Indirect expenses
Loss of income due to hospitalization of the patient or a family member who has to stay with a patient in the hospital was observed in all income quintiles. We classified the employment status of the patients into three categories; as those who were 1. Unemployed 2. Employed with a daily wage or non-fixed income (daily-paid workers), 3. Employed with a monthly salary or retired with a pension.
The worst impact of hospital admission on household economy was seen in patients earning a daily wage or those whose mode of income was small-scale self-employment (e.g. manual laborers, owners of small shops, taxi drivers). The loss of income of hospitalization had a direct impact on their households. A patient who is a manual laborer mentioned, “I have been in the hospital for the last eight days. My household income is totally lost, and my wife had to leave the children with our neighbor and find daily-paid manual work. We also borrowed money from relatives.”
The impact was also seen to be higher among the poorer people who had minimal or no savings. This is illustrated in the following statement of a patient who was a manual laborer, belonging to the second income quintile: “Me and my son are the two breadwinners of the family. My wife stays at home and our two daughters are still schooling. I have been in the hospital for the last five days and my son has to stay with me. My son has to pay daily to the owner of the three-wheeler, which he drives. Thankfully he has been given a months’ time to pay his debt. My wife’s brother is helping us.”
On the other hand, loss of income was not a problem or was only a minor problem for patients with more stable, fixed-income occupations in either the government or private sector. A patient’s income is not affected if they are paid a monthly salary and the duration of hospital admission is within the approved quota for medical leave.
Patients with long-standing diseases such as cirrhosis are likely to be affected more by recurring out-of-pocket expenditures and disruptions to household income. Many of these patients had multiple medical problems requiring numerous hospital visits and admissions. As a result of their illness, most of their household activities and functions were also disturbed. Furthermore, there were patients whose illnesses have rendered them unsuitable to carry out their occupations and/or for employment.
Patients of lower income categories were less protected from these direct and indirect costs due to lack of savings, support, compensation or inability to find an alternative occupation. Patients from lower economic backgrounds often used terms such as “helpless, disrupted, lost, devastated” when describing the household impact of illness and hospital admission. The impact on patients in middle- and higher-income categories was less, mainly due to the availability of a monthly wage or pension, savings and stronger family support.