Journal of Health and Medical Sciences
Published: 23 February 2021
Catastrophic Health Expenditure, Distress Financing and Impoverishment due to Out-of-Pocket Expenses for Healthcare among Patients with Chronic Liver Disease: A Cross-sectional Study among Hospitalized Patients in Bangladesh
Mohammad Farhadul Haque, ANM Shamsul Islam, Samina Pervin, Emily Akter, Md Mahmudul Hasan
National Institute of Preventive and Social Medicine (Bangladesh), Enam Medical College and Hospital (Bangladesh), Amar Hospital Ltd (Bangladesh)
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Keywords: Catastrophic Health Expenditure, Distress Financing, Impoverishment, Out-of-pocket Expenses, Liver disease
Out-of-pocket (OOP) expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct non-medical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.
Arenliu Qosaj, F., Froeschl, G., Berisha, M., Bellaqa, B., & Holle, R. (2018). Catastrophic expenditures and impoverishment due to out-of-pocket health payments in Kosovo. Cost effectiveness and resource allocation : C/E, 16, 26.
Asrani, S.K., Devarbhavi, H., Eaton, J., & Kamath, P.S. (2019). Burden of liver diseases in the world. J Hepatol, 70(1), 151–71.
Azzani, M., Roslani, A. C., & Su, T. T. (2019). Determinants of household catastrophic health expenditure: a systematic review. The Malaysian Journal of Medical Sciences: MJMS, 26(1), 15–43.
Bangladesh National Health Accounts 1997-2015 (BNHA-V). 2018. Retrived from
Byass, P. (2014). The global burden of liver disease: A challenge for methods and for public health. BMC Med, 12(1),1–3.
Chowdhury, M. N. M., & Hossain, M. M. (2019). Poverty, income inequality and growth in Bangladesh: Revisited Karl-Marx. American Finance & Banking Review, 4(2), 1-10.
European Association for the Study of Liver (2012). EASL clinical practical guidelines: management of alcoholic liver disease. Journal of hepatology,57(2), 399–420
Flores, G., Krishnakumar, J., O'Donnell, O., & van Doorslaer, E. (2008). Coping with health-care costs: implications for the measurement of catastrophic expenditures and poverty. Health economics, 17(12), 1393–1412.
Hope, V. D., Eramova, I., Capurro, D., & Donoghoe, M. C. (2014). Prevalence and estimation of hepatitis B and C infections in the WHO European Region: a review of data focusing on the countries outside the European Union and the European Free Trade Association. Epidemiology and Infection, 142(2), 270–286.
Huq, N. M., Al-Amin, A. Q., Howlader, S. R., & Kabir, M. A. (2015). Paying out of pocket for healthcare in bangladesh - a burden on poor?. Iranian journal of public health, 44(7), 1024–1025.
Islam, A., & Biswas, T. (2014). Chronic non-communicable diseases and the healthcare system in bangladesh: current status and way forward. Chronic Dis Int, 1(2):1-6.
Kabir, M.A., Begum, M.F., & Hossain, M.A. (2006). Rural poverty in Bangladesh and its associated factors : evidence from micro-level study. The Jahangirnagar Economic Review, 17 (1), 43-52.
Kastor, A., & Mohanty, S. K. (2018). Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: Do Indian households face distress health financing?. PloS one, 13(5), e0196106.
Khammarnia, M., Keshtkaran, A., Kavosi, Z., & Hayati, R. (2014). The Household health spending and impoverishment: findings from the households survey in Shiraz, Iran. Bangladesh Medical Research Council bulletin, 40(2), 58–62.
Khan, J,A,M., Ahmed, S., &Evans, T.G. (2017). Catastrophic healthcare expenditure and poverty related to out-of-pocket payments for healthcare in Bangladesh- An estimation of financial risk protection of universal health coverage. Health Policy Plan, 32(8):1102–1110.
Kim, I.H., Kisseleva, T., & Brenner, D.A. (2015). Aging and liver disease. Current Opinion in Gastroenterology, 31,184–91.
Mahtab, M. A., Rahman, S., Karim, M. F., Khan, M., Foster, G., Solaiman, S., & Afroz, S. (2008). Epidemiology of hepatitis B virus in Bangladeshi general population. Hepatobiliary & Pancreatic Diseases International : HBPD INT, 7(6), 595–600.
Mahumud, R. A., Sarker, A. R., Sultana, M., Islam, Z., Khan, J., & Morton, A. (2017). Distribution and determinants of out-of-pocket healthcare expenditures in Bangladesh. Journal of Preventive Medicine and Public health = Yebang Uihakhoe chi, 50(2), 91–99.
Mamun-Al-Mahtab (2016). Past, present, and future of viral hepatitis in Bangladesh. Euroasian Journal of Hepato-Gstroenterology, 6(1), 43–44.
Marcellin, P., & Kutala, B. K. (2018). Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver International : Official Journal of the International Association for the Study of the Liver, 38 Suppl 1, 2–6.
Noor-E-Alam S. M. (2018). Management of hepatocellular carcinoma: Bangladesh Perspective. Euroasian Journal of Hepato-Gastroenterology, 8(1), 52–53.
Pavel, M.S., Chakrabarty, S. & Gow, J. (2016). Cost of illness for outpatients attending public and private hospitals in Bangladesh. Int J Equity Health ,15 (167),1-12.
Prinja, S., Bahuguna, P., Duseja, A., Kaur, M., & Chawla, Y.K.(2018). Cost of intensive care treatment for liver disorders at tertiary care level in India. PharmacoEconomics Open, 2(2), 179–190.
Rahman, M. M., Gilmour, S., Saito, E., Sultana, P., & Shibuya, K. (2013). Self-reported illness and household strategies for coping with health-care payments in Bangladesh. Bulletin of the World Health Organization, 91(6), 449–458.
Rahman, M. M., Zhang, C., Swe, K. T., Rahman, M. S., Islam, M. R., Kamrujjaman, M., Sultana, P., Hassan, M. Z., Alam, M. S., & Rahman, M. M. (2020). Disease-specific out-of-pocket healthcare expenditure in urban Bangladesh: a Bayesian analysis. PloS one, 15(1), e0227565.
Rahman, S., Faroque Ahmed, M., Jamshed Alam, M., Ranjan Debnath, C., Izazul Hoque, M., Mahbub Hussain, M., Shamsul Kabir, A., Fazal Karim, M., Ahmed Khondokar, F., Mamun-Al-Mahtab, A. K., Golam Masud, M., Uddin Mollick, M. K., Lutful Moben, A., Mohammad Noor-E-Alam, S., Kumar Podder, P., Kumar Raha, A., Abdur Rahim, M., Harun Or Rashid, M., Zaki, K., & Mohammad Fazle Akbar, S. (2014). Distribution of liver disease in Bangladesh: A Cross-country Study. Euroasian Journal of Hepato-Gastroenterology, 4(1), 25–30
Sajja, K. C., Mohan, D. P., & Rockey, D. C. (2014). Age and ethnicity in cirrhosis. Journal of Investigative Medicine : the Official Publication of the American Federation for Clinical Research, 62(7), 920–926.
Saleem, S. M. (2019). Modified Kuppuswamy socioeconomic scale updated for the year 2019. Indian J Forensic Community Med,6(1),1-3.
Sarin, S. K., Kumar, M., Eslam, M., George, J., Al Mahtab, M., Akbar, S., Jia, J., Tian, Q., Aggarwal, R., Muljono, D. H., Omata, M., Ooka, Y., Han, K. H., Lee, H. W., Jafri, W., Butt, A. S., Chong, C. H., Lim, S. G., Pwu, R. F., & Chen, D. S. (2020). Liver diseases in the Asia-Pacific region: a lancet gastroenterology & hepatology commission. The lancet. Gastroenterology & hepatology, 5(2), 167–228.
Stepanova, M., De Avila, L., Afendy, M., Younossi, I., Pham, H., Cable, R., & Younossi, Z. M. (2017). Direct and indirect economic burden of chronic liver disease in the United States. Clinical Gastroenterology and Hepatology : the Official Clinical Practice Journal of the American Gastroenterological Association, 15(5), 759–766.
Tahsina, T., Ali, N,B., Hoque, D,M,E., Huda, T,M., Salam, S.S., Hasan MM, Hossain M,A., Matin, Z.,Kuppen, L., Garnett S, P., & El Arifeen,S. (2017). Out-of-pocket expenditure for seeking health care for sick children younger than 5 years of age in Bangladesh: findings from cross-sectional surveys, 2009 and 2012. J Heal Popul Nutr, 36(1), 33.
Uz-Zaman, M. H., Rahman, A., & Yasmin, M. (2018). Epidemiology of hepatitis b virus infection in Bangladesh: prevalence among general population, risk groups and genotype distribution. Genes, 9(11), 541.
van Doorslaer, E., O'Donnell, O., Rannan-Eliya, R. P., Somanathan, A., Adhikari, S. R., Garg, C. C., Harbianto, D., Herrin, A. N., Huq, M. N., Ibragimova, S., Karan, A., Ng, C. W., Pande, B. R., Racelis, R., Tao, S., Tin, K., Tisayaticom, K., Trisnantoro, L., Vasavid, C., & Zhao, Y. (2006). Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data. Lancet (London, England), 368(9544), 1357–1364.
van Doorslaer, E., O'Donnell, O., Rannan-Eliya, R. P., Somanathan, A., Adhikari, S. R., Garg, C. C., Harbianto, D., Herrin, A. N., Huq, M. N., Ibragimova, S., Karan, A., Lee, T. J., Leung, G. M., Lu, J. F., Ng, C. W., Pande, B. R., Racelis, R., Tao, S., Tin, K., Tisayaticom, K., … Zhao, Y. (2007). Catastrophic payments for health care in Asia. Health economics, 16(11), 1159–1184.
Wagstaff, A., Flores, G., Hsu, J., Smitz, M. F., Chepynoga, K., Buisman, L. R., van Wilgenburg, K., & Eozenou, P. (2018). Progress on catastrophic health spending in 133 countries: a retrospective observational study. The Lancet. Global health, 6(2), e169–e179.
Weersink, R. A., Taxis, K., Drenth, J., Houben, E., Metselaar, H. J., & Borgsteede, S. D. (2019). Prevalence of drug prescriptions and potential safety in patients with cirrhosis: a retrospective real-world study. Drug Safety, 42(4), 539–546.
World Data Atlas. (2020).Bangladesh - Out of pocket expenditure as a share of current health expenditure. Retrived from
Xiao, J., Wang, F., Wong, N. K., He, J., Zhang, R., Sun, R., Xu, Y., Liu, Y., Li, W., Koike, K., He, W., You, H., Miao, Y., Liu, X., Meng, M., Gao, B., Wang, H., & Li, C. (2019). Global liver disease burdens and research trends: Analysis from a Chinese perspective. Journal of hepatology, 71(1), 212–221
Xu, K., Evans, D. B., Kadama, P., Nabyonga, J., Ogwal, P. O., Nabukhonzo, P., & Aguilar, A. M. (2006). Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Social science & medicine (1982), 62(4), 866–876.