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Sample Research Paper on Indirect Cost of Cancer: Evaluation of productivity loss of patients and Care Givers in North East India

Indirect Cost of Cancer: Evaluation of productivity loss of patients and Care Givers in North East India

Background

In the first of all Indian data publication on cancer conducted by WHO and ICMR, 217174 cancer cases were collected from 2001-2002 from 105 centers all over India (National Cancer Registry Programme, n.d)​. From the data, the State of Mizoram was the most affected by cancer than other states. The state of Mizoram is located in the northeastern region of India, which is made up of 8 smaller states populated by different tribes and ethnic communities racially and culturally distinct from the rest of mainland India. The state has six districts among the top ten highest prevalence districts for cancer among males and four districts among the top ten highest cancer prevalence districts among females (Zomawia et al., 2010).  The Atlas report further shows that Mizoram leads in 10 cancer sites among Indian states while the other north-east states also showed high incidences of various cancers compared to other regions in India. According to this report, the state of Mizoram leads in various forms of cancers, including cancers of all sites in both men and women; tongue cancer in men; lung cancer in both men and women; stomach cancer for both men and women; cancer of the hypopharynx in men; cancer of the esophagus in men; and non-Hodgkin’s lymphoma (gland cancer) in men (National Cancer Registry Programme, n.d). Data collected from 2012-2014 shows that the cancer incidence in Mizoram is 55.1 percent for males and 44.9 percent for females (National Cancer Registry Programme, n.d). The prevalence of cancer in the state also varies from district to district.

The cancer incidence rates in different districts have been the key consideration in the placement of various cancer facilities in the state. For instance, the state of Mizoram has a Population-Based Cancer Registry based at Civil Hospital, Aizawl, which was launched in 2003 under the National Cancer Registry Program of the Indian Council of Medical Research (Zomawia et al., 2010). In an international comparison of some cancer sites, Aizawl district in Mizoram remains 6th in the world for stomach cancer among males, while it is highest in the world for stomach cancer among females and also for both esophagus cancer and hypopharynx among males (Zomawia et al., 2020). In Mizoram as a whole, the proportion of stomach cancer is the highest, followed by the esophagus and lung cancer, the 3 sites collectively contributing almost half (49%) of all cancers (National Cancer Registry Programme, n.d). Among females, the most prevalent cancers include Cervix Uteri cancer is the highest followed by lung and breast cancer, totaling nearly half (45%) of all cancer cases in females (National Cancer Registry Programme, n.d). Approximately 44% and 24% of all cancers in males and females are respectively associated with the use of tobacco, followed by dietary habits (Nghaite, Zomawia & Kaushik, 2019). According to the cancer registry, the two highest causes of cancer in India are tobacco-related cancers and gastrointestinal tract issues, and the two are likely to remain the leading causes in the projected national burden on new cases of cancer for both sexes in 2020 (National Cancer Registry Programme, n.d).  The burden of cancer, therefore, remains heavy among those who are already at risk of gastrointestinal issues and who use tobacco. 

Rationale

North-eastern India generally shows a peculiar pattern of cancer incidence among the populations, as exemplified by the State of Mizoram. Moreover, the patterns of cancer distribution and the cancer-related mortality in northeastern India are distinctive, mostly due to the underlying marginalization of the community. The districts are characterized by poor infrastructure, limited cancer-care human resources and facilities, and subsequently, low levels of cancer-treatment seeking (Nghaite et al., 2019). These characteristics have resulted in relatively low survival rates for cancer patients in the region and high percentages of metastasis cases during diagnosis (Nghaite et al., 2019). The cancer prevalence in the region, thus imposes a significant burden on the communities, especially socially and financially. According to Nghaite et al., the prevalence of cancer in the region is the highest among adults, while child cancer is at its lowest prevalence compared to other regions, indicating exposure to risk factors, such as tobacco smoking in the environment. With a large proportion of the adult population affected by various types of cancers, the implications on regional productivity and household income levels are significant, as well as the social implications of the disease.

The population-based cancer registry and the Atlas 2012 are relatively new initiatives taken up in India to combat cancer mortality and improve care for patients with cancer. Even as prevalence studies are ongoing, and focus is geared towards early detection and treatment options, little is known about the financing options available and the financial burden on households with cancer patients. Particularly in the northeastern region where health-seeking behavior is very low, and families normally do not prepare for health financing costs/emergencies in the form of health insurance, the morbidity costs of cancer can become catastrophic for the households involved.  Ngangbam and Roy (2019) report that the health-seeking behaviors in northeastern India are very low as workforce availability and healthcare quality remain major concerns for the region. Moreover, healthcare service delivery to uneducated, scheduled tribes, Muslims, higher-aged, and rural people in northeastern India has been generally poor and is further worsened by poor road connectivity (Ngangbam & Roy, 2019). These factors have resulted in many people remaining untreated or even seeking care in under-equipped health facilities. Increasing costs of healthcare services also contribute to the disparate care reception across the nation and the negative effects on the population in northeastern India (Ngangbam & Roy, 2019). The combination of high disease prevalence, low health-seeking behavior, and poor access to healthcare resources and personnel, therefore, inevitably means that cancer has significant effects on the households in the region. Thus, the study intends to explore these effects, with a focus on household financial loss associated with cancer morbidity.

Study objectives and methodology

The study focuses on the economic effects of morbidity by cancer on the household sectors in Mizoram. The economic effect of the illness is studied in terms of the Out-of-Pocket expenditure on healthcare, productivity loss of the ill and the caregivers, the mechanisms for financing healthcare, and the extent to which the costs incurred could be catastrophic for the households. Additionally, the study explores the overall welfare loss of households, the implications of health education (promotion), and household assets in relation to the cancer scourge in the region.

According to Feldstein (2012), patients’ demand for healthcare is affected by three broad factors which can be classified as (i) the illness incidence and need for care, (ii) cultural-demographic characteristics such as age, education, marital status, number of persons in the family, employment status, and (iii) economic factors such as income, cost of healthcare, opportunity costs of ill health (value of the patient’s time). Healthcare expenditure, therefore, is assumed to depend on the morbidity pattern and health status of the patient, the socio-economic and demographic characteristics of the households, and economic factors. The morbidity pattern, health-related expenditure, and the foregone income due to living with cancer under different socio-economic and clinical characteristics will be reported and analyzed in this paper.

 

The study will have the following as its specific objectives:

1. To examine the morbidity patterns and the demand for the healthcare of cancer patients based on qualitative and quantitative reviews of medical data.

2. To examine the direct and indirect costs of cancer morbidity on individuals and households based on opportunity costs and market cost approaches recommended by the WHO (2009).

3. To measure the extent of the financial burden for households based on implications such as loss of savings and change in socio-economic statuses of affected households.

4. To examine the sustainability of the financial coping strategies adopted using a qualitative methodology targeting affected families.

The study will use a mixed research methodology to realize the stated objectives. Determining the morbidity patterns and demands for healthcare, the direct and indirect costs of cancer morbidity, the extent of the financial burden for households, and the sustainability of financial coping strategies requires the use of a longitudinal approach to study. However, the longitudinal approach can be time-consuming as it would be necessary to collect data running for up to one year following the cancer incidence. Therefore, a case study approach will be utilized for the initial stages of the study, whereby up to 10 cancer cases involving patients who have been receiving care for at least six months by the time of the study will be reviewed to address the issues around time for a longitudinal study. The qualitative data to be collected from patients and their families will be obtained through a survey methodology.

References

Feldstein, P. J. (2012). Healthcare economics. Cengage Learning.

National Cancer Registry Programme (n.d.). Development of an atlas of cancer in India: First of all India report 2001-2002. Retrieved from https://www.ncdirindia.org/ncrp/ca/Discussion_1.aspx

Ngaihte, P., Zomawia, E., & Kaushik, I. (2019). Cancer in the North East India: Where we are and what needs to be done? Indian Journal of Public Health, 63(3), 251-253. Retrieved from https://www.researchgate.net/publication/335939755_Cancer_in_the_NorthEast_India_Where_we_are_and_what_needs_to_be_done

Ngangbam, S., & Roy, A. K. (2019). Determinants of health-seeking behavior in Northeast Indian Journal of Health Management, 21(2), 234-257. Retrieved from https://journals.sagepub.com/doi/abs/10.1177/0972063419835118#articleCitationDownloadContainer

World Health Organization (WHO) (2009). WHO guide to identifying the economic consequences of disease and injury. Retrieved from https://www.who.int/choice/publications/d_economic_impact_guide.pdf?ua=1

Zomawia, E., Sailo, L., Kima, L., Zohmingthanga, J., Chenkual, S., Pautu, J. L. (2013). Population based cancer registry Mizoram State: Civil Hospital, Aizawl. Individual Registry Write-up, 442-491. Retrieved from https://main.icmr.nic.in/sites/default/files/reports/Mizoram_State.pdf

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