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ORIGINAL ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 3  |  Page : 252-257  

Out-of-pocket health expenditure on diarrheal illness among under-five children in a teaching hospital ins Odisha, India


1 Associate Professor, Department of Public Health, School of Public Health, KIIT Deemed to be University, Bhubaneswar, Odisha, India
2 Associate Professor, Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India
3 Faculty Associate, Department of Public Health, School of Public Health, KIIT DU, Bhubaneswar, Odisha, India
4 Director, Department of Public Health, School of Public Health, KIIT DU, Bhubaneswar, Odisha, India

Date of Submission27-May-2019
Date of Decision10-Dec-2019
Date of Acceptance10-Jun-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Nirmal Kumar Mohakud
Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_258_19

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   Abstract 


Background: Diarrhea is the most common illness in children under 5 years of age, accounting for a financial burden for families in developing countries. Objective: The aim of this study is to determine the out-of-pocket health expenditure for the management of diarrhoeal illness among the under-five children in in-patient and out-patient cases. Methods: A cross-sectional study was conducted during January-April 2018 among 60 under-five children with diarrheal illness reporting to pediatric outpatient department (OPD) and 60 under-five children admitted to pediatric ward of a tertiary care teaching hospital. For determining the out-of-pocket health expenditure, both direct and indirect costs for the management of diarrheal illness were estimated both for out-patient and in-patient cases. The cost of the treatment has been presented as the cost of prehospital visits, during a hospital visit and posthospital visit. Results: Overall, median out-of-pocket health expenditure for the management of diarrheal illness for out-patient and in-patient cases were Rs. 1186 (interquartile range [IQR]: Rs. 510) and Rs. 6385 (IQR: Rs. 5889), respectively. The median direct expenditure for OPD cases was Rs. 778.50 (IQR: Rs. 263) and indirect expenditure for OPD cases were Rs. 407.50 (IQR: Rs. 336) The median direct and indirect expenditure for inpatient cases were Rs. 3823 (IQR: Rs. 1942) and Rs. 2237 (IQR: Rs. 4256) respectively. Only 13% of in-patient cases had some kind of medical insurance. Conclusion: A considerable economic burden is faced by the families for treating diarrhea in under-five children. Improved access to safe drinking water and sanitation, promotion of hand hygiene, exclusive breastfeeding, rotavirus vaccination, and use of oral rehydration therapy will reduce hospitalization and out-of-pocket expenditure. The study findings recommend for appropriate policy for provision of financial protection while seeking health care services.

Keywords: Diarrhea, direct cost, indirect cost, Odisha, out-of-pocket expenditure, under-five children


How to cite this article:
Pradhan HS, Mohakud NK, Kavitha A K, Nayak MK, Satpathy SK. Out-of-pocket health expenditure on diarrheal illness among under-five children in a teaching hospital ins Odisha, India. Indian J Public Health 2020;64:252-7

How to cite this URL:
Pradhan HS, Mohakud NK, Kavitha A K, Nayak MK, Satpathy SK. Out-of-pocket health expenditure on diarrheal illness among under-five children in a teaching hospital ins Odisha, India. Indian J Public Health [serial online] 2020 [cited 2020 Oct 26];64:252-7. Available from: https://www.ijph.in/text.asp?2020/64/3/252/295787




   Introduction Top


Diarrhea is the most common illness in children under 5 years of age. Globally, 1.7 billion cases of childhood diarrheal disease occur annually. Each year diarrhea kills around 525,000 children under 5 years of age.[1] In low-income countries, children under 3-year-old experience an average of three episodes of diarrhea every year, contributing to malnutrition as a major cause.[1] Diarrhea accounts for 13% of all deaths among under-five children and the third-leading cause of childhood mortality in India.[2] Rotavirus infection accounts for 39% of diarrheal admission in India.[3] As per the National Family Health Survey round 4 (2015–2016), in India, the prevalence of diarrhea was 9.2% among under-five children in the 2 weeks before the survey.[4] In Odisha, the prevalence was 9.8% in the last 2 weeks preceding the survey.[4] Children aged 0–4 years constitute 9.7% of India's total population,[5] indicating high disease burden of diarrheal illness among this group. Diarrheal disease poses a severe burden on the health system because of out-patient department (OPD) attendance and hospitalization.

In India, >70% of ailments, including diarrhea were treated in private health facilities, indicating people's choice of the private sector for seeking health care.[6] While seeking health care, people in India incur a high out-of-pocket expenditure, which is around 65% due to low public financing on health and poor medical insurance coverage.[7] As per the available report, in 2015, an estimated 8% of India population had been pushed below the poverty line by high out-of-pocket expenditure for health care.[8]

To reduce the incidence of diarrhea among children, rotavirus vaccine has been introduced in the Universal Immunization Program in India in a phased manner. Cost analysis of diarrheal episode among under-five children is necessary to inform the policymakers and implementers for appropriate decision making. Few studies have been conducted to estimate the diarrheal illness among the children under five. However, considering the regional diversities on socioeconomic aspects and health-seeking behavior of the people, it is necessary to conduct such kind of cost analysis studies in different regions of the country, including the eastern part of India. Scanty information is available on the costing of diarrheal illness among children under five in Odisha state.

The present study was undertaken with the aim to determine the out-of-pocket health expenditure (both direct and indirect) for the management of diarrheal illness among the under-five children in in-patient and out-patient care facilities in a private not for profit tertiary care teaching hospital in Odisha, India.


   Materials and Methods Top


A cross-sectional cost analysis study was conducted between January and April 2018, in tertiary care not for profit teaching hospital in Bhubaneswar, Odisha. Children in the age group of 0–59 months with diarrhea reporting to the pediatrics OPD and admitted in the indoor were included in the study. The case of diarrhea among under-five children (0–59 months) was defined as-”passing of three or more liquid stools in a 24-h period.” Sixty cases of under-five children with diarrhea attending pediatrics OPD were selected for the study following a systematic sampling (every fifth case of diarrhea). Sixty (60) cases of diarrhea admitted in pediatrics indoor were selected based on the census method (all under-five diarrheal cases admitted in indoor) till achieving 60 cases.

Inclusion criteria

The cases meeting the definition of diarrhea presenting at either OPD or in-patient department (IPD) and whose parents/caretakers consented to participate in the study were included. Patients with chronic diseases, parenteral diarrhea and who developed diarrhea after 24 h of hospitalization were excluded.

The standardized World Health Organization questionnaire for costing of diarrheal illness contextualized to the local situation was used for interviewing the parents/caretakers of the patients.[9] The questionnaire was validated by a pilot study conducted at Christian Medical College (CMC) and a secondary care hospital in Vellore, India. For determining the out-of-pocket expenditure, both direct and indirect expenditure for the management of diarrheal illness was estimated in the present study. The direct medical expenditure included the cost of medicine, diagnostic tests, registration fees/doctor's fee, and cost of personal medical appliances (e.g., bedpan, thermometers, etc.). The indirect expenditure included the cost of transportation, lodging, food, income loss because of taking care of the child during hospital visit/stay and expenditure on other nonmedical expenses such as procurement of jar, plate, glass and mosquito repellent coil. Income loss of the parents/caretakers was estimated based on the self-reported daily income.

Data were collected while the patients were in OPD or in the ward, and they were also re-contacted on the 7th day for OPD cases and on the 7th and 14th day for IPD cases to know if any additional expenditure incurred posthospital visit. Case records for IPD cases and OPD prescriptions were referred for extracting relevant case-related information. A trained researcher was involved in data collection. The data collected was entered and analyzed by R software version 3.6.0 (Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: the R Foundation for Statistical Computing. http://www.r-project.org/). To determine the total cost of treatment for diarrhea paid by the people from their pocket, the analysis included the direct and indirect costs of treatment. The out-of-pocket health expenditure for the treatment of one episode of diarrheal illness was calculated both for OPD and IPD cases, and the same has been presented in the form of mean, standard deviation (SD), median with ranges and interquartile range (IQR). The overall out-of-pocket expenditure of the treatment has also been presented in a segregated manner, i.e., the cost of prehospital visit, during hospital visit, and posthospital visit.

The research protocol of the study was approved by the institutional ethical committee (Ref. no.: KIMS/KIIT/IEC/121/29.11.2016). Before the collection of data, informed consent was obtained from the parents/caretakers of all the children who were included in the study.


   Results Top


Among 60 outpatient study cases, 70% were male and 30% were female. Of this, 10% were from rural and 90% from urban areas. Out of 60 inpatient study cases, 67% were male and 33% were female and 53% of IPD cases were from rural and 47% were from urban areas. Majority of IPD cases (56.7%) were <12 months, whereas in OPD majority of cases (60%) were >24 months of age. The severity of cases at the time of reporting to hospital in IPD and OPD cases were 63.3% and 20%, respectively. The majority of cases stayed at the IPD (60%) for treatment was 4–6 days. Most of the cases (93.3%) were well at the time of discharge. Among the IPD cases, 51.7% and among OPD cases, 56.6% were vaccinated against rotavirus [Table 1].
Table 1: Sociodemographic profile of study children with diarrhea reported to the pediatrics out-patient and in-patient department

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The overall out-ofpocket expenditure for the management of one episode of diarrheal illness among under-five children in OPD and indoor includes prehospital, during hospital and posthospitalization (follow-up) cost. The median out-of-pocket health expenditure for management of one episode of diarrheal illness among OPD cases was Rs. 1,186 (IQR: Rs. 510) ranged from Rs. 705–Rs. 5740. Out of the median out-of-pocket expenditure, the direct and indirect expenditure were Rs. 778.50 and Rs. 407.50, respectively. Of the mean out-of-pocket expenditure, the direct and indirect cost was 55% and 45%, respectively. Within the direct cost in OPD, the major cost was due to expenditure on medicine (67%), followed by registration/doctor's fee (17%). In case of indirect cost, the major cost was on account of transportation (60%) followed by other nonmedical expenses (15%) and income loss of accompanying parents/primary caretakers (14%) [Table 2].
Table 2: Summary of direct and indirect expenditure for diarrheal illness in outpatient department (n=60)

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For IPD cases, the median out-of-pocket health expenditure for the management of one episode of diarrheal illness was Rs. 6385 (IQR: Rs. 5889) ranged from Rs. 2652–Rs. 24,299. Within the median out-of-pocket health expenditure, the direct and indirect expenditure were Rs. 3823 and Rs. 2237, respectively. Out of the mean out-of-pocket expenditure, the direct and indirect cost was 61% and 39%, respectively. Of the direct cost for IPD cases, the major cost was due to expenditure on medicine (34%) followed by bed charges (31%) and diagnostic tests (25%). Among the item of indirect cost, the major cost was on account of transportation (36%), followed by food (34%) and income loss of accompanying parents/primary care takers (26%) [Table 3].
Table 3: Summary of direct and indirect expenditure for diarrhoeal illness in in.patient department (n=60)

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[Table 4] indicates people spend even before visiting, during hospital and post hospital visit for the same episode of diarrheal illness both for OPD and IPD cases. The mean expenditure of prehospital visit, during hospital visit and posthospital visit for the management of diarrheal illness for OPD cases was Rs. 293 (SD: Rs. 194), Rs. 876 (SD: Rs. 534) and Rs. 204 (SD: Rs. 268), respectively. In case IPD, the mean expenditure of prehospital visit, during hospital visit and posthospital visit for the management of diarrheal illness was Rs. 352 (SD: Rs. 308), Rs. 7799 (SD: Rs. 5186), and Rs. 208 (SD: Rs. 300), respectively.
Table 4: Pre, during and posthospital visit expenditure due to diarrhoeal illness

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Among the indoor study cases, only 13% (8 cases) had some kind of health insurance coverage, which is negligible to cover the full treatment cost incurred. But none of the OPD cases had any kind of health insurance coverage.


   Discussion Top


As per the present study, the mean total expenditure for the management of one episode of diarrheal illness among IPD cases was Rs. 8,357 (SD: Rs. 5517). A multi-centric study conducted in 2008–2009 by CMC, Vellore, reported a figure of Rs. 6634 as cost of hospitalization for one episode of diarrhea in nonprofit referral hospital and Rs. 6071 in a private hospital. The figure for government hospitals was much less, i.e., Rs. 233.[10] The higher expenditure in our study may be on account of higher inflationary cost and hospital treatment policy. As would be expected, the expenditure of treating diarrhea in OPD was lower than the expenditure of treating diarrhea in IPD. A study conducted in Taiwan in the year 2004–2006 on rotaviral diarrhea among under-five children reported a higher total cost (medical and nonmedical costs) in IPD and OP cases as compared to our study.[11] In our study, the cost of treatment for one episode of diarrhea in OPD is approximate 1/5th of IPD expenditure. Only 13% of IPD cases had some kind of health insurance coverage, which is negligible to cover the cost of the treatment incurred. Consequently, people had to bear the full cost of the treatment of diarrhea. None of the studied OPD cases had any kind of health insurance coverage indicating the expenditure made from out-of-pocket. This highlights the need for increasing both public and private health insurance coverage.

The direct expenditure was higher than the indirect expenditure in IPD cases and medicine being the major cost component in our study. For the indirect costs in IPD cases, the major cost component in our study was on transport. A similar pattern in direct cost was reported by the study conducted by Joby Jacob et al. while estimating the cost of pediatric gastroenteritis cases at CMC Vellore, however in their study, the major component of the indirect cost was on food.[10]

In the case of OPD, the direct expenditure was also more than indirect and the major component of expenditure was on medicine and transport, respectively, in our study, which is similar to the findings of Joby Jacob et al. study.[10]

Although cost analysis studies are available on diarrhea, the comparison becomes difficult due to different methods adopted in different studies for calculation of treatment cost of diarrhea at different points of time, and at different types (public and private) and levels of health facility.

As per the 2014 World Bank data, 21.9% of Indians live below the poverty line where, water and sanitation are a problem.[12] Lack of access to safe, clean drinking-water and basic sanitation, as well as poor hygiene cause nearly 90% of all deaths from diarrhea, mainly in children.[13] While 89.9% of households of India have access to improved drinking water sources, however, 51.6% still lack of access to improved sanitation. Hand hygiene practices is poor in community level in India.[4] A study conducted by the WaterAid Indiarevels that among respondents who have a child under 5 years in their family, 26.3% washed hands before child feeding, 14.7% before breastfeeding, 16.7% after disposing of child faces and 18.4% after cleaning a child's bottom highlighting the huge gap in hygienic practices.[14]

A study at child day-care centers or schools reveals that there was a 31% reduction in the incidence of diarrhea in the group who received a handwashing promotion intervention.[15]

The present study highlights the very high out-of-pocket expenses incurred by the people on the treatment of diarrhea, which is largely a preventable illness. Focusing more on available preventive measures for diarrhea, i.e., improving access to safe drinking water and improved sanitation, promotion of hand hygiene in the community, enhancing community awareness, Vitamin A supplementation, breastfeeding promotion, rotavirus vaccination, and use of oral rehydration therapy would reduce hospitalization and the consequent cost.

Even those who are hospitalized, ensuring availability and accessibility to essential medicine and transfusion therapy, will further reduce the out-of-pocket expenditure. Speedy implementation of universal health coverage strategy by providing financial protection in the form of public and private insurance will further reduce the burden of out-of-pocket expenditure of the public.

A national rotavirus immunization program was estimated to prevent 65% of all rotavirus-related deaths and the economic burden of rotavirus-associated hospitalizations and outpatient visits among children aged <5 years in Iran. About 60% of this cost could be prevented through vaccination.[11]

John et al.,[16] in their study, have estimated that 11.37 million episodes of rotavirus gastroenteritis occur each year in India, requiring 3.27 million outpatient visits and 872,000 inpatient admissions when health access is unconstrained, resulting in a need for Rs. 10.37 billion each year in direct costs. An estimated 78,000 rotavirus-associated deaths occur annually, of which 59,000 occur in the first 2 years of life. Introduction of a rotavirus vaccine in the national immunization program would result in 686,277 fewer outpatient visits, 291,756 fewer hospitalizations, and 26,985 fewer deaths each year in India, assuming no indirect effects of the vaccine.[16]

The present study findings are important from the policy and management point of view. This type of costing study will have relevance to the financial protection policy (Ayushman Bharat) of the government of India.


   Conclusion Top


A considerable out-of-pocketeconomic burden is faced by the families for treating diarrhea in under-five children. Due to a lack of medical insurance, almost all the cost of diarrhea treatment was borne by the people from their pocket. The study findings recommend for appropriate policy for the provision of financial protection while seeking health-care services. Improved access to safe drinking water and improved sanitation, promotion of hand hygiene in the community, promotion of breastfeeding, use of rotavirus vaccine, ensuring availability and accessibility of essential drugs, and speedy implementation of universal health coverage strategies will have a significant impact in reducing hospitalization and out-of-pocket expenditure.

Acknowledgments

We acknowledge our sincere thanks to Prof (Dr) Gagandeep Kang, CMC Vellore for providing the financial and technical support to conduct this study. Also, our gratitude to Dr. Rishab Pugalia and Dr. Mirabai Das for data collection and technical help for preparing the manuscript. The authors are also thankful to all the patients and their parents for their cooperation.

Financial support and sponsorship

This study was funded by CMC Vellore.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Diarrhoeal Disease. WHO. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease. [Last accessed on 2019 Mar 19].  Back to cited text no. 1
    
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Diego G, Bassani PP. Causes of neonatal and child mortality in India: Nationally representative mortality survey. Lancet 2011;376:1853-60.  Back to cited text no. 2
    
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Kang G, Arora R, Chitambar SD, Deshpande J, Gupte MD, Kulkarni M, et al. Multicenter, hospital-based surveillance of rotavirus disease and strains among indian children aged 5 years. J Infect Dis 2009;200 Suppl 1:S147-53.  Back to cited text no. 3
    
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National Family Health Survey (NFHS-4). India. Mumbai; 2015. Available from: http://rchiips.org/nfhs/NFHS-4Reports/India.pdf. [Last accessed on 2019 Mar 19].  Back to cited text no. 4
    
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Government of India. Population Composition. Census of India. 2011:11-28. Available from: http://www.censusindia.gov.in/vital_statistics/SRS_Report/9Chap 2-2011.pdf. [Last accessed on 2019 Mar 19].  Back to cited text no. 5
    
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Out-of-Pocket Expenditure (% of Current Health Expenditure). Data. Available from: https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?end=2015&locations=IN&start=2000&view=chart. [Last accessed on 2019 Mar 19].  Back to cited text no. 7
    
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Kumar K, Singh A, Kumar S, Ram F, Singh A, Ram U, et al. Socio-economic differentials in impoverishment effects of out-of-pocket health expenditure in China and India: Evidence from WHO SAGE. PLoS One 2015;10:e0135051.  Back to cited text no. 8
    
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Sowmyanarayanan TV, Patel T, Sarkar R, Broor S, Chitambar SD, Krishnan T, et al. Direct costs of hospitalization for rotavirus gastroenteritis in different health facilities in India. Indian J Med Res 2012;136:68-73.  Back to cited text no. 9
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10.
Jacob J, Joseph TK, Srinivasan R, Kompithra RZ, Simon A, Kang G. Direct and Indirect Costs of Pediatric Gastroenteritis in Vellore, India. Vol. 642; 2016. Available from: https://www.indianpediatrics.net/july2016/642.pdf. [Last accessed on 2019 Mar 15].  Back to cited text no. 10
    
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Javanbakht M, Moradi-Lakeh M, Yaghoubi M, Esteghamati A, Mansour Ghanaie R, Mahmoudi S, et al. Cost-effectiveness analysis of the introduction of rotavirus vaccine in Iran. Vaccine 2015;33 Suppl 1:A192-200.  Back to cited text no. 11
    
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Poverty Headcount ratio at National Poverty Lines (% of Population) – India. Data. Available from: https://data.worldbank.org/indicator/SI.POV.NAHC?locations=IN. [Last accessed on 2020 Feb 19].  Back to cited text no. 12
    
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WHO. Water, Sanitation and Hygiene Interventions and the Prevention of Diarrhoea. WHO; 2015. Available from: https://www.who.int/elena/titles/bbc/wsh_diarrhoea/en/. [Last accessed on 2020 Feb 19].  Back to cited text no. 13
    
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Spotlight on Handwashing in Rural India Findings from a Study on Hand Hygiene Related Knowledge and Practices in Four Indian States 2 Spotlight on Handwashing in Rural India. WaterAid India; 2017. Available from: https://www.outlineindia.com/othermedia/1531392037. Hand-hygiene-study.pdf. [Last accessed on 2020 Feb 19].  Back to cited text no. 14
    
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Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA. Hand washing promotion for preventing diarrhoea. Cochrane Database of Systematic Reviews 2015. Art. No.: CD004265. DOI: 10.1002/14651858.CD004265.pub3.  Back to cited text no. 15
    
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John J, Sarkar R, Muliyil J, Bhandari N, Bhan MK, Kang G. Rotavirus gastroenteritis in India, 2011–2013: Revised estimates of disease burden and potential impact of vaccines. Vaccine 2014;32:A5-9.  Back to cited text no. 16
    



 
 
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