June 21, 2018

by Eleni Helbling

Poverty is bad for health, not least for those surviving on little money, who often have to put their own health last. New studies of health spending in private households in India and Cameroon underline the financial burden faced by poor people in their efforts to treat neglected tropical diseases.


Numerous studies have already shown that the risk of falling ill – and staying ill – is far greater for some than for others. The social gap is widest in the low and middle-income countries, and it is getting wider all the time. Despite a variety of free-of-charge, state-covered health services, the majority of healthcare spending is funded by patients through so-called ‘out-of-pocket payments’. For people already affected by poverty, such private expenditure is a heavy financial burden. Recent studies from India and Cameroon have measured the health expenditure of people suffering from the neglected tropical diseases leprosy and podoconiosis, with an emphasis on the first-hand experiences of the patients themselves. The striking results underline how inequality in access to healthcare is a very real problem.

Leprosy in India – A health problem of the poor

Around 60% of all leprosy afflictions worldwide occur in India. Not surprisingly, leprosy represents one of the largest public health challenges for the Indian health system. Like most neglected tropical diseases, leprosy is a typical poverty-associated disease that, in addition to causing social exclusion, is also a terrible financial burden for sufferers. For the first time, Indian health experts have examined the direct and indirect healthcare costs associated with leprosy from the perspective of private households. In a comparative study, the health systems of two bordering regions in western India were analysed for their accessibility to leprosy treatment. The six-month study documented how leprosy patients from a total of 240 households manage their affliction and investigated the true extent of their contribution to treatment costs.

The region determines the costs

The health systems of both regions offer free-of-charge leprosy treatment but differ in terms of infrastructure, accessibility and the quality of health services, as well as the extent of government subsidies for the respective programmes. The results show marked differences between the regions: Patients in the region with less access to public health services ultimately paid around one dollar less in direct costs (i.e. treatment and medication) than the region with the better-subsidised health system. The reverse is true for indirect costs such as the loss of wages. Patients in the weaker health system paid over $12 in indirect costs, which is around 30% more than those in the stronger healthcare system. As such, the greater part of costs cannot be traced back to treatments and medicines, but to the loss of wages that is a consequence of the disease and its treatment.

The stronger the public health system, the lower the burden

Based on these findings, the researchers conclude that the state of the health system is in direct correlation with the health expenditure of the patient: the better the health system, the lower the out-of-pocket payments. Moreover, the healthcare system has a stronger influence on health awareness. For example, patients in the deprived region were less likely to visit a health centre, but if they did, associated costs were higher because they more often had to resort to more expensive private facilities. Strengthening the health system meant that patients were more likely to visit public facilities, which significantly reduced the cost burden.