International Journal of Health Sciences and Research

Vol.10; Issue: 5; May 2020

Website: www.ijhsr.org
Original Research Article ISSN: 2249-9571

Financial Coping Mechanisms in Patients with Type

II Diabetes Mellitus in Rural India
Saima Nazir1; Ashiq Rashid Mir1; Arshad Rashid2
1
Senior Resident, Department of Community Medicine, SKIMS Medical College, Bemina, Srinagar - 190018
2
Lecturer, Department of Surgery, Government Medical College, Srinagar - 190010.
Corresponding Author: Arshad Rashid

ABSTRACT

Background: Understanding the financial burden and the pattern of costs involved in managing
diabetes can help planners strengthen the basic health care programs. The present study was carried
out to assess the cost of diabetes care and the financial coping mechanisms thereof.
Methods: The present study was carried out in the rural areas of district Tumkur, Karnataka. A total
of 180 participants were included in this study. Data was collected using a pre-tested questionnaire,
which was administered as a face-to-face interview during house-to-house visits by the second author.
Results: The mean age of the participants was 62.68 ± 8.4 years. The mean total direct cost incurred
on managing diabetes was 408.12 ± 23.37 INR/month, while as the total indirect cost was 145.88 ±
11.42 INR/month (P<0.001). The total cost incurred during hospitalization was 201600 INR, which
when calculated for individual admissions turned out to be 9600 INR. Majority of the people [126
(70%)] mobilized cash savings to cope-up with this financial burden, which was followed by
borrowing money from friends /professional lenders in 52 (30%) individuals. None of our study
subjects sold any assets to meet this expenditure and none of our patients had access to any health
insurance scheme.
Conclusion: The present study points to the ever-increasing cost of diabetes care. The major
economic impact of type II DM was due to high cost of the drugs. There is a glaring deficit of social
insurance schemes that needs to be addressed.

Key Words: Diabetes Mellitus; Financial; Cost; Rural.

INTRODUCTION care and frequent visits to health care

The global prevalence of facilities thus increasing the cost of care. [3]
diabetes has been estimated to be 9% among The per capita cost of managing DM is 2 – 4
adults more than 18 years of age. In 2012, folds higher than the non-diabetics. [4]
an estimated 1.5 million deaths were Healthcare expenditures on diabetes
directly attributed to diabetes mellitus accounted for 11.6% of the total healthcare
(DM), with more than 80% of these expenditure in the world in 2010. By 2030,
occurring in low and middle-income this amount is projected to exceed USD 490
[1]
countries. The World Health billion. [5] For obvious reasons, the
Organization projects that diabetes mellitus treatment costs increase with disease
will be the 7th leading cause of death by the duration, presence of complications, and
year 2030. [2] DM is a chronic disease that hospitalization.
not only drains the body but also drains the One of the most bothersome facts is
pocket of the patient. DM affects quality of that despite the United Nations raising the
life, requires close monitoring and control. status of non-communicable diseases to that
The persistent hyperglycaemia and of communicable diseases; there is neither
associated complications demand intensive support, nor financial risk protection/

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 Saima Nazir et.al. Financial coping mechanisms in patients with type II diabetes mellitus in rural India

exemption for DM, which is presently sample was calculated by the formula n =
assuming an epidemic proportion. [6] Every Z2*P*(1-P)/e2, where, z = Level of
year more than 150 million individuals in confidence at 95 %( 1.96); P = Proportion of
the world face financial catastrophe and income spent and e = Margin of error taken
more than 100 million individuals are (absolute error of 1.5%). Thus the calculated
pushed into poverty as a direct result of sample size came out to be 162, which after
paying for health care related to DM. adding 10% non-response was rounded off
According to the World Bank, out-of-pocket to 180. Systematic random sampling did the
expenditure in India was one of the highest selection of participants.
in the world (around 87%) between 2008- A semi-structured pre-tested
2012 in terms of direct and indirect costs proforma, which included socio-
incurred on managing DM, and this was demographic profile of the participants and
mainly borne by family members of diabetic questions based on knowledge of DM and
individuals who used various coping up its complications, was used. Data was
mechanisms. [7] collected using this pre-tested questionnaire,
Survey data on these coping which was administered as a face-to-face
mechanisms provide overall direction by interview during house-to-house visits by
helping to pinpoint the obstacles in society, the second author. Information was
region specific issues and weaknesses in specifically collected regarding the financial
services that need to be overcome. Program coping mechanisms used to deal with cost
managers also need to look at the total cost of managing DM. Before the study was
incurred on managing complications of formally conducted, this questionnaire was
diabetes to gauge whether they need to raise translated into local language and was tested
awareness of the benefits of early detection on 30 diabetics of the same area for
and proper control of blood sugar levels. In reliability and consistency as part of a pilot
the absence of insurance, most of the project. The questionnaire was asked in the
patients pay out of their own pockets, more local language understood to them. If any of
so in the rural areas. Hence to address these the selected individual was not found during
views, the present study was carried out to the first visit, a second visit was given at
assess the financial burden and their coping some other time.
strategies among patients living with The data thus collected was
diabetes mellitus in rural India. compiled and analyzed using SPSS version
21 for Mac (IBM Corporation, 2012).
MATERIALS AND METHODS Qualitative variables were expressed as
The present observational proportions in percentages. For quantitative
community based, cross-sectional study was data, mean and standard deviation was
carried out in the rural field practice area of calculated. The association between
Sri Siddhartha Medical College Tumkur variables was calculated for 95% confidence
which consists of 23 villages around the intervals by using “Chi square test” and
rural health-training center (RHTC) located “One-way ANOVA”. “Unpaired t – test”
in Nagvelli, and caters to a total population was used to compare the means. A P-value
of 8223. This study targeted all the <0.05 was taken as significant. All
individuals over the age of 30 years who procedures performed in this study were in
were permanent residents of the area and accordance with the ethical standards of the
were living with type-II DM for at least 1 1964 Helsinki Declaration and its later
year. Persons with type I DM and those who amendments or comparable ethical
didn’t consent were excluded from the standards. The Institutional Ethical
study. The proportion of income spent in Committee approved this study. All the
rural areas in managing DM as reported subjects were fully informed about the
elsewhere [7] in rural India was 27%. The purpose and nature of the study. A written

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 Saima Nazir et.al. Financial coping mechanisms in patients with type II diabetes mellitus in rural India

and informed consent was obtained in the financial burden, which was followed by
language they understood, and assurance borrowing money from friends /professional
regarding confidentiality was given. The lenders in 52 (30%) individuals. None of
study posed no financial burden on the our study subjects sold any assets to meet
participants. this expenditure and none of our patients
had access to any health insurance scheme.
RESULTS
The mean age of the participants was DISCUSSION
62.68 ± 8.4 years. There were more male Diabetes mellitus imposes a large
patients [94(53%)] as compared to females economic burden on the global health-care
[85(47%)]. Most of the patients were in the system and the wider global economy. This
age group of 50-59 years [94 (52%)]. Sixty- burden can be measured through direct
seven (37%) patients were illiterate and only medical costs, indirect costs associated with
six (3%) patients were having a diploma productivity loss, premature mortality and
degree. One-hundred-and-twenty-six (70%) the negative impact of diabetes on nation’s
patients were living in joint families. gross domestic product. [8] Direct costs are
Agriculture was the predominant occupation those generated by the resources used in
and was seen in 86 (49%) patients; but in treating or coping with the condition. It
case of females the predominant occupation includes expenditures on inpatient
was “engaged in homemaking” and was treatment, physician and other specialist
seen in a total of 60 (33%) participants. consultation fees, prescriptions, drugs
According to Modified B.G. Prasad’s (insulin and oral hypoglycaemic agents)
classification of socio-economic status, 74 and, laboratory tests, etc. It also includes
(41%) patients belonged to class V. any cost incurred on any co-morbidity
Majority of the study subjects [128(71%)] attributed to DM. While the major diabetes
were diabetic for 1-4 years, with mean years cost drivers are hospital inpatient and
of duration being 4.8 ± 1.2 years. outpatient care, a contributing factor to this
increase is the rise in expenditure on
Table 1: Mean Direct and Indirect Costs incurred on patented, branded medicines used to treat
managing DM.
Type of Cost Purpose Monthly Cost (INR) people with diabetes. Indirect costs of
Direct Cost Consultation 160 diabetes address the potential resources that
Diagnostics 62
Drugs 186 are lost as a result of one having diabetes.
Total Direct Cost 408 They include the time absent from work due
Indirect Cost Wages Lost 70
Refreshments 5
to illness or attendance to healthcare,
Transportation 70 inability to work because of disability, cost
Total Indirect Cost 145 of transportation, premature mortality
TOTAL COST INCURRED 553
because of acute or chronic complication of
The mean total direct cost incurred diabetes, and time taken off work by care
on managing diabetes was 408.12 ± 23.37 takers of the diabetics. [9]
INR/month [Table 1], while as the total The mean monthly cost of
indirect cost was 145.88 ± 11.42 consultation, as reported by our study, is
INR/month. This difference was statistically 160 INR, which is more than as reported
significant [P<0.001]. A total of 21 (12%) elsewhere. [7-10] A study conducted in
patients required hospital admissions over Haryana in 2014, showed that the mean cost
the study period for managing DM. The of consultation per month was 106 rupees.
[7]
total cost incurred during hospitalization Another study reported the cost on
was 201600 INR, which when calculated for consultation at 116 rupees per month. [10]
individual admissions turned out to be 9600 Increased cost on consultation in our study
INR. Majority of the people [126 (70%)] could be due to increase in consultation fee
mobilized cash savings to cope-up with this by private practitioners over the years. Also

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 Saima Nazir et.al. Financial coping mechanisms in patients with type II diabetes mellitus in rural India

there has been an increase in the awareness for healthcare. Respondents may choose
to consult a specialist doctor, which may other risky coping mechanisms like
also have contributed to the higher cost. skipping appointments, skipping doses of
There is an increase in expenditure drugs when feeling well, or using alternative
on investigations with passing of years. This healthcare believing it to be cheaper to save
can be attributed to inflation with the or evade the costs, which can lead to
resultant increase in cost of investigations at catastrophic complications and poor control
diagnostic centers and the availability of of diabetes, and thus indirectly increasing
better and more expensive investigation the cost. Borrowing and trading out assets
modalities like HbA1C. In our study, the may push respondents deeper into poverty
mean cost incurred on investigations of especially if borrowed from money lenders
diabetes is 62 INR/month. Again, this cost as interest on the money will further
was higher than reported earlier. [7-11] increase the cost burden while disposal of
Loganathan et al reported a mean assets may provide immediate cushion but
expenditure on investigations at 28 rupees the persons are denied the value and
per month. [11] A study in northern India comfort of their use. Borrowing was
showed that the mean expenditure on preferred to selling out assets in our study.
investigation was 47 rupees. [7] Similar trend One of the major findings of our
was seen as regards the cost of medications; study is the lack of health insurance
even though the patients were using free schemes being used by the rural population,
drugs available at the rural health centers. and most of the patients were forced to
In the present study, total monthly spend out of their pockets. Thus, there is a
indirect diabetic expenditure is reported at need to strengthen the basic health care
145 INR, which is comparable to as facilities and the provision of free health
reported by Kapur et al. [12] Though the cost care schemes like Ayushman Bharat. Also,
of transportation and refreshment costs were the use of generic drugs should be
similar to other reported studies, [7-12] encouraged, to offset the cost of branded
however, the costs incurred due to loss of medications. Hospitalization costs occur in
wages by accompanying persons were much the setting of diabetes complications, which
lesser [70 INR] in our study as compared to can be minimized by proper screening and
others. This is probably due to the fact that counseling of the patients. There is a need to
our study included only rural population and regulate the cost of investigations by the
a major chunk of this population was private diagnostic centers, which can further
“engaged in homemaking”. Hence the help in alleviating this financial burden.
wages lost by them were not accounted for. Our study has some potential
The total cost (direct & indirect) incurred by limitations. First, it was not possible to
our subjects was 553 INR/month, which calculate the wages lost by housewives that
was higher than that reported by could have affected the indirect costs.
Ramachandran et al. [13] This is attributed to Second, duration of stay in hospitals was not
the inflation and overall increase of cost of accurately calculated which could affect
living. total hospital expenditure. We agree to the
Most of the patients used cash fact that hospitalization could have been due
savings as a coping-up strategy, which has to other reasons and wrongly attributed to
also been reported elsewhere. [10-13] But, this DM, owing to recall bias. Our study may
carries an important caveat as using money also be criticized on the plea that these
saved for other basic items like food could results cannot be extrapolated to the national
jeopardize the health of the patients and or global scenario, as the sample was not a
further push them into poverty because total nationally representative one. The strengths
expenditure is inflated and necessary of this study were that the subjects were
consumption is temporarily sacrificed to pay

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 Saima Nazir et.al. Financial coping mechanisms in patients with type II diabetes mellitus in rural India

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