Indian Journal of Medical Research

: 2017  |  Volume : 146  |  Issue : 3  |  Page : 426--429

Out-of-pocket expenditure due to hepatitis A disease: A study from Kollam district, Kerala, India

PS Rakesh1, Rahul Retheesh2, Rangeen Chandran2, A Sadiq2, S Ranjitha2,  
1 Centre for Public Health Protection, Kollam, Kerala, India
2 Department of Community Medicine, Travancore Medical College, Kollam, Kerala, India

Correspondence Address:
P S Rakesh
Centre for Public Health Protection, Kollam, Kerala

How to cite this article:
Rakesh P S, Retheesh R, Chandran R, Sadiq A, Ranjitha S. Out-of-pocket expenditure due to hepatitis A disease: A study from Kollam district, Kerala, India.Indian J Med Res 2017;146:426-429

How to cite this URL:
Rakesh P S, Retheesh R, Chandran R, Sadiq A, Ranjitha S. Out-of-pocket expenditure due to hepatitis A disease: A study from Kollam district, Kerala, India. Indian J Med Res [serial online] 2017 [cited 2021 Jun 14 ];146:426-429
Available from:

Full Text

Several outbreaks of hepatitis A have been reported from Kerala, India, in the last 10 years [1],[2],[3],[4]. An average of 8268 [standard deviation (SD) 1767] cases suspected to have hepatitis A per year has been reported to the State's official disease surveillance system[4],[5]. Most of the affected individuals were young adults between 15 and 35 yr age group. Many public health experts have opined that the Government should start thinking of hepatitis A vaccination in Kerala[6],[7]. Cost is considered as a major concern by many for recommending hepatitis A vaccine in the State. Knowing the out-of-pocket expenditure due to hepatitis A will help the policymakers to decide on the vaccination policy in the State. The present study was done in Kollam district of Kerala in 2015 to estimate the out-of-pocket expenditure experienced by households due to hepatitis A disease.

Kollam district with a population of around 2.6 million has reported maximum number of hepatitis A cases in the State[4],[5]. The female literacy rate for the district is 92 per cent[8]. Integrated disease surveillance programme (IDSP) has been performing reasonably well in the district with the help of a good primary health care team and notifications from major private hospitals. Apart from IDSP weekly reporting, the State also depends on a daily telephone-based reporting system, which collects information regarding communicable diseases from all the government hospitals on a daily basis. The District Surveillance Unit (DSU) prepares a line list of affected people for major communicable diseases based on information from daily and weekly reports. The district reported 584 cases of hepatitis A during 2015. Line list of people affected with hepatitis A notified to the DSU during August-October 2015 (n=114) was obtained.

All 114 individuals with confirmed hepatitis A were contacted with the help of primary health care team. Exploratory interview, using a pretested and validated questionnaire, was conducted during November 2015-January 2016, with the selected participants at their houses. Details of cost during hospitalization, consultation fees to doctors including traditional healers, amount spent on drugs including traditional medicines, laboratory investigations, additional amount spent for food and travel due to illness by the patient and relatives, informal tips, payment to caregivers, wages lost due to sickness for the patient and wage loss to any relative were collected in detail. Bills and medical records available with the patients were verified. The study was approved by Ethics committee of Center for Public Health Protection, Kollam (6/2015 dated 15.06.15).

For assessing the indirect cost, only the actual income loss to patient and relatives was considered. The productivity loss due to forgone non-market activities including school, household works and intangible cost was not converted to monitory terms. Data were analyzed using SPSS version 12 (SPSS, Chicago, IL, USA). Data were presented as a total and as an average with a SD in local currency, i.e., Indian Rupees (') and US dollars (US$) applying the exchange rate (US$1='68).

A total of 95 of 114 patients were interviewed. Others could not be contacted (n=6) or were not available at the address provided (n=13) during the data collection period. Among them, 40 per cent (n=38) were less than 15 yr, 47.4 per cent (n=45) were between 16 and 30 yr and 10.5 per cent (n=10) were between 31 and 45 yr. Males constituted 60 per cent (n=57). Of them, 60 per cent (n=57) were students, 16.8 per cent (n=16) were unskilled/semi-skilled labourers, 6.3 per cent (n=6) were homemakers, 4.2 per cent (n=4) were professionals/semi-professionals, 3.2 per cent (n=3) were skilled labourers and 2.1 (n=2) per cent were doing petty business. Further, 78.9 per cent (n=75) of the household interviewed possessed a below poverty line card.

Of the 95 patients, 79 (83.2 %) had hospital admission, and 77.1 per cent (61/79) had admissions in government hospitals. The mean number of days admitted in hospital was 7.60 (standard error 0.92), median being four days. Of them (n=95), 30.6 per cent (n=29) consulted only modern medicine doctors, 18.9 per cent (n=18) consulted Ayurveda system, 6.3 per cent (n=6) visited traditional healers while 44.2 per cent (n=42) visited practitioners from more than one system. The median work days lost due to illness was 60 (range 21-180 days). The details of amount spent for each purpose and the total out-of-pocket expenditure (OOPE) are given in [Table 1]. The mean direct medical cost, direct non-medical cost and indirect costs were '8446.2 (95% confidence interval (CI) '6726.1-10,166.3), '4438.1 (95% CI '3502.1-5374.2) and '11890.5 ('6762.2-17,018.4), respectively. Total OOPE for the households due to one of its members affected with hepatitis A disease in Kollam district was '24,774.8 (95% CI '19426.3- 30,123.2) (364 US$) with a median expenditure of '17,700 (260 US$).{Table 1}

The details of OOPE by various categories are given in [Table 2]. The OOPE due to hepatitis A disease was higher among those who sought care in modern medicine, especially from private sector.{Table 2}

In our study 34 per cent of total OOPE was found to be contributed by direct medical expenses while nearly 47 per cent was due to indirect expenditures. Majority of the patients were students and hence not working. The period of absence in schools and year lost due to missing examinations were not converted to monitory terms in the current study. Capturing the health system costs due to hepatitis A which includes service and material costs at government hospitals and cost of public health interventions to deal with hepatitis A cases will give the true picture of the economic loss due to hepatitis A disease. It should also be noted that the indirect costs of health care also contribute to the financial burden incurred by households. There could be some recall bias as data were collected after receiving treatment. However, to minimize the bias, we conducted all interviews between three and four months after initial diagnosis. Sample size was small limiting the ability to look at sub-groups and interactions. The official disease surveillance system has its own weaknesses that it may miss many hepatitis A cases.

The HAV antibody seroprevalence rates reported from Kerala was <10 per cent in children below five years when compared to 60-80 per cent from many other parts of the country [9],[10],[11]. Among the Indian States, Kerala has the highest average out-of-pocket healthcare spending share and there is very little variation in this share across consumption expenditure quintiles[12]. We could not find any recent studies on OOPE due to hepatitis A from India; however, the OOPE in the current study seemed very high when compared with the same estimated by other studies for other communicable diseases such as tuberculosis under DOTS from Chennai and acute illness including hospitalizations from Puduchery[13],[14]. The OOPE for those who sought treatment from private sector was high in this study, and this result was consistent with other study reports from India[15].

To conclude, the average household OOPE due to one of its members affected with hepatitis A disease in Kollam district was around '25,000. Directions for future research include assessing the real burden of hepatitis A and detailed economic analysis of universalizing HAV vaccination in the State.


Authors acknowledge the District Surveillance Unit, Integrated Disease Surveillance Project, Kollam, and primary health care team of Kerala State Health Services, Kollam, for permissions and help.

Conflicts of Interest: None.


1Kumar T, Shrivastava A, Kumar A, Laserson KF, Narain JP, Venkatesh S, et al. Viral hepatitis surveillance - India, 2011-2013. MMWR Morb Mortal Wkly Rep 2015; 64 : 758-62.
2Arankalle VA, Sarada Devi KL, Lole KS, Shenoy KT, Verma V, Haneephabi M, et al. Molecular characterization of hepatitis A virus from a large outbreak from Kerala, India. Indian J Med Res 2006; 123 : 760-9.
3Rakesh PS, Sherin D, Sankar H, Shaji M, Subhagan S, Salila S, et al. Investigating a community-wide outbreak of hepatitis A in India. J Glob Infect Dis 2014; 6 : 59-64.
4Directorate of Health Services. Data on Communicable Diseases. Thiruvananthapuram, Kerala: DHS; 2016. Available from:, accessed on May 16, 2016.
5Directorate of Health Services. Information Regarding Hepatitis A Data. Right to Information Act No.: PH4 1698/2016 DHS 13.1.16. Thiruvananthapuram, Kerala: DHS; 2016.
6Rakesh PS, Abubakar A, Dev S, Dharman V, Ramachandran R. Return of the water devil: Kerala need to be cautious about Hepatitis A outbreaks. Kerala Med J 2015; 4 : 14-6.
7Maya C. Hepatitis Outbreaks Warrant New Strategies. The Hindu 2014. Available from:, accessed on March 15, 2016.
8Census 2011, Government of India. Kollam District: Census 2011 data Available from:, accessed on May 20, 2016.
9Mall ML, Rai RR, Philip M, Naik G, Parekh P, Bhawnani SC, et al. Seroepidemiology of hepatitis A infection in India: Changing pattern. Indian J Gastroenterol 2001; 20 : 132-5.
10Mathew P, Bobba R, Zacharias P. Hepatitis A seroprevalence in Kerala. Indian J Gastroenterol 1998; 17 : 71-2.
11Mittal SK, Rastogi A, Rastogi A, Kumar N, Talukdar B, Kar P, et al. Seroprevalence of hepatitis A in children - Implications for hepatitis A vaccine. Trop Gastroenterol 1998; 19 : 120-1.
12Soumithra G. Catastrophic payments and impoverishment due to out-of-pocket health spending. Econ Polit Wkly 2011; 46 : 63-70.
13Archana R, Kar SS, Premarajan K, Lakshminarayanan S. Out of pocket expenditure among the households of a rural area in Puducherry, South India. J Nat Sci Biol Med 2014; 5 : 135-8.
14Ananthakrishnan R, Muniyandi M, Jeyaraj A, Palani G, Sathiyasekaran BWC. Expenditure pattern for TB treatment among patients registered in an urban government DOTS program in Chennai city, South India. Tuberc Res Treat 2012; 2012 : 747924.
15Shepard DS, Halasa YA, Tyagi BK, Adhish SV, Nandan D, Karthiga KS, et al. Economic and disease burden of dengue illness in India. Am J Trop Med Hyg 2014; 91 : 1235-42.