SPECIAL ARTICLE

The High Cost of Dying

Laishram Ladusingh, Anamika Pandey

The cost of the inpatient care of decedents is much higher than that of survivors at all stages of life. The differential is significantly higher for those residing in rural areas, staying longer in hospitals, utilising private health facilities and suffering from chronic diseases. The difference is due to physicians in private hospitals prescribing more expensive drugs, subjecting patients to more clinical tests and higher charges on utilisation of amenities and facilities. The findings support the absolute income hypothesis that the economically better-off spend more on healthcare and the end-of-life care hypothesis that healthcare expenditure on efforts to save life is high.

Laishram Ladusingh (lslaishram@iips.net, ladusingh2010@gmail.com) is with the International Institute for Population Sciences, Mumbai and Anamika Pandey (anamika_anamika20@yahoo.co.in) is a PhD scholar at the International Institute for Population Sciences, Mumbai.

ut-of-pocket (OOP) healthcare expenditure in India constituted 4.8% of household consumption and 10.7% of household non-food expenditure in 1999-2000 (Garg and Karan 2009) which escalated to 12.2% and 21.7% respectively in 2004-05 (Ladusingh and Pandey 2013). This is unprecedented and is one of the highest OOP expenditures in the world. In the Indian context an unexplored but alarming aspect of OOP healthcare expenditure is the high cost of decedents as compared to survivors. Little is known about how the cost of inpatient care of decedents differs from that of survivors cost by sex, residence background and types of disease. In this paper an attempt is made to ll this research gap and provide key inputs for strengthening the public health system and broadening the social security coverage. One of the earliest studies by Sutton (1965) has shown that 48% of all deaths occurred in short stay hospitals and 63% of these had used some hospital services, but did not provide information on treatment cost. In the US in 1997 per capita medicare paid to patients in the last year of life is six times the cost of that paid to survivors (Raphael et al 1993) while it was seven to one in 1988 (Lubitz and Riley 1993). Payne et al (2009) in a study in Canada found that during 1991 to 2001, the ratio of decedent to survivor costs have increased for all age groups, and were greatest for hospital and continuing care costs. About one-quarter of medicare outlays are for the last year of life and it remains unchanged from 20 years ago (Hogan et al 2001). Emanuel et al (2000) have found that for patients needing substantial care, 10% of household income was spent on healthcare, families had to cope with loans, second mortgages or take an additional job. In India 5.6% of households had to nance OOP healthcare expenditure by taking loans (Ladusingh and Pandey 2013). Ginzberg (1980) attributed the high cost of dying to disproportionate spending on patients who are terminally ill. The advancement in healthcare technology and availability of costly life-saving drugs have also contributed to inpatient care cost. Epidemiological transition too escalates inpatient OOP healthcare expenditure for decedents since most deaths are a result of chronic diseases and multi-organ failures. The decline in age-specic mortality rates over time postpones death to later ages pushing up the healthcare costs of dying (Seshamani and Garg 2004a). The relationship between age and time with death and health expenditure has been extensively studied for different countries by Seshamani and Garg (2004b), Stearns and Norton (2004), Zweifel et al (2004) and Werblow et al (2005). This study seeks to shed light on the high cost of inpatient care for the decedents in comparison to that of survivors in
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India by socio-demographic and types of disease of patients. It covers a broad spectrum of inpatient care, such as the duration of hospitalisation, medical and non-medical component of OOP expenditure, and comparison of cost of inpatient care between public and private health facilities. The other main objectives of this study are to test two main hypotheses: the end of life hypothesis and the absolute income hypothesis of healthcare expenditure. This study is the rst of its kind in India and hopes to enrich literature on public health research.
Data and Methods

The data used in this study consists of 31,868 hospitalised cases of which 2.2% died as inpatients in the course of treatment. The source is the 60th round of National Sample Survey Ofce (NSSO, 2004-05) on morbidity and healthcare. It is a nationally representative household survey and a multi-stage stratied sampling design is adopted. For each member of the sampled representative households, details about age, sex, morbidity status of acute and chronic diseases, status of treatment and hospitalisation were collected. Further for each individual, episodes of ailment in the one-year period preceding the survey, treatment status, medical and non-medical OOP expenditures, duration of hospitalisation and public or private afliation of health facilities utilised for treatment were collected using a semi-structured questionnaire. The concern that inpatient care expenditure is limited to hospital cost and does not give the full picture of the total cost according to Scitovsky (2005) is taken care of in this study by considering both medical and non-medical costs, fees and charges for clinical tests, transportation cost, cost of drugs and appliances, and expenditure towards food and lodging of the accompanying person. Descriptive statistics and bivariate analysis are employed to describe characteristics of inpatients and comparison of unadjusted mean OOP expenditure for inpatients care between decedents and survivors, between public and private health facilities and characteristics of inpatients. It is the annual OOP expenditure that has been considered in this study. A multilevel hierarchical model is used for OOP expenditure for inpatient care and analyse differential by survival status demographic and economic background, types of disease and public-private afliation of health facility. During the one-year reference period an individual suffering from certain diseases may be hospitalised for inpatient care a number of times. For each episode of hospitalisation, the data provide medical and non-medical and other OOP expenditure for inpatient care together with the disease and other information. The types of disease in this study are grouped into chronic, acute and others. Items included in other medical expenditure and other charges together with grouping of diseases are provided in the Appendix (p 49). At the individual level the data has information on age, sex, survival status, residence background and economic status. Considering the clustering of episodes of hospitalisation for an individual a two-level hierarchical model is considered appropriate for modelling the OOP inpatient care expenditure.
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The multilevel model used in this study is of form Log(OOPEij)=oij+1 xij+eij (1) (2) oij = 0+uoj where i denotes episode of hospitalisation for inpatient care, the j denotes an individual and OOPEij the OOP expenditure for inpatient care for ith episode of jth individual. Explanatory variables x ij include variables measured at both episode and individual levels. In this random intercept model, the mean OOP expenditure (in log scale) for inpatient care varies by individuals and between episodes of hospitalisation. The random part of the model comprises the random terms, u0j at the individual level and eij at the episode level. Random terms are assumed to follow independent normal distributions, u0j~N(0, u2) and eij~N(0, e2). For estimation of model parameters MLW iN version 2.02 is used.
Results and Discussion

The gap in the mean OOP expenditure for inpatient care between decedents and survivors by age are shown in Figure 1. Two distinct features can be noticed. First, the mean OOP expenditure of decedents is signicantly higher than that of survivors across age and second, the OOP inpatient care cost regardless of survival status at old age is still high but tends to drop.
Figure 1: Mean Out of Pocket Expenditure for Inpatient Care of Decedents and Survivors by Age in India (2004-05)
Mean annual inpatient care cost (Rs) 20,000 15,000 Survivors 10,000 5,000 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Decedents

Further to examine differential in mean costs of inpatient care by types of diseases for decedents and survivors, Table 1 (p 46) shows the distribution of inpatients cross classied by survival status and types of disease. It is observed that 19% of the decedents sought inpatient care for treatment of cardiovascular diseases (CVD) followed by 16.3% for other chronic ailment, 11.6% for other diagnosed ailments, 8.4% for accidents, injuries burns and bone fractures. The inpatients that died of tuberculosis (TB), bronchial asthma, respiratory and those diseases of the ear, nose and throat and neurological disorder constitute 7.8%, 7.1%, 5.4% and 4.3% respectively of decedents. About 8% died of undiagnosed ailments. On the other hand, 15.5% of the survivors sought inpatient care for other chronic ailments and 16.8% for other diagnosed ailments. Survivors who were treated as inpatients for CVD, accidents, injuries, burns and bone fractures, fever and diarrhoea and dysentery constitute 9.2%, 9.8%, 7.7% and 7.4% respectively of survivors. While comparing the mean OOP health expenditure for inpatient care of decedents and survivors, the treatment costs for accidents, injuries, burns and bone fractures, CVD and diseases of kidney and urinary system are higher than that of other diseases, the cost incurred by decedents for treatment of
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other chronic diseases and other diagnosed ailment not in the list is nearly double that of the OOP expenditure incurred by the survivors for these diseases while it is the other way round in the case of treatment of neurological disorders. It is obvious that for most ailments and diseases the mean OOP inpatient care expenditure of decedents is higher than that of the survivors. As there is no information about the seriousness and critical stages of the ailments and diseases, it is not possible to comment on whether spending more can save lives or not. However, it is clear from Figure 2 that among the decedents who died in the 15-59 and 60 years and above groups, the cause of death was chronic diseases.

Figure 2: Distribution of Inpatients by Survivor Status, Broad Age Groups and Type of Diseases in India (2004-05)
Relative distribution of diseases 100 80 60 40 20 0 Decedents Survivors Others Chronic Acute Decedents Survivors Decedents Survivors Less than 15 years 15-59 years 60 years and above

mean medical expenses for decedents are Rs 6,571 as compared to Rs 3,651 of survivors while the corresponding gures are Rs 13,550 and Rs 8,916 respectively for inpatients treated in private facilities. Table 1: Distribution of Inpatients by Disease and Mean Annual Out-of-Pocket Expenditure by Survival Status of Hospitalised Cases in India (2004-05) The OOP expenditure towards physician Disease Groups % N % N Mean Inpatient Care fee, medicine costs and other medical items Decedents Survivors Decedents Survivor Expenditure (in Rs) Decedents Survivors for inpatients hospitalised in private facilities Fever of unknown origin 2.61 24 7.67 2,074 5,820 2,882 is invariably higher than utilisation of public Diarrohea/dysentery 0.79 16 7.39 2,542 3,953 1,729 facilities for inpatient care. But the gap betBronchial asthma 7.14 54 3.16 883 5,199 4,102 ween private and public health facilities utiliRespiratory including ear/nose/throat 5.39 13 3.18 816 1,896 4,555 sation for inpatient care for each component Accidents/injuries/burns/fractures/poisoning 8.42 49 9.83 3,020 9,489 9,609 of medical expenses for the decedents are Other acute ailment 2.38 22 5.9 1,888 7,901 3,809 much wider than those of survivors. The Gastritis/gastric/peptic ulcers 1.92 17 4.66 1,634 21,680 5,401 mean physician fees for decedents treated in Tuberculosis 7.85 53 2.41 847 7,603 7,060 private facilities is Rs 4,416 as compared to Neurological disorders 4.26 25 3.17 1,016 6,566 12,153 Diseases of kidney and urinary system 3.87 36 4.14 1,368 15,649 11,383 Rs 714 for those treated in public facilities Cardiovascular diseases 19.12 148 9.24 2,785 10,326 12,628 and for the survivors the mean expenses are Other chronic ailment 16.68 136 20.94 6,645 16,898 8,158 Rs 1,123 and Rs 2,249 respectively for the Other diagnosed ailment 11.63 79 16.78 5,087 11,298 6,597 corresponding health facilities. The mean Other undiagnosed ailment 7.95 43 1.52 548 4,890 4,759 medical costs of decedents who died in priTotal 100 715 100 31,153 10,036 7,126 vate hospital facilities are Rs 6,872 as against It indicates that decedents were admitted to hospital for dis- Rs 2,681 for those treated in public facilities. As for the survivors the mean medical costs of inpatients treated in private eases of a more serious nature than that of the survivors. The OOP expenditure for inpatient care disaggregated by and public facilities are Rs 2,606 and Rs 1,835 respectively. the major purpose of expenditure under medical and non- There is no doubt that the facilities, amenities and appliances medical categories can reveal differentials in charges for phy- used in the private health facilities are better than those used sician, costs of medicines, payment for clinical tests, trans- in the public facilities. The exorbitant medical expenses for port and lodging expenses. The public health system in India seeking treatment in private facilities partly include the charges is unable to keep pace with the demand for healthcare (Singh for these amenities. It is a known fact that the economically better-off patients and Ladusingh 2010) and functions under the public-private partnership strategy. However there is no standardisation of and those who were willing to pay availed healthcare from fees and charges for services, facilities, medicines and appli- private facilities. The high medical cost of decedents treated ances. As a consequence both outpatient and inpatient care as inpatients in private facilities may be due to physicians expenses in the private health facilities are Table 2: Mean Annual Inpatient Care Expenditure of Decedents and Survivors by Heads of Expenditure and Public-Private Status of Hospitals in India (2004-05) exorbitant. Table 2 shows the mean annual Heads of Inpatient Care Expenditure Mean Expenditure (in Rs) OOP expenditure for inpatient care for mediPublic Hospital Private Hospital All Inpatients Decedents Survivors Decedents Survivors Decedents Survivors cal and non-medical purposes disaggrega714 1,123 4,416 2,249 3,610 2,094 ted by public and private health facilities for Doctor/surgeon fees Medicine 2,681 1,835 6,872 2,606 4,407 2,266 decedents and survivors. Both medical and Other medical expenditure 762 974 3,098 1,948 2,013 1,629 non-medical expenses of decedents are much Other charges 664 557 2,291 753 1,382 666 higher than that of survivors regardless of Expenditure not reported elsewhere 6,117 2,556 9,921 6,768 8,182 5,314 the public or private status of the hospital. Total medical expenditure 6,571 3,651 13,550 8,916 10,134 6,885 The OOP expenditure for care of inpatients Transport 436 276 1,005 360 701 327 treated in private health facilites is much Lodging charges 621 714 1,528 797 1,006 764 371 350 439 463 405 417 higher than that of those treated in public Other non-medical expenditure 632 484 1,266 615 932 563 facilities, both for decedents and survivors. Total non-medical expenditure 6,212 3,829 14,151 9,319 10,036 7,126 For inpatients treated in public facilities the Total inpatient expenditure
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prescribing more expensive life-saving drugs and subjecting patients to advanced treatments. The share of non-medical expenses in the total OOP expenditure for inpatient care is within 8-12% irrespective of the survival status of inpatients and public-private afliation of the health facilities.
Table 3: Distribution and Mean Annual Inpatient Care Expenditure by Survival Status and Background Characteristics of Inpatients in India (2004-05)
Background Characteristics Percent/ Mean Decedents N Mean Inpatient Expenditure (in Rs) Percent/ Mean Survivors N Mean Inpatient Expenditure (in Rs)

Age (in years) Less than 15 15-59 60 and above Sex Male Female Place of residence Rural Urban MPCE tertile Poor Middle Rich Hospital type Public Private Disease groups Acute Chronic Others Hospitalisation days Total

19.3 44.8 36.0 64.2 35.8 66.9 33.1 37.9 34.1 27.9 51.8 48.2 26.7 53.4 19.9 11.0

95 345 275 421 294 444 271 236 253 226 396 319 178 411 126 715 715

5,729 11,257 10,827 9,420 11,139 10,025 10,059 6,447 8,801 16,424 6,212 14,151 6,148 12,439 8,820 10,036

19.3 5,753 62.3 19,866 18.5 5,534 52.6 16,475 47.4 14,678 68.8 19,643 31.2 11,510 33.2 10,613 35.5 10,604 31.3 9,936 39.9 14,249 60.1 16,904 37.1 11,223 42.7 13,687 20.2 6,243 9.0 31,153 31,153

3,854 7,727 8,514 7,495 6,717 6,144 9,294 4,563 6,150 10,946 3,829 9,319 4,828 9,389 6,567 7,126

care of the survivors of the same sex and residence background. The mean OOP expenditure for the inpatient care of the survivors shows a signicant difference by MPCE tertiles both for decedents and survivors. The mean OOP expenditure for rich inpatients is more than twice the expenditure of poor inpatients irrespective of the survival status. The four versions of the two-level random intercept model described in the methodology section are implemented to assess the t of the proposed model and make out which of the demographic and economic correlates have a signicant effect on OOP expenditure. Model I is an empty model with no covariate control but with a random intercept, which is found to be signicant at p<0.01. The signicance of random intercept indicates considerable variation in mean OOP expenditure for inpatient care between individuals and between episodes of hospitalisation of individuals. The random effect parts of the twolevel model points out considerable variation in OOP expenditure between individuals and also between episodes of individuals and these are statistically signicant at p<0.01. In Model II residence, economic well-being measured by MPCE tertile and the survival status of individuals are included, in addition to random intercept. Even after controlling for residence, economic and the survival status of inpatients, the OOP expenditure varies signicantly between individuals and between episodes of hospitalisation and are still statistically signicant at p<0.01. The OOP expenditure for inpatient care for survivors is signicantly less than that for the decedents after

The OOP expenditure for hospitalised care for decedents and survivors not only varies by ailments but also by demographic and economic background of the inpatients as can be seen from Table 3. The distribution of decedents and survivors varies by age, for survivors there are more inpatients in the 1559 years age group and lesser in the 60 plus group while for decedents a sizeable proportion of them are in 60 plus group. There are more male and rural residents for both decedents and survivors but no distributional differential by monthly per capita consumption expenditure (MPCE) tertile, a proxy for economic well-being. Among the decedents nearly an equal proportion of inpatients utilised the public and private health facilities while three-fths of the survivors utilised the private facilities. A higher proportion of decedents utilised inpatient care for chronic diseases as compared to the survivors. The mean number of days of hospitalisation of decedents is higher by two days than that of the survivors. It has been noted in the preceding discussion on results that the mean cost of inpatient care is higher for the treatment of chronic diseases and for the hospitalisation in private health facilities. It is noted that for decedents the mean OOP expenditure for inpatients in all the three broad age groups is more than the expenditure of survivors in the corresponding age groups. For male and rural decedents the mean cost of the OOP inpatient care is nearly twice the OOP expenditure on inpatient
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Table 4: Main Effects of Selected Variables on Cost of Inpatient Care in India (2004-05)
Fixed Effects Model I Model II Model III Model IV

Constant Place of residence Rural Urban MPCE tertile MPCE 1 MPCE 2 MPCE 3 Survival status Decedents Survivors Sex Male Female Age (in years) Less than 15 years 15-59 years More than 59 years Type of health facility Public Private Disease groups Chronic Acute Other diseases Duration of hospitalisation (in days) Random effects u2 e2 Deviance Intraclass correlation coefficient

7.95

8.76

6.87

6.96

-0.19

-0.16

0.26 0.74

0.20 0.53

-0.44

-0.40

-0.41

-0.13

-0.13

0.30 0.26

0.27 0.20

1.17

1.12

-0.51 -0.18 0.03

-0.49 -0.17 0.03

0.65 0.62 0.49 0.48 1.58 1.53 1.15 1.13 1,15,021 1,13,896 1,05,160 1,04,467 0.29 0.29 0.30 0.30

: Reference category, MPCE: monthly per capita consumption expenditure.

inpatients in the 15-59 and 60 plus years age group is signicantly higher than that of younger inpatients under 15 years of age. The result supports the hypothesis of high healthcare cost at the end of life. OOP expenditure for inpatients treated in private health facilities is higher than that of inpatients in public health facilities and the longer the duration of hospitalisation the higher is the cost of inpatient care. Inpatient care for acute and other diseases is less expensive than that of treatment for chronic diseases. These differences by age, duration of hospitalisation and afliation of health facilities are all signicant at p<0.01. Model V examines the contribution of demographic, economic and survival status, type of disease, duration of hospitalisation and public-private status of health facilities in explaining variation in OOP expenditure for inpatient care. From the 2 test of deviance statistics of the successive aforesaid models, it comes out that Model IV provides the best t. Even after controlling all the aforesaid correlates, there is still signicant difference in the mean OOP expenditure for inpatient care between individuals and between episodes of hospitalisation, but the size of difference has reduced as compared to the empty model and the other two models where the effects of correlates were partially controlled. In the nal model the direction and levels of statistical signicance of individual correlate when the rest are controlled remain unchanged but the magnitudes of their main effects have reduced marginally. This indicates the importance of age, sex, residence background, economic and survival status, types of diseases, duration of hospitalisation and public-private afliation of the health facilities in explaining the variation in OOP expenditure of inpatient care in India.
Conclusions

controlling for residence and the MPCE tertile and so is that of urban residents in comparison to that of rural residents after adjusting for economic and survival status (Table 4). The rural-urban difference is largely because of the urban residents who enjoy better provision and accessibility of facility for inpatient care and adoption of preventive care from worsening health conditions. The signicantly higher OOP expenditure for inpatient care of decedents even after adjusting for residence and economic status conrms the high expenses for decedents regardless of the background of the inpatients. When the confounding effect of residence and economic status are adjusted compared to inpatients from the lowest MPCE tertile, those from the middle and the highest MPCE tertile incurred higher OOP expenditure. This nding is statistically signicant at p<0.01 and supports the absolute income hypothesis that the economically better off spend more on healthcare. Model III is designed to examine differential in OOP expenditure for inpatient care by age, sex, public-private afliation of the health facility, types of disease and duration of hospitalisation controlling for survival status of inpatients. The inpatient care OOP expenditure for females is less than that for their male counterparts when the other effects of other correlates just mentioned are adjusted and the difference is statistically signicant. This is a reection of discriminatory social practices in intra-household resource allocation. It is also evident that inpatient care cost tends to increase according to the advancing age of inpatients as expenditure of
48

This study examined the relationship between decedents and survivors OOP expenditure for inpatient care, which includes both medical and non-medical expenses. The ndings that the cost of inpatient care of decedents is much higher than that of the survivors, particularly for those residing in rural areas, staying longer in hospitals, utilising private health facilities and suffering from chronic diseases are important for future healthcare system development and resource planning. The knowledge of the high decedent-to-survivor inpatient care costs ratio can be combined with increasing life expectancy and prevalence of morbidity to access the healthcare needs of the gradually ageing population of India. Lower inpatient care OOP expenditure for urban residents is indicative of the need for the expansion of the public healthcare system in rural areas. Higher inpatient care expenditure by richer patients also indicates the high utilisation of health facilities by the afuent leaving the poor out of the healthcare net. There is signicant differential in the OOP inpatient care cost between individuals and between episodes of hospitalisation of individuals. The intra-class correlation coefcient of hospitalisation episodes expenditure of individuals is as high as 0.30, which indicates that subsequent inpatient care OOP expenditure remains high. There is no evidence of such a study in India and the geriatric healthcare programme can take note of the high inpatient care cost at the end of life for especially embarked social security and other social assistance.
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References
Emanuel, E, D L Fairelough, J Slutsman and L Emanuel (2000): Understanding Economic and Other Burdens of Terminal Illness: The Expenditure of Parents and Their Caregivers, Annals Internal Medicine, 132: 451-45. Garg, C C and A K Karan (2009): Reducing Out-ofPocket Expenditure to Reduce Rural Poverty: A Disaggregated Analysis at Rural-Urban Level in India, Health Policy Planning, 24 (2):116-28. Ginzberg, E (1980): The High Cost of Drying, Inquiry, 17: 293-95. Hogan, C, J Lunney, J Gabel and J Lynn (2001): Medicare Beneciaries Costs of Care in the Last Year of Life, Health Affairs, 20(4): 188-95. Ladusingh, L and A Pandey (2013): Health Expenditure and Impoverishment in India, Journal Health Management (forthcoming). Lubitz, J D and G F Riley (1993): Trends in Medicare Payment in the Last Year of Life, New England Journal of Medicine, 328: 1092-96. Payne, G, A Laporte, D K Foot and P C Coyte (2009): Temporal Trends in the Relative Cost of Dying: Evidence from Canada, Health Policy, 90: 270-76. Raphael, C, J Attens and N Fowlex (2001): Financing End of Life Care in the USA, Journal of Royal Society of Medicine, 94: 458-61. Scitovsky, A A (2005): The High Cost of Dying: What Do the Data Show?, The Milbank Q 83(4): 825-41. Seshamani, M and A M Garg (2004a): Time to Death and Health Expenditure: An Improved Model for the Impact of Demographic Change on Health Care Costs, Age and Ageing, 33:556-61. (2004b): A Longitudinal Study of the Effects of Age and Time to Death on Hospital Costs, Journal of Health Economics, 23: 217-35.

Singh, C H and L Ladusingh (2010): Inpatient Length of Stay: A Finite Mixture Modeling Analysis, European Journal of Health Economics, 11(2): 119-26. Stearns, S C and E C Norton (2004): Time to Include Time to Death? The Future of Health Care Expenditure, Health Economics, 13(4): 315-27. Sutton, G F (1965): Hospitalisation in the Last Year of Life, United States-1961, Vital and Health Statistics, Series 22(1), US Department of Health, Education and Welfare, Hyatt & Ville. Werblow, A P Felder S Zweifel (2005): Population Aging and Health Care e\Expenditure: A School of Red Herring , Faculty of Economics and Management Magdeburg, Working Paper No 11. Zweifel, P, Felder S Werblow A (2004): Population Aging and Health Care Expenditure: New Evidence on the Red Herring, Health Economics, 8(6): 485-96.

and other chronic diseases (includes amoebiosis, gynaecological disorders, sexually transmitted diseases, jaundice, lariasis, cancer and other tumours, anaemia, goitre, undernutrition, psychiatric disorders, cataract, disease of mouth, teeth and gum, prostrate disorders, locomotor disability, visual disability, speech disability and hearing disability). Acute Diseases The acute illnesses considered in this study are fever of unknown origin, diarrhoea/ dysentery, bronchial asthma, respiratory including ear/nose/throat, accidents/injuries/ burns/fractures/poisoning and other acute diseases (includes diseases of mouth/teeth and gums, disease of skin, whooping cough, malaria, conjunctivitis, tetanus, mumps, eruptive, diphtheria). Other Diseases The others category of diseases includes other diagnosed and undiagnosed ailments. Other Expenditures Other medical expenditure includes diagnostic charges, bed charges, attendant charges, physiotherapy, and personal medical appliances. Other charges under medical expenditure include expenditure on food and other materials, blood, oxygen cylinder, etc, services (ambulance, etc).

Appendix
The list of diseases in chronic, acute and others groups and items of expenditure included in other medical expenditure and charges for this study are provided below: Chronic Diseases The chronic diseases considered in this study includes gastritis/gastric/peptic ulcer, disorders of joints and bones, tuberculosis, neurological disorders, disease of kidney and urinary system, cardiovascular diseases (includes hypertension, diabetes mellitus, heart disease)

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