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Indian Journal of Community Medicine

Economic Cost and Consequences of Kala-Azar in Danusha and Mahottari Districts of Nepal

Author(s): S.R. Adhikari, N.M. Maskay

Vol. 30, No. 4 (2005-10 - 2005-12)

Abstract:

Research question: Is there accurate assessment of burden of disease? Hypothesis: There is inaccurate assessment of the burden of disease. Objective: Demonstrate underestimation in the assessment of burden of disease by examining the case of Kala-azar (KA) in Nepal. Design: A combination of cross-sectional survey and descriptive case study. Setting: Danusha and Mahottari districts of Nepal, over period of April to August, 2000. Participants: Eighteen KA affected households representing a cross-section of hospital admitted and treated patients. Statistical analysis: Tabular form for comparison. Results: The cost of a KA episode on households consumed almost two and a half times of total average annual per capita household income. This figure, however, masks the true burden of the disease. This is because fourteen of those eighteen households fell below the absolute poverty line where financing of the disease related costs had catastrophic consequences. This is especially true when the sampled households borrow from the informal sector moneylenders whose cost were more than three times greater than the formal sector, forcing them into a poverty spiral. Conclusion: This suggests that the standard measure of the economic burden of KA in Nepal has been grossly understimated. Key words: Assessment of economic burden, Direct and indirect cost, Kala-azar, Nepal.

Introduction:

It is essential to accurately assess the economic burden of disease to allocate scarce resources effectively and appropriate. In this regard, there have been a number of studies that have only assessed the economic cost of disease, most commonly of malaria, but have given limited examination to their economic consequences viz in Ghana1, both2 and in Sri Lankal3, for Nepal4 and South Africa5. This paper endeavors to show that simply examining the cost of disease, without giving due analysis to the economic consequences, gives a biased perspective of the burden of disease.

Unlike the above mentioned studies which examine Malaria, this paper focuses on Kala-azar (KA: visceral leishmaniasis), a disease caused by Leishmania donovani which is debilitating and fatal6, that has surprisingly received scant attention in the literature. This is all the more troubling since in Nepal, KA threatens over one quarter of the nation?s population7 mainly in the south-eastern portion of Nepal which border with India, with data from 1999-2000 showing a KA case incidence of 2.88 to 346.87 per 100,000 population and case fatality rate varying from 0.84 to 1.75 percent, with both the parameters revealing a rising trend8. These suggest that KA in becoming a problem in the country and thus, it is essential to accurately assess the economic burden to households (HH) of the disease, to assist the policy makers for making suitable decisions.

The objective of this study, therefore, was to fill this gap by examining the economic burden of KA to HH in Nepal and to demonstrate that standard measures significantly understimated it. For this study, cost of illness approach was adopted to analyze the economic burden of KA to HH. The findings presented in this paper are from a survey of a crosssection of KA affectd HH located in two of the thirteen KA prone districts in Nepal, namely the Dhanusha and Mahottari District (DMD), all of which border India7. Due to the descriptive nature of the study, it is important to highlight its general limitations: first, the study is only indicative, limited to 18 KA patients in DMD; second there are systemic data problems and general difficulties associated with a developing country. Nonetheless, the precise methodology used in this study captures the cross-section of the KA population in DMD, allows for ease in replicability, and is suggestive of the burden and consequence of KA on HH in those districts.

Materials and Methods:

Study areas and population : The study focused on the two low-lying Nepalese districts of Dhanusha and Mahottari which border with India, and are composed of one municipality and 101 Village Development Committees (VDCs) for the prior and one municipality and 76 VDCs for the later district. The population of DMD, according to a 1991 census9, was respectively 543,672 and 440,146. Further, an equivalent level of human development exists with Dhanusha ranked 33rd while Mahottari ranked 38th in the Human Development Index among all districts of the country Nepal10. Given the population in DMD, a list of the total pupulation of KA patients was constructed from the hospital record of those admitted for KA treatment during months of Baishak of Bhadra, 2057 BS of the Nepali calendar which is approximately equivalent to the period of April to August, 2000 AD. It should also be noted that in DMD there are only two institutions that diagnose and treat KA, namely Janakpur Zonal Hospital, in the Dhanusha District, and Mahottari District Hospital in the Mahottari District.

Method of Sampling : The study covers only in small sample size and reflects a cross-section of cases from the hospital admitted KA patient population in DMD. This was constructed by first grouping the KA patients by geographical area to either urban or rural and second, then randomly selecting 18 KA patients and categorizing them further into male, female and child (below 15 years of age) KA patient. The purpose of this later categorization was to capture a cross-section of KA patients and reveal the similarities (or differences) and tendencies in the burden of KA by patient type of HH. This final selection is represented in the table below.

Table I: Selection criteria for KA HH in selected area of DMD.

Selected area M F Children Total
Jaleshwor 3 2 3 8
Janakpur 7 3 6 16
Mahendranagar/Sakhuwa 3 2 10 15
Ekdara Bela 7 3 1 11
Samsi 5 3 4 12
Total 25 13 24 62

Urban category: 2 male, 2 female and 2 children will be randomly selected.
Rural category: 4 male, 4 female and 4 children will be randomly selected.
Source: Patient list were obtained from Janakpur zonal Hospital and Mahottari District Hospital during mid April to mid September during which systematic hospital records were available.

Method of Data Collection: Having identified the sample KA patients the next step was to extract the necessary information. This was achieved through structured questionnaires to KA HH. It should be noted that local health workers were used to facilitate location of identified KA patients due to the generalized nature of the addresses in the medical records. In the event that it was impossible to meet the KA patient and HH, or if any KA HH members were not able to provide required information, then another KA HH was selected from the same group, in its place.

Results:

Demography and income patterns: Survey results show that the average KA HH size was 8, which is higher than the national average of 5.6 (population census, 1991). The economically active population (15-59 age groups) found to be only 47 per cent indicating a high dependency ratio in the sample KA HH. Likewise 61 per cent were found to the Hindus while 39 percent were Muslims with most of the settlements clustered rather than scattered based on their ethnic/religious characteristics. A number of observations can be made for the income patterns on the sampled KA HH.

First, agriculture was the main source of income for most of the sampled KA HH with one KA HH totally dependent on agriculture; twelve KA HHs depended both on agriculture as well as other sources to supplement their income while five KA HH had no agricultural sources of income. Second, another major source of earning for most of the KA HHs was through wages which acted as a supplement to agriculture income. The wage earnings were in the agriculture sector where workers were either paid in kind (i.e. paddy, pulses, etc.) working in the adjoining villages or traveling to far off places, like Bihar and Punjab of India, during plantation and harvesting to take advantage of the higher relative wage rates. Lastly income in the sampled KA HH was also supplemented by small-scale trade, service and repair works in the urban and semi-urban area such as through bicycle repair as well as selling fuel wood etc.

From these income patterns, the total average income for the 18 sampled KA HH were calculated which are presented in the table II.

Table II: Average income level of sampled KA HH.

Category Average
HH annual
income
Average
per capita HH
income Rs.
% of HH
below
poverty line
Rural 32980 4147 97
Urban 66888 10217 50
Total 44283 6170 77
Male 58579 7980 -
Female 37680 5632 -
Children 36590 4899 -
Total 44283 6170 -

Note: * Poverty line income = Rs. 4404 at 1996 constant price;
**The percentages are taken where 11 of 12 rural HH are below the poverty line, 3 to 6 urban HH are below the poverty line thus in total 14 of 18 HH were below the poverty line 3;
- indicates that no figures are available;
Source: Field survey.

By using the absolute poverty line income in Nepal as proposed in His Majesty?s Government of Nepal?s 9th Development plan11, which is Rs. 4404 at constant price of 1996, the proportion of sample KA HH under absolute poverty line was 77.78% or 14 of 18 KA HH. To put this figure of absolute poverty in perspective at the then exchange rate of about Rs. 56.5 for 1 USD, this is equivalent to USD 78.0 annually! Importantly, income was found to be lower in rural areas than in the urban areas, consistent with the national scenario and suggesting greater income opportunities and larger inequality exists in urban vis-a-vis rural areas.

KA Episodes and treatment : KA episodes occur year round since KA symptoms take a few weeks, to a few months, to appear after having been infected by the carrier sand fly. In DMD, occurence of KA symptoms initially led individuals to either consult quasi- (or 'quack') doctors or faith healers, however with no improvement from 'treatment', admission to the nearest hospital was sought. Hospital admission was only given once bone-marrow aspiration tests revealed the presence of Leishmania-Donovan bodies. Once admitted the patients were then administered Fungizone as an anti-KA drug intravenously with 5 per cent dextrose solution, for treatment of generally 15-20 days. After adequate doses of Fungizone had been administered, the patients were discharged with advice to visit the hospital after one month to again test for the presence of KA. The KA patients generally required one to three months for fully recovery although this being faster in children, During the period, the caretakers (usually spouses, parents or relatives) had to given up their work to look after KA patients. Also, some of KA patients were found to be prone to other diseases, such as turberculosis, due to their weakened immunity resulting from recovery of KA episode. These costs relating to an episode of KA can be categorized as Direct (i.e. quantifiable or direct pay) and Indirect (i.e. nonquantifiable or opportunity cost). Cost and are discussed below:

Direct costs of a KA episode: The cost direct cost of a KA episode is comprised of a number of components whose summary statistics are given in Table- III.

Table III: Components of and Total average direct cost of KA HH (in Rs.)

Category Medical cost Food expenses Trans
portation
cost
Other
costs
Total
average
direct
cost
Rural 3915 (53) 2343 (31) 455 (6) 620 (8) 7334
Urban 3818 (65) 1098 (18) 200 (3) 706 (12) 5825
Total 3905 (56) 1928 (28) 370 (5) 648 (9) 6853
Male 2992 (45) 2308 (35) 443 (6) 814 (12) 6559
Female 5875 (61) 2366 (24) 403 (4) 894 (9) 9539
Children 2847 (63) 1110 (24) 264 (5) 238 (5) 4460
Total 3905 (56) 1928 (28) 370 (5) 648 (9) 6853

Source: Field survey; Note : Figures in parenthesis indicate percentage of Average Total Direct Cost.

The largest direct cost of the Total Average Direct Case (TADC) was the "Medical cost". While the anti-KA drug Fungizone is free of cost in government hospitals, the patients themselves had to bear the medical costs involved in the process of treatment such as for drugs and bone-marrow test, medical equipment like syringes and IV-sets, patients registration fee etc. Also, it is important to note that this figure was significantly higher in case of HH with female patients. This is attributed to females reluctance to go to hospitals, with first preference to so-called "quacks", which resulted in non-suitable diagnosis and, frequently, in treatment failures. It has also been suggested that the local environment may not have been hospitable to females thus making them reluctant to go to hospitals.

The second largest component of the TADC was the 'Food expenses' which involved both the purchase and preparation cost of food items for the patient and the caretaker with care taken to reduce the problem of double counting of expenses. This differed from urban and rural households since rural patients were forced to purchase foodstuff and provisions while urban patients similar for male and female patients and significantly lower for children, due to lower intake.

The third largest component of the TADC was the 'Transportation cost' which included round trip transportation cost for the patient and caretakers in course of obtaining diagnosis and treatment. The average transportation cost for a single episode of KA differed significantly among the rural and urban category since hospitals were located in the urban ares forcing rural patient to travel great distances. While transportation cost was similar for make and female patients, it was significantly lower for children due to concessional transportation expenditures.

The smallest component of the TADC was the "Other costs" which included non regular food expenses consumed by the KA patient for recovery after having been discharged from the hospital. This cost was relatively lower for the rural, compared to the urban, category due to both easy availability nutritioinal items in the rural areas. As above, male and female KA patient results are similar although children patients had significantly lower cost.

In sum, the TADC to KA HH was Rs. 6853 per patient that was approximately 110% of annual per capital HH income. However, this cost was significantly larger for the rural vis-avis the urban patient category due to the components of cost related to transportation and magnified by the relative income inequality. In other words, the rural HH over one and three quarters, i.e. 176.8%, of their annual per capital HH incomes as direct cost, on an average, in the treatment of a single KA episode while the urban HH spent less than a third of this, i.e. 57% of their annual per capita HH incomes. It was also observed that costs varied between adult patients regardless of sex and children, which was due to the different intakes of food as well as concession costing in transportation.

Indirect costs of a KA episode: The indirect cost of KA captured the opportunity cost (i.e. the method of valuing time lost) of both the KA patient and the caretakers in the economically active age group (15.59 years) as well as school days lost to children below 15 years age. The span of time lost included time lost due to disability after appearance of KA symptoms, time lost treatment and time lost during recovery period. It should also be noted that the opportunity cost of work days lost was measured in terms of the marginal productivity during of labor expressed as the prevailing local market wage rate. Likewise, if the wage was paid in kind, this opportunity cost was converted into monetary term on the basis of prevailing market rate. The indirect costs are represented in the Table IV:

Table IV: Average time lost by patients and caretaker (in person days)

Category Patient Caretaker Total times
loss of HH
Male Female Total
Rural 127 49 47 80 185
Urban 97 48 53 84 163
Total 117 48 49 71 178
Male 153 50 71 101 225
Female 135 61 37 76 212
Children 62* 36 36 67 67**
Total 117 48 49 71 178

*School days lost;
**Time lost by caretakers only;
Source: Field survey

The average time lost for KA patients and caretakers were 117 and 83 person days respectively with the average total time lost of the KA HH was 178 person days; the light differences are due to defects of the averaging, not with the figures being in error. In the case of male and female caretakers the result indicated that both devoted almost equal time regardless of patient type. In case of the caretakers, the average time lost was similar for both the rural and urban category although the somewhat greater time lost for rural versus urban caretakers was attributed to greater traveling time as urban family members brought meals and snaks etc. from home. Among the different patient categories, the average total time lost was greatest in case of male patients followed by female patients and children patients. The significantly lower time lost for children KA was due to the relatively quicker diagnosis and treatment. The reason for greater total average time lost on the part of the male KA patient was due to the greater number of caretakers involved, generally the patient's wife and some other male for support, in assisting the recovery process. In case of the children KA patients, the male and female caretakers spent almost equal time.

The average opportunity cost of HH for a single episode of KA was found to be Rs. 8914. Though the wage rate in the urban area was relatively higher than some of the rural areas, the effect of higher wage rate, and thus higher opportunity cost, has been offset by relatively higher time loss in rural area. Among the different patient categories, the average opportunity cost was found highest in male patients followed by female patients and children patients. For the later, the time lost was not emphasized as they were not considered economically active, even though there are important implications for the country's long-run human capital development.

Total cost of a KA episode: The total cost of a KA episode can represented as the sum of the direct and indirect costs which is represented in the Table-V.

Table V: Average direct and indirect cost of KA HH (in rupees).

Category Total
Average
Direct
Cost
Total
Average
Indirect
Cost
Total
Average
Cost
Rural 7367.41 9139.41 16506.82
Urban 5825.00 8461.67 14286.67
Total 6853.27 8913.50 15766.77
Male 6559.50 13208.83 19768.33
Female 9539.83 10132.08 19671.91
Children* 4460.50 3399.58 7860.08
Total 6853.27 8913.50 15766.77

*Indirect cost involves only caretakers time;
Source: Field survey.

The average cost of a KA incident was thus Rs. 15,766.77, which is almost two and a half times of total average annual per capital HH income. The figure suggests that the direct cost may not reflect even one half of the total picture.

Financing of a KA episode: The cost of a KA episode were finanaced either by tapping financial resources through selling land, cattle or gold, which was true for five of sampled KA HH, or borrowing money, which was true for thirteen our of eighteen HHs that were limited to those HH below the absolute poverty line. Among the borrower KA HHs, one had borrowed from the bank at annual 18 percent interest rate, one had borrowed from both the bank at annual 19 percent interest rate and from the local money lender at annual 60 percent interest rate while the remaining eleven HH had borrowed from the local money lender at at annual 60 percent interest rate. The average among of loan borrowed was Rs. 5450, with the average interest cost to be paid during the reference period was Rs. 1148; for computation, interest cost was calculated for outstanding debts from the date of admission in hospital to th date of field survey with the time span being approximately five months. Given, the real possibility of loan default since sampled HH lack other productive assets that yield them regular income flows even during inability to work, the burden of financing a KA episode to HH is catastrophic.

Discussion:

The result from the focused descriptive study for the sampled 18 KA HH in DMD suggests that the direct cost of an episode of KA accounted for approximately 110% of annual per capita HH income. However, this figure more than doubled the cost of a KA episode, in terms of annual HH income, when looking at the total cost of HH, i.e. the sum of direct and indirect cost : summary observations are that:

  • There was significant difference between urban and rural HH with respect to direct cost from a KA episode.
  • There was insignificant difference in direct cost of a KA episode between male and females although this was relatively smaller for children.
  • There was insignificant difference between urban and rural cost for HH although this was significantly higher, in terms of patient days lost, for rural vis-a-vis urban patients.
  • There was higher indirect cost for males than females since males were the main income earners, which was mainly physical labour. Also, there were significant school days lost leading to deterioration in human capital investment.

These aspects suggest significant total cost of a KA episode on HH income of the 18 HH in DMD which asymmetric effects resulting from being either situated in rural or urban areas or, to a lesser degree, for the KA patient being male, female or child.

For assessing the consequence of the disease in DMD, it is important to examine the nature of the sampled HH. From the statisties described earlier, 14 of 18 KA HH fell below the absolute poverty line. Further, of the remaining 4 KA HH, many were not to far from the absolute poverty line. In other words, the common characteristic of the HH is their povertyafflicted nature. This makes their situation precarious where the shock to income flow of disease expenditure, forces them to obtain additional funds, which for the majority of HH takes the form of borrowing. As most of the borrowing occurred through the informal sector moneylenders who charge extremely higher interest rates, this increases the probability of default. Since a default has to be repair, the debt is rolled over and snow-balls the financial burden. This is a devasting blow for the poor HHs with an in temporal (carry over) effect of the debt which will be passed o across generations (i.e. inherited). This suggests that the economic consequence of KA on affected households is fatal and leads to propagation of poverty which detracts from their productive contribution to economic development of that area. In other words, taking these considerations into account suggests that the economic burden of KA to HH has been grossly underestimated!

Conclusion:

The direct and indirect cost of a Kala-azar episode on households were examined whose results indicate that it consumed almost two and half times of total average annual per capita household income. This figure, however, masks the true burden of the disease Most (75%) of households fell below the absolute poverty line suggesting that the poor were suceptible to the disease and that, due to their subsistence income situation, financing of the disease related costs had catastrophic consequences. This is espicially the case when the sampled households turn to the informal sector moneylenders for borrowing whose interest rate charges were more than three times greater than the formal sector, forcing them into a poverty spiral. This suggests that the standard measure of the economic burden of Kala-azar in Nepal has been grossly underestimated.

Nonetheless, by ending, some preliminary policy recommendations are put forward based on the indicative results: first the Nepalese government must put forward appropriate and effective policies for combating KA with one avenue being through greater education to increase awarenes of KA preventing and treatment; this is consistent with12 and13; a second a avenue may be for greater facilities in hospital to reduce the direct cost of KA treatment with methods and facilities to mitigate transporation cost for rural HH; a final avenue may be for having a viable system for financing the cost of the disease such as health insurance to the poor.

Acknowledgment

We would like to thank, Nimal Gunatilleke, Kevin Frick and Anne Mills for their precious and valuable comments and Anduka M. Wijeyaratne for welcome encouragement. We would also like to mention that this paper is based on study financed and technically assisted by the Environmental Health Project (EHP-Nepal) through USAID funds.

References:

  1. Asenso-Okyere, W.K. and Janet A. Azator. Household cost of seeking malaria care. A Retrospective Study of Two Districts in Ghana Soc Sci Med. 1997; 45(5): 659-67.
  2. Konradsen, Flemming, Wim Van Der Hoek, Priyanie H. Amerasinghe and Felix P. Amerasinghe. Measuring the Economic Cost of Malaria to Household in Sri Lanka. Am J Trop Med Hyg 1997; 56(6): 656-60.
  3. Konradsen, Flemming, Wim Van Der Hoek, Priyanie H. Amerasinghe, Felix P. Amerasinghe and K.T. Fonseka, Household responses to malaria and their costs: a study from rural Sri Lanka. Transactions of the Royal Society of Tropical Medicine and Hygiene 1997; 91: 127-30.
  4. Mills, A. The economic consequence of malaria for households: a case-study in Nepal. Health Policy. 1994; 29: 209-27.
  5. Tren, Richard. The Economic Cost of Malaria in South Africa 2000; http://www.iea.org.uk/env/malaria.htm.
  6. Wijeyaratne, P.M., L.K. Jones Arsenault, C.J. Murphy. Endemic disease and development: the leishmaniases. Acta Tropica 1994; 56: 349-64.
  7. Bastola S.P., P. Karki, Suman Rijal and Akshaya Gautam (ed.) Kala-azar in Nepal: Principles, Practice and Public Health Pespective, Kathmandu: Epidemiology and disease Control Division, Department of Health Service/MoH, Kathmandu, B.P. Koirala Institute of Health Sciences, Dharan and World Health Organization, Country Office/ Nepal.
  8. His Majesty's Government. Ministry of Health, Department of Health Services. Annual Report 2000, Kathmandu Nepal.
  9. His Majesty's Government, National Planning Commission Secretariat, Cental Bureau of Statistics, Population Census, 1991: Kathmandu: Ramshah Path.
  10. Nepal South Asian Centre. Nepal Human Development Report 1998, Nepal South Asian Centre, 1998; Kathmandu, Nepal.
  11. His Majesty's Government, National Planning Commission Secretariat. The Ninth Plan (2054-2058). Kathmandu: (2054 BS- equivalent date 1997 AD).
  12. Filmer, Deon and Lant Pritchett. The impact of public spending on health; does money matter? Social Science and Medicine, 1999; 49; 1309-23.
  13. Adhikari, Shiva Raj, Nephil Matangi Maskay and Bishnu Prasad Sharma - Nepalese Health Policies: Some Observations from an Economic Development Perpective. Economic Review (of Nepal Rastra [Central] Bank), April 2002; Occasional Paper Number 14; 55-72.
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