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 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 4  |  Page : 409-412  

Cost of treatment and consequences for chronic hepatitis B and C virus infection at a tertiary care hospital in Delhi

1 Senior Resident, Government Medical College, Chandigarh, India
2 Professor and Head, Department of Planning and Evaluation, The National Institute of Health and Family Welfare, New Delhi, India
3 Assistant Research Officer, Department of Statistics and Demography, The National Institute of Health and Family Welfare, New Delhi, India

Date of Submission05-Aug-2019
Date of Decision14-Oct-2019
Date of Acceptance31-Jul-2020
Date of Web Publication11-Dec-2020

Correspondence Address:
Vijay Kumar Tiwari
Prof. and Head, Department of Planning and Evaluation, Dean of Studies, The National Institute of Health and Family Welfare, Munirka, New Delhi - 110 067
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_356_19

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Patient living with chronic viral hepatitis in India faces the high cost of treatment and impoverishment. The present study is aimed to assess the cost of treatment and economic consequences among chronically infected viral hepatitis patients at a tertiary care hospital in Delhi. The descriptive cross-sectional study was undertaken during October 2016–January 2017. Three hundred and eighty-nine participants were interviewed through a schedule for variables and assessing both direct and indirect costs. Costs of hospital expenditure were extracted from records available with patients or databases of the hospital. The average outpatient expenditure and the inpatient costs were calculated. Direct nonmedical costs were also included. The analysis revealed the total cost of treatment ranged from Rs. 16,600/-to Rs. 1,709,000/-with a median of Rs. 193,500 per year. The cost of treatment increased with the severity of the disease. The cost of treatment led to impoverishment in 52.8% of families and imposed a substantial economic burden and consequences on the patients.

Keywords: Catastrophic expenditure, cost of treatment, hepatitis C virus, viral hepatitis B

How to cite this article:
Balasundaram P, Tiwari VK, Sherin Raj T P. Cost of treatment and consequences for chronic hepatitis B and C virus infection at a tertiary care hospital in Delhi. Indian J Public Health 2020;64:409-12

How to cite this URL:
Balasundaram P, Tiwari VK, Sherin Raj T P. Cost of treatment and consequences for chronic hepatitis B and C virus infection at a tertiary care hospital in Delhi. Indian J Public Health [serial online] 2020 [cited 2022 Aug 12];64:409-12. Available from:

   Introduction Top

Hepatitis B (HBV) and C (HCV) virus infections are major threats to global public health.[1],[2],[3] Chronic HBV and HCV infections are responsible for nearly 57% of liver cirrhosis cases and 78% of hepatocellular carcinomas (HBV 53%, HCV 25%), the third-most common cause of cancer deaths worldwide.[4],[5] Approximately 3% of the world's population (170–200 million people) is chronically infected with HCV, and almost 500,000 people die each year, mostly in lower-middle-income countries, from complications secondary to HCV infection.[6],[7],[8]

The HBV is often transmitted vertically from infected mothers to their offspring, horizontally in early childhood through exposure to infected children, donor blood transmission, unsafe therapeutic injection practices (and other healthcare-related procedures), or through sex.[9],[10],[11]

India accounts for a large proportion (10%–15%) of the worldwide HBV burden[12] and has approximately 11% global burden of the chronic HBV-infected people.[13] Population prevalence of chronic HBV infection in India is around 3%–4%, and chronic HCV infection is around 1%.[14] Outbreaks of acute and fulminant hepatitis B still occur mainly due to improperly sterilized needles and syringes.[15],[16]

A large majority of HCV patients are left deprived of a cure to HCV infection.[17] The HCV infection remains asymptomatic until the development of decompensated cirrhosis. The nature of lasting and recurring conditions from HBV/HCV infection compounded by the frequency of delayed consultation imposes a heavy economic burden on patients with HBV/HCV and their families. Due to the chronic nature of diseases, many patients push to poverty.[18] The cost-of-illness studies play a role as they might be used as references for resource allocation, development of policy, and for the determination of the cost-effectiveness of new therapies.[19]

Estimating costs of illness due to chronic HBV/HCV infections is an important public health issue. However, the exact total economic burden in India has not been well characterized. Some studies have investigated cost-effectiveness/cost benefits for various therapies of hepatitis, but not a single published study on the cost of illness of chronic HBV/HCV could be found in India. In this context, the present study was conducted to assess the economic burden and ability to pay for the treatment of Chronic HBV/HCV at a tertiary care super specialty hospital in Delhi.

   Materials and Methods Top

A descriptive cross-sectional study was conducted at one of the apex tertiary care government hospitals in Delhi during October 2016–January 2017, among patients chronically suffering from HBV/BCV infections.

The inclusion criteria for the study participants were those patients diagnosed with HBV or HCV infections for >6 months and belonging to age between 18 and 75 years. Patients with acute viral hepatitis, hepatitis B/C with cancer, or coma were excluded.

The sample size was estimated at 5% level of significance, considering the proportion of patients facing economic vulnerability (p) = 0.5 in the absence of information from prior studies, 95% confidence interval, and 5% allowable error. In addition, an anticipated 10% nonresponse was also considered, and finally, a sample of 422 patients was included.

All eligible indoor patients were included, and the rest of the study participants were selected from outpatient department (OPD) through systematic sampling.

The data were collected by interviewing the subjects with the help of a pretested structured interview schedule. The interview schedule included data on recalling information about the condition and use of inpatient and outpatient services, direct and indirect cost of treatment as well as personal characteristics (such as age, gender, education, occupation, and insurance), disease status (disease stage, the elapsed time of diagnosis, follow-up results, and symptoms), prescribed drugs.

To estimate costs, many human capital methods,[20] which decomposes costs into direct categories, such as medical expenses (number of physician visits, levels of facility use, types of checkups, prescribed drugs, hospital stay, investigations, etc.), and indirect categories, such as lost earnings of the patient as well as attendants from family, costs of travel and accommodation and meals costs, etc., The billing system and patient records were used as the data source for direct medical costs. Other services used outside the health system were also taken into account. The cost incurred at the hospital and cost incurred before coming the hospital was considered and added to estimate expenditure till January 2017 to assess the burden of treatment.

The outdoor cost of expenditure was calculated by dividing the median outdoor cost of expenditure by median family income. The indoor cost of expenditure was calculated by dividing the median indoor cost of expenditure by median family income. Average spending on indoor and outdoor cost of expenditure was calculated by dividing the sum of the median of outdoor coast and indoor cost of expenditure by median family income.

Before interview, the study participants were briefed about the purpose of the study and their informed consent obtained. Ethical approval was granted by the institutional ethics committee, vide F. No 2-16/2015-Acad dated 5.7.2016 and vide F.25/5/64/ILBS/AC2014/1331 dated 6.10.2016.

After scrutinizing for accuracy and completeness of data, a total of 389 (350 outpatients and 39 inpatients) interview schedules were included in the final analysis. The data were analyzed using SPSS Version 23.0 (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). Data were presented in tables calculating percentages, range, median OPD, median indoor, and total median costs. Chi-square test of association was applied.

   Results Top

In the study, of 389 patients, 76.8% were male and 23.2% were female patients. Only 4% of patients had Below Poverty Line (BPL) card. The median household yearly income was Rs. 360,000. Around 13.9% of respondents had a history of receiving blood.

Among 389 patients, the majority were suffering from HBV (334, 85.9%), 49 (12.6%) by HCV, and only 6 (1.5%) by both HBV and HCV. Out of total HBV and HCV-infected patients, 73.1% and 46.8%, respectively, were only serology positive, and the rests were severely affected with cirrhosis [Table 1]. The overall median cost of treatment according to type and severity of the disease is presented in [Table 1], and clearly cost of treatment increased with severity, both for HBV and HCV.
Table 1: Distribution of patients according to type and severity of disease and overall median cost of treatment (n=389)

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[Table 2] describes the detailed cost of treatment for chronic HBV/HCV patients. Overall for all 389 patients, the median yearly cost of treatment was Rs. 193,500; while among 382 patients attending OPD median cost of treatment was Rs. 72,800, and for 39 indoor patients, the median cost was Rs. 55,600/-.
Table 2: Cost of treatment of chronic hepatitis patients according to various nature of service categories (n=389)

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Only about a quarter of patients (23%) paid through insurance, and rest had to pay from their pocket. Moreover, around 97% of patients did not have BPL card, so they could not get treatment on subsidized rates. On the interview, 81% of respondents opined that they were financially affected in one way or another due to the high expenditure on the treatment. Further analysis revealed that about one-third of the patients had to spent 40% or more of their family income on treatment and two-third of the patients had spent <40% of their family income on treatment.

Opinion of patients on economic consequences/hardships faced by them due to high cost of treatment was solicited from patients. Varied consequences were faced by the patients, the commonly encountered consequences were-mortgaging assets (21.3%), selling of assets (19.3%), cut on food expenditure (15.2%), loss of job (6.2%), stopping schooling of children (3.1%), and postponing marriages in the family (2.8%). Overall, 57.8% of respondents opined they had been experiencing impoverishment in the family due to the cost of treatment for their illness.

   Discussion Top

In India, even as many states have a high prevalence of HCV infection, there is a scarcity of organized data on the cost of illness, making it difficult to perform a comprehensive and uniform cost-of-illness study regarding HBV/HCV infection. Therefore, 'out of pocket expenditure' by patients is used to assess the burden of the cost of illness. Our findings show that the total expenditure incurred for the treatment of HBV/HCV ranges from Rs. 16,600/to 1,709,000/-with a median of Rs. 193,500.00/-per year and cost of treatment increased with the severity of the disease. Our study found that around 80% of patients were financially affected; only by 23% of patients paid through insurance; about 40% of patients had to sell/mortgage their assets. The whole findings indicate a huge financial burden in the absence of any protection mechanism and subsidized treatment by the government in the apex tertiary care treatment hospital. Comparable studies are very limited. Few studies are available showing the high cost of treatment. A study conducted in Shandong China[21] found that the direct cost in US dollars for acute hepatitis B, severe hepatitis B, chronic hepatitis B, compensated cirrhosis, decompensated cirrhosis, and primary liver cancer was $2954, $10,834, $4552, $7400.28, $6936, and $10,635, respectively. These costs ranged from 30.72% (for acute hepatitis B) to 297.85% (for primary liver cancer) of the average annual household income. Even for patients with health insurance, the direct out-of-pocket cost of all HBV-related diseases except acute hepatitis B exceeded 40% of the patient's disposable household income, making it a catastrophic expenditure for the household. The study concluded that hepatitis B imposes a considerable economic burden on a family.

Many of the cost of illness studies[22] estimated only direct costs related to the disease, excluding indirect costs such as loss of productive job and transportation fees due to absent or incorrect data. Ki et al.[23] found that costs per patient during the study period were $19,743 in those who underwent antiviral therapy, while the costs in those who did not undergo antiviral therapy were $3126. A substantial proportion (78.5%) of costs in patients who received antiviral therapy was incurred on drugs. However, 37.2% of the total costs were incurred on drugs other than antiviral agents in those who did not undergo antiviral therapy. The message emerged that cost-of-illness study is the just estimate of immediate costs, and it might be addressed by another kind of cost study whether antiviral treatment-related high costs could lower overall costs in long-term outcomes.

Due to the chronic nature of diseases, patients had to spend huge money on the indirect cost, which always underreported. While the calculation of total cost, many times, we had to rely on recall-based prior treatment expenditure details that may have affected the accuracy of the total cost.

The high cost of treatment borne by the patients in the absence of subsidized treatment/reimburse mechanism is bound to cause impoverishment in families. Targeted screening facilities at primary health centers/community health center level need to be strengthened under the “National Viral Hepatitis Control Program” and to provide advance treatment on subsidized rates to noninsurance patients.


The authors are thankful to the Director, ILBS for giving permission to conduct the study at the ILBS hospital.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2]


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