockets.

The Health Economics Unit of the Ministry of Health and Family Welfare says patients spend a whopping 64% of their health expenses on drugs, while 23% used for meeting hospital expenses (both indoors and outdoors) and 8% for diagnosis purposes.

Only 3% patients receive medication from government hospitals and 14.9% obtain diagnostic services. Most patients have to buy medicines from private pharmacies and go to private diagnostic centres. This increases the out-of-pocket expenses of households and often leads them to face financial disaster.

Abdur Razzaque also advocated for introducing health insurance to check the distress financing.

According to the study, the average hospital stay in Bangladesh was 7.2 days. The longest hospital stay – average 25.7 days – was due to cancer, followed by tuberculosis average 20 days, mental health 13.8 days and injury or accident 10.1 days.

Dr Nurul Amin, director (research) at the Health Economics Unit, told TBS that government healthcare facilities must be more functional to reduce out-of-pocket expenditure. Otherwise, it would not be possible to attain the SDG target to bring down the expenditure to 30% by 2030.

Abdul Aziz, member of parliament and also a member of the Parliamentary Standing Committee on Health and Family Welfare, said the government has introduced health insurance in some areas on a trial basis. There are plans to expand the facility across the country.

Studies show how health insurance helped countries reduce the burden of health costs on families by cutting their out-of-pocket payments.

Different health insurance policies for different income groups introduced in China dramatically reduced the CHE since 2007.

Despite their higher public spending for health in the annual budget, advanced economies have massive health insurance coverage with a maximum cap for out-of-pocket payments for patients. The ceiling ranges between $1,688 and $3,375 in Korea depending on the personal income of insured patients.

If the cap in Switzerland – $728 – is concerned, Sirajul Islam, the Bangladeshi farmer, has already spent 13 times higher.

Every year, approximately 44 million households throughout the world face catastrophic expenditure, and about 25 million households are pushed into poverty because of catastrophic healthcare payments, the WHO says, referring to low household capacity, poor public budget for health and lack of insurance contributions.

Bangladesh's budget allocation for health has been less than 1% of GDP - the lowest among 46 least developed countries –  for the last two decades, requiring families to spend beyond their means for treatment of non-communicable diseases which need treatment and hospitalisation for longer periods.

Some 1.56 lakh people are diagnosed with cancer in Bangladesh every year, according to a Globocan 2020 report.

In 2015, a report of the National Institute of Cancer Research Hospital (NICRH)  shows that the total number of outdoor patients was 174,037, while the admitted patients were 7,285.

According to health data, more than 2 crore people in Bangladesh suffer from kidney disease as non-communicable diseases (NCD) are increasing day by day.  Major NCDs include cardiovascular diseases, diabetes, chronic respiratory diseases, cancer and mental health disorders. NCD accounts for 67% of total deaths in Bangladesh.

The facts indicate an increasing burden of CHE in Bangladesh with much greater incidence among patients at private facilities mainly for treatment of NCDs.

"More precisely, we discovered that cancer had the greatest devastating impact, followed by liver diseases and paralysis," the study adds, noting that about 43% of households meet healthcare costs by selling properties, borrowing, or receiving assistance from relatives.

The study shows how the health cost burden impacts the poverty situation directly as it estimates that about 5 million people in Bangladesh fall below the poverty line each year due to high out-of-pocket payment for healthcare.

To reduce the cost burden on families, the study strongly suggests introducing national-level social health security schemes with a particular focus on low-income households, regulating the private sector health cost and implementing subsidised healthcare for cancer, heart, liver and kidney patients.

"Finally, in order to reduce reliance on out-of-pocket expenditure, the government should consider increasing its allocations to the health sector," it concludes.