Heart failure (HF) is a complex and chronic clinical condition in which the heart is unable to pump blood efficiently to meet the body’s needs. It is not a single disease but a syndrome that develops due to underlying cardiovascular conditions such as coronary artery disease, hypertension, or cardiomyopathy.
Globally, heart failure affects an estimated 26 million people, with its burden rising steadily, particularly in low- and middle-income countries (LMICs). In India, the scale of the problem is equally concerning. Heart failure accounts for nearly 1.8 million hospitalisations every year and places immense pressure on an already stretched healthcare system. The disease often requires long-term management, repeated hospital admissions, and continuous medication, making it not just a medical challenge but also a significant economic burden for patients and their families.
A new multicentre study published in the journal Global Heart by researchers from the Sree Chitra Tirunal Institute of Medical Sciences and Technology in Thiruvananthapuram sheds light on this financial strain. The findings reveal a stark reality: managing heart failure in India largely depends on out-of-pocket spending, with only about one in three patients having any form of health insurance.
What the study found
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The study was conducted across 21 hospitals in different regions of India to capture a diverse and representative sample. Researchers recruited 1,859 heart failure patients and collected detailed clinical and economic data using structured questionnaires.
As noted in the study, “We recruited HF patients from 21 hospitals across India, selected to reflect regional diversity and varying stages of epidemiological transition.” The average age of participants was 55.9 years, which is notably younger than patients in Western or Chinese registries, highlighting how the disease affects Indians during their most productive years.
One of the most striking findings was the low level of insurance coverage. Only 32.2% of participants reported having any form of health insurance, leaving nearly seven out of ten patients financially unprotected.
The financial burden on patients was substantial. The study found that the average annual out-of-pocket (OOP) expenditure was Rs 1,06,566, accounting for 92.6% of total health spending. This means that the vast majority of treatment costs are borne directly by patients and their families.
The economic impact extended beyond medical bills. About one-third of individuals (32.3%) and households (36.2%) reported a decline in monthly income following a heart failure diagnosis. This drop in income is often due to patients being unable to work or caregivers having to reduce their working hours.
The study also highlighted the prevalence of catastrophic health spending (CHS) and distress financing (DF). Catastrophic health spending refers to healthcare costs that consume a large portion of a household’s income, while distress financing includes borrowing money, selling assets, or taking loans to pay for treatment.
According to the findings, “Catastrophic health spending (CHS) and distress financing (DF) were observed in 37.7% and 17.7% of the households, respectively.” In simpler terms, nearly two out of five households faced severe financial strain due to heart failure.
Insurance coverage, although limited, did offer some protection. Among insured patients, CHS and DF were lower, 30.8% and 13.6%, respectively, compared to 40.3% and 18.9% among uninsured patients. However, the study points out that, “most existing insurance schemes are largely limited to inpatient care, leaving outpatient visits and long-term medication costs uncovered.”
The study also identified key predictors of financial hardship. Lower socioeconomic status, rural residence, lack of insurance, and the presence of multiple health conditions were all associated with higher financial burden. Patients from rural areas reported significantly greater economic stress compared to their urban counterparts.
Another important insight was the broader societal impact of the disease. Reduced income not only affects access to treatment but can also worsen health outcomes and overall quality of life. The study noted that similar patterns have been observed globally, where chronic diseases reduce labour force participation and increase economic vulnerability.
“Addressing this financial burden, including CHS and DF, is essential for improving clinical outcomes and ensuring health equity,” the study concluded.
What are the limitations?
One key strength of the study was its large and diverse sample. As the authors noted, “We embedded this study within the National HF Registry (NHFR), one of the largest HF registries in India, with robust representation from all geographic regions.” The use of a standardised methodology across multiple centres enhanced the reliability and comparability of the data.
However, the study also faced challenges related to representativeness. It did not include individuals who were unable to seek medical care due to financial constraints or those too ill to attend follow-up visits. This means that the actual economic burden may be even higher than reported.
“Our findings may be influenced by the non-representativeness of the sample, as we did not account for individuals who forewent medical treatment entirely due to financial constraints,” the researchers stated.
Another limitation was survival bias. The analysis included only those patients who returned for follow-up, potentially excluding more severe cases or those who did not survive. This could lead to an underestimation of both clinical severity and financial burden.
The study also relied on self-reported expenditure data, which introduces the possibility of recall bias. Patients may not accurately remember or report their healthcare expenses, especially over extended periods.
“Estimates of OOP and CHS relied on self-reported expenditure data, which is susceptible to recall bias,” the authors acknowledged.
From a methodological perspective, the lack of adjustment for clustering, such as differences between hospitals or regions, may have affected the precision of the estimates. Additionally, the study assessed expenditure only immediately after a hospital admission for heart failure.
As a result, it may not fully capture the long-term and cumulative financial burden associated with managing a chronic condition like heart failure.
“Expenditure was assessed only immediately after a hospital admission for HF, this represents a limited assessment of financial burden and may not capture the cumulative, long-term economic burden experienced by patients and their families,” the study noted.
Despite these limitations, the researchers emphasised that the findings provide valuable insights into the economic realities faced by heart failure patients in India and highlight critical gaps in financial protection mechanisms.
Why affordability remains a challenge: Expert insight
Dr Swarup Swaraj Pal, Chief CVTS Surgeon at Gleneagles Hospital, Mumbai, noted that heart failure occurs when the heart is unable to pump blood efficiently, often as a result of underlying conditions. “First, you have to understand what heart failure is and what causes it,” he said, adding that the disease is not a standalone illness but develops due to other cardiovascular problems.
According to Dr Pal, heart failure affects a significant number of people in India. He estimated that “it affects at least 30 lakh people in the country,” and pointed out that the mortality burden is substantial, with “over three lakh deaths occurring every month.”
He explained that one of the most common causes is ischemic cardiomyopathy, which results from blockages in the heart following a heart attack. In many cases, especially among diabetic patients, the disease progresses silently. “They don’t feel pain, so by the time they come to a doctor, the heart function is often down to 15–20%,” he said. In comparison, normal heart function ranges between 60% and 80%.
Patients typically present late, often with symptoms such as breathlessness and reduced physical capacity. Diagnosis is usually confirmed through investigations like a 2D echocardiogram. Dr Pal added that apart from ischemic heart disease, other causes include cardiomyopathy and complications arising in cancer patients.
A key challenge, he emphasised, is delayed presentation. “Most patients come to us very late,” he said. By that stage, they often require hospital admission, intensive treatment, and expensive medications. Recurrent hospitalisations further add to the financial burden.
Highlighting the cost of advanced care, Dr Pal pointed out that treatment options escalate significantly in severe cases. “If medicines don’t work, then we have to move to transplant pathways,” he said. He noted that heart transplants can cost between Rs 25–30 lakh, while artificial heart devices may cost up to Rs 1.3 crore.
Such high costs, he explained, are one of the reasons insurance companies are reluctant to provide comprehensive coverage. “Insurance providers see this as a high-risk, high-cost condition, so they are hesitant to cover it fully,” he said.
Dr Pal also addressed why insurance coverage remains low among heart failure patients. One major reason, he said, is lack of awareness. “Most patients who develop heart failure were healthy a few years earlier, so they don’t feel the need to take insurance,” he explained.
Even when patients seek insurance after diagnosis, they face multiple barriers. “Once you already have heart failure, getting insurance is difficult. Either the application is rejected or there is a waiting period of up to three years,” he said, adding that premiums also rise significantly—from around Rs 20,000 annually to Rs 50,000–Rs 70,000 for high-risk individuals.
He further pointed out that the nature of the disease itself discourages insurers. “Heart failure requires repeated hospitalisations, sometimes even monthly, so companies anticipate recurring costs,” he said.
Comparing India with other countries, Dr Pal noted that more comprehensive insurance systems can make a significant difference. “In many countries, advanced treatments like artificial hearts and transplants are covered by insurance,” he said.
He suggested that broader, mandatory insurance coverage could improve access to care in India. “If we move towards a system where everyone has insurance coverage, it would work in favour of patients. Otherwise, managing heart failure will continue to be financially challenging,” he added.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS
