You paid WHAT?

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09 Dec You paid WHAT?

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UPDATE: For Universal Health Coverage Day on 12 December 2023, Every Breath Counts launched a new arm of the You Paid WHAT? campaign – Documenting the Crippling Costs of Oxygen Treatment. We want to hear from patients and caregivers all over the world who were forced to pay high costs for medical oxygen treatment in the last five years, no matter the cause of the illness or condition. Submit your stories here.

The You Paid WHAT? campaign was launched on Universal Health Coverage Day 2022, with an initial focus on documenting the high costs of pneumonia treatment…

For the 340 million children and adults who get sick with pneumonia each year, the costs of treatment can be crippling. In settings where there is no universal health coverage (UHC) and individuals and families are forced to pay out-of-pocket for healthcare, the costs can be catastrophic – plunging people into poverty, or further into poverty.

In recent years, a strong body of research has documented the costs of pneumonia treatment, especially for children, and the impact on their families. Most of these studies have been conducted in low- and middle-income countries where rates of pneumonia infection and death are highest, according to the Global Burden of Disease.  

The results are sobering. 

How much are people paying for pneumonia treatment? 

A multi-country review (2016) – and individual studies from The Gambia (2016), Ethiopia (2017), Nepal (2018), Uganda (2021), Bangladesh (2021), Nigeria (2022), and India (2022) – have reported average costs of treatment for a child hospitalized with pneumonia ranging from $US55 to $US243.[1] Costs include both the direct costs of medical care as well as the indirect costs of lost wages, and food and travel incurred while caring for a child in hospital.

For a large proportion of families – more than one in three in most of the studies – these costs are catastrophic, meaning they amount to more than 25% of monthly household income. In the Nigeria study, one third of families paid the equivalent of more than 25% of their monthly income on pneumonia treatment, while the poorest families paid 53%. And in Bangladesh 39% of households spent over 40% of their monthly income, excluding food, to treat an episode of pneumonia.

Costs were generally higher when families used private and not-for-profit hospitals. For example, in the India analysis most of the families (76%) incurring catastrophic costs had used private hospitals. In the Ethiopia study, private hospital costs were three times higher ($US140) compared to government hospitals ($US48). While in Uganda, it was not-for-profit hospital care that cost the most – $US50 compared to $US21 for private for-profit care and $US17 for government hospitals. Even in government primary healthcare centers, pneumonia treatment was not entirely free of charge with families forced to pay consultation fees and/or buy medication from private outlets because of a lack of drug stock.

To pay these costs, many families had to deplete savings, borrow money, and/or sell household items to pay for care. In the Uganda study, poor households turned to friends and family for help (>15%), took out bank loans (>13%), and/or sold assets (>8%). The Bangladesh study reported higher rates of borrowing (19%) and using savings (37%). The struggles that families go through to finance pneumonia treatment have been powerfully documents by the International Vaccines Access Center (IVAC) in a series of videos from Nepal, including Niruta’s Story, Tej and Reshma’s Story, Sarita’s Story, and Gita’s Story.

There are few studies estimating the out-of-pocket costs that adults with pneumonia face, in any setting. Some US studies have estimated the out-of-pocket costs for influenza treatment above $US900 and for COVID-19 patients over $US1,000.

What can be done to reduce the high costs? 

Governments, families, and individuals can take key actions to reduce the high costs of pneumonia treatment, including:

1. Increasing access to pneumonia-fighting vaccines

        • First, governments can make sure that all the pneumonia-fighting vaccines are available free of charge to adults and children as part of UHC. The Nepal study concluded that pneumococcal vaccination alone could avert up to half of catastrophic healthcare cases caused by childhood pneumonia treatment. This is why we need a concerted push to lift pneumococcal vaccine coverage among children from the current 51% to more than 90% in every country as well as expand coverage among adults.
        • In addition, governments need to subsidize the cost of vaccines that target the leading viral causes of pneumonia – influenza and COVID-19 – and when the new vaccine for respiratory syncytial virus (RSV) becomes available, governments need to include it as part of routine vaccinations. Individuals and families, for their part, must take advantage of these vaccines, and ensure that children and vulnerable adults are protected by asking for these vaccines when they seek healthcare.

2. Reducing risks

        • The risk of pneumonia infection can be further reduced by limiting exposure to air pollution – including from smoking – both inside and outside homes – and by improving nutrition and infection control through hand washing and reducing overcrowding. This is as important for adults and children – from the newborn to the aging grandparent – especially if they live together under the same roof.  

3. Strengthening primary health care

        • But even with full coverage of the pneumonia-fighting vaccines and risk reduction, pneumonia will still infect, and a subset of people will require hospitalization. 
        • Governments must ensure that the costs of pneumonia diagnosis and treatment are affordable for even the lowest income households. One strategy is to strengthen primary health care to treat non-severe cases, including with oxygen and antibiotics if required, which should reduce the need for expensive hospitalization. For example, the multi-country review found that the total cost per episode for treatment of severe pneumonia in the community was $US4 compared to $US243 for hospital care. In The Gambia out-of-pocket costs were US$15 for outpatient services compared to US$109 for hospital care, and $US8 versus $US64 in Ethiopia.
        • Achieving this will require investments in the diagnostic capacity of primary health care to accurately identify the pneumonia patients needing hospital care. Pulse oximetry is one tool that can help by identifying patients with hypoxemia in urgent need of oxygen. And for the subset of patients with severe pneumonia who do need critical care, governments must cover the costs as part of UHC.

4. Increasing care seeking

        • Studies have revealed that the high costs of pneumonia treatment are one of the major reasons so many children (40%) with pneumonia symptoms are not taken for care. The proportion is even higher (up to 77%) in the countries where pneumonia deaths concentrate, according to the Every Breath Counts Pneumonia Care Seeking Scorecard. 
        • As pneumonia care seeking is the official indicator for “child treatment” in the UHC Service Coverage Index, developed by the World Health Organization (WHO) and the World Bank, countries will be judged on UHC progress according to the proportion of children with pneumonia who seek treatment.

How you can help

To document the high out-of-pocket costs of pneumonia treatment in low- and middle-income countries, Every Breath Counts is launching a new campaign on UHC Day – You Paid WHAT? The Crippling Costs of Pneumonia Treatment. If you are an adult or the parent of a child who has incurred high out-of-pocket costs for an episode of pneumonia, we want to hear from you.

Simply answer these seven simple questions here. Your identity will be protected. We will be collating the information you share on out-of-pocket costs by location and type of treatment and sharing the information publicly, without attribution, to raise awareness. Share the campaign materials here with your family, friends, and networks, especially on your preferred social media channels. 

The stakes are high

The high costs of pneumonia treatment are one of the reasons pneumonia remains the world’s leading infectious killer of children and adults. And COVID-19 has increased deaths from respiratory infections exponentially in the past three years. By taking three actions – (1) increasing pneumonia vaccination, (2) strengthening primary health care to treat non-severe pneumonia at home, and (3) fully covering the costs of hospital treatment for pneumonia as part of UHC, especially for low-income households – governments can simultaneously reduce pneumonia deaths, poverty rates, and healthcare costs. A win-win-win for all.

[1] India ($59), Ethiopia ($US77), Nigeria ($US64), The Gambia ($US109), Bangladesh ($US147).

More resources

In addition to the eight studies cited, take a look at the wealth of information on the costs of pneumonia treatment from the The Decade of Vaccine Economics (DoVE) and the Value of Immunisation Compendium of Evidence (VOICE) led by International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health.

December 2022, Universal Health Coverage Day