The cancer burden in India has more than doubled over the last two and a half decades, and this trend is expected to increase in the future due to many reasons, including demographic (mainly change in the age structure of the population) and epidemiological transition (from communicable to non-communicable), and increased case detection. According to recent estimates of incidence and mortality, more than a million new cases of cancer were reported in India that led to more than 700,000 deaths in 2018 alone. While, the growing burden of cancer cases in the country is a cause for concern for many oncologists, the varying cost of cancer care has made public health experts apprehensive. The recent National Sample Survey (NSS) 75th round conducted during July 2017–June 2018 has revealed alarming pictures associated with cancer care in India. Based on data recently released, we present major features associated with cost incurred on cancer care at the national and state levels including medical and non-medical expenditure and public–private differences.
Overall cancer care expenses in 2017-18
The survey included 1,200 cancer patients at different stages of cancer based on either known or suspected symptoms. All of them have used either inpatient care or outpatient care or both in the one year preceding the survey. At the national level, average total cancer care expenditure was around Rs 1,16,218. In private hospitals, the total cost of cancer care was estimated to be Rs 1,41,774, whereas it was comparatively lower at Rs 72,092 in public hospitals. The state wise pattern shows that the overall cost of cancer care in India varies from Rs 74,699 in Odisha to Rs 2,39,974 in the state of Jharkhand. In eight states, namely, Odisha, Tamil Nadu, Andhra Pradesh, Telangana, West Bengal, Chhattisgarh, Bihar and Haryana, the overall cost of cancer treatment was under Rs 1 lakh. However, cancer patients spent between Rs 1 lakh to Rs 1.5 lakh on treatment in Punjab, Karnataka, Gujarat, Kerala, Madhya Pradesh and Maharashtra. In Jammu & Kashmir, Uttar Pradesh, Rajasthan, Assam, Himachal Pradesh and Jharkhand, cancer treatment cost over Rs 1.5 lakh.
Share of medical and non-medical expenses
An important aspect that needs to be highlighted is the percentage share of medical and non-medical expenditure. About 90 per cent of the total cancer care expenses relate to medical care, which includes expenses on doctors’ consultancy, medicines, diagnostic tests, bed charges, and other medical services like blood transfusions and oxygen supplementation. The residual 10 per cent is on non-medical heads, which includes transportation, food, escort and transport for other family members. The state wise pattern suggests that in two states, namely Chhattisgarh and Bihar, non-medical expenses contributed to over 20 per cent of all cancer expenditure, whereas, in nine states―Odisha, Andhra Pradesh, Jharkhand, Kerala, Himachal Pradesh, Rajasthan, Tamil Nadu, Assam and Jammu & Kashmir, over 10 per cent of the expenses were on non-medical services.
Out-of-pocket expenditure in cancer care
The most worrying aspect of cancer care expenditure in India is high out-of-pocket expenditure (OOP). OOPs are defined as direct payments made by individuals to healthcare providers at the time of service use. This excludes any prepayment for health services, for example in the form of taxes or specific insurance premiums or contributions and, where possible, net of any reimbursements to the individual who made the payment. Nearly, 93 per cent (Rs 1,08,659 out of Rs 1,16,218) of all cancer care expenses were met through OOP in 2017-18. The state wise pattern revealed that in Bihar, Jammu & Kashmir and Assam, all cancer expenses were met from OOP, followed by Tamil Nadu and Himachal Pradesh (99 per cent). The lowest OOP expenditure on cancer care was observed in Haryana (76 per cent), followed by Jharkhand (78 per cent) Andhra Pradesh and Odisha (85 per cent).
Public-private difference in out-of-pocket expenditure
A contrasting pattern in cancer care cost has emerged with respect to public and private healthcare facilities. At the national level, the OOP in a public health facility was Rs 64,977, which was more than twice, that is nearly Rs 1,33,464 in a private health facility. There was considerable variation in terms of public and private OOP expenditure in cancer care across the major states. For instance, in Tamil Nadu, the out-of-pocket expenditure on cancer care in a public health facility was Rs 8,448, whereas it was Rs 2,49,086 in the case of a private health facility, which was nearly 30 times that incurred in a public health facility. In Telangana, Gujarat, Andhra Pradesh and Jharkhand, the OOP expenditure on cancer care in a private health facility was five times higher than that in a public health facility. On the contrary, the survey revealed that in Rajasthan and Bihar, the cost of cancer treatment was higher in a public health facility than in a private one.
Another interesting pattern that requires special mention is the variation in cancer care expenditure within public and private health facilities across the states. For instance in Tamil Nadu, Telangana and Andhra Pradesh, the OOP expenditure on cancer treatment was less than Rs 20,000 in public health facilities, whereas it was over Rs 1 lakh in Assam, Jammu & Kashmir and Rajasthan. Similarly, in a private health facility, OOP expenditure was less than Rs 80,000 in West Bengal, Bihar, Odisha and Chhattisgarh but it was more than Rs 2 lakh in Assam, Punjab, Tamil Nadu and Jharkhand.
It is evident that the cost of cancer treatment in India is largely met through out-of-pocket means. Considerable variations in cancer care expenditure across states and between public and private healthcare facilities is another matter of concern. Why does the cost of cancer treatment deviate significantly even in public health facilities in certain states? This needs further investigation. Non-medical expenditure associated with cancer care poses a significant threat to the poor in many states as any healthcare insurance scheme including Ayushman Bharat Yojana (ABY) covers only cost associated with medical expenses. All the figures presented here were prior to the launch of the ABY. Therefore, the impact of ABY on cost of cancer care could not be assessed using this round of NSS data. Recently, the National Health Agency has decided to revamp the cancer treatment packages under ABY and include all cancers and their treatment. We have to wait until the next round of NSS data is available to examine the extent to which the ABY has reduced OOP expenditure in cancer care at the national and state levels.
Dr Prashant Kumar Singh and Dr Shalini Singh are affiliated with Indian Council of Medical Research-National Institute of Cancer Prevention and Research, Noida