Cost/benefit evaluations in low-middle/upper-middle income countries: biases about “out of pocket money”

This article is related to:

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An added value of peer reviewing is gaining better knowledge on how health systems are organized and working worldwide, particularly in the so-called middle-low/middle-upper income countries.

A recent peer review made me meditate on the high number of papers having to do with this very hot topic. Actually, several papers have been published on the local cost/benefit ratio of two key points of breast cancer: drugs in adjuvant or advanced setting and screening^1–5.

These studies could be useful for local Health Authorities’ information and decision making, and also represent a possible suggestion for other countries with similar health systems. Furthermore, they allow foreign readers to compare different situations under the equity perspective. Published results from different countries are different not only for the availability vs non-availability of drugs and tools but also according to the local health system (full national, insurance based or a mix of both), not forgetting the role of charities^6,7.

In such papers usually methods are well described in any section, results reported in detail, statistical analysis often sophisticated and conclusions are optimistic and reassuring, suggesting a predictable further improvement. In the most part, the cost/benefit analysis in papers is in favor of the tested action even if the sentence “further studies are needed” is often the closing remark.

Paying out of pocket (percentage of gross domestic product)

In any country, no matter the national health system, pharmaco-economical evaluations should pay attention to the so called “paying out of pocket” (OOP). This means the money the patient should pay in any case out of his or her pocket for medical assistance and it should be related to the gross domestic product (GDP) per capita, which is the country GDP divided by its total population. This value is the index of the real total cost of any medical action and a good substitute index of equity of the system, in particular over time^8–13.

There is evidence that the majority of published papers do not consider at all this problem. The methodological choice of perspective taken by health economists is commonly justified by local methodological guidelines, who ignore the burden on patients, even if this is commonly justified by local methodological guidelines.

Table 1 is based on data from The World Bank, World Health Organization Global Health Expenditure database¹⁴ and I think it shows how “equity” in Asian countries with “similar” health systems has slowly improved over time but the amount of money paid out of pocket by patients remains unacceptably high, particularly for people with a lower income.

Table 1. OOP and GDP trend over time in selected countries, according to income.

Country	OOP 2000 %	OOP 2010 %	OOP 2017 %	GDP per capita 2019 (USD)	OOP 2018 per capita (USD)
China^b	60.12	40.80	36.05	10,261	179.13
Cambodia^a	68.68	51.90	60.43	1643	52.09
Indonesia^b	43.86	56.98	34.60	4135	38.92
South Korea^c	43.86	34.40	33.66	31,846	826.45
Thailand^b	34.18	14.49	11.14	7806	30.38
Vietnam^a	37.19	37.42	45.25	6790	68.11
Canada^c	16.60	14.64	14.22	46,194	735.69
Italy^c	26.46	20.54	23.48	33,228	703.76
USA^c	15.46	12.20	10.99	65,297	1148.32
Low-middle				2174	47.70
Upper-middle				9036	161.06

^aLow-middle; ^bupper middle; ^chigh income countries.

Looking at the same data in countries with a “full-covering” national health system, like Italy and Canada, the OOP should become much lower, below 25%. The GDP per capita of South Korea is similar to the Italian one and much higher than in the other cited Asian countries, and nevertheless the OOP remains too high. In Italy and Canada the amount of OOP is high but usually related to personal choices. Data from the USA appears quite good already in 2000 and the substantial improvement is clearly due to the Affordable Care Act (ACA) (2010); nevertheless the healthcare system is definitely unfair. Even after ACA more than 30 million Americans still remained without health insurance, and 7% of them were children¹⁵. Insolvent cancer patients are reported at poorer survival¹⁶, bankruptcy and serious debt problems are much higher compared to the overall population^17,18. I partially discussed the above USA data in a paper published in 2017¹⁹, but the situation is currently not improving with the tremendous impact of COVID-19 both on health and economy.

It is also surprising that China, the second richest country in the world in 2019, reports a very high OOP²⁰.

It would be nice if authors, apart from the specific interest on the treated topic, could enrich papers with the above considerations in order to make information more appealing for readers not particularly interested in a specific country situation but concerned with the global cost/benefit problem in oncology. And that could be honestly done if “how much already poor people are claimed to pay out of pocket” is included in the described economic panorama.

Pharmacoeconomic studies are very important in any country, particularly in the low-medium income ones. The findings reported by studies are different among countries and this is a big limitation of the reliability of the studies itself.

Furthermore, reviews on this topic should go deep in the cited studies and analyze the details of the single evaluation in order to understand who is really the payer. In this way readers could better understand the real problem: the large part of developing countries still have a quite unfair health system and what they need is a radical modification of the rules.

In conclusion, I know the topic deserves to be discussed more comprehensively, and my comments probably contrast with health economic guidelines, but poor patients and their families are not particularly concerned about economic guidelines when asked to pay out of pocket.

Transparency

Declaration of funding

No funding.

Declaration of financial/other relationships

No potential conflict of interest was reported by the author. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.