Indian Journal of Urology
: 2018  |  Volume : 34  |  Issue : 4  |  Page : 237--238

Health-care expenses – A need to be cautious

Santosh Kumar 
 Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India

Correspondence Address:
Santosh Kumar
Department of Urology, Christian Medical College, Vellore, Tamil Nadu

How to cite this article:
Kumar S. Health-care expenses – A need to be cautious.Indian J Urol 2018;34:237-238

How to cite this URL:
Kumar S. Health-care expenses – A need to be cautious. Indian J Urol [serial online] 2018 [cited 2019 May 21 ];34:237-238
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Full Text

By the time this editorial is published, the Ayushman Bharat scheme, the largest government-funded health-care scheme in the world, would have been launched. It promises to insure 100 million families for half a million Indian rupees per family per year from secondary and tertiary hospital care expenses. The scheme proposes to amalgamate the present Central and State Government Health Schemes and cater to the poorest of the poor. It promises to be portable across the country in government and impaneled private hospitals. Many states are already running similar health schemes with success. It is a welcome change in a country often rated as one among the worst in per capita expenses (Rs. 1112) and percentage of gross domestic product (GDP) (1.06%) spent on public health.

The aim of these health-care schemes is to reduce the out-of-pocket expenses of the poor and vulnerable on health care, thus indirectly preventing from them being pushed to poverty due to a sudden illness. A study by Shahrawat and Rao[1] showed that 3.5% of the population in India falls below the poverty line and 5% of the households suffer from the ill effects of health expenditures. Cost of medicines constitutes the main share (72%) of out-of-pocket expenses (82% of outpatient and 42% of inpatient bills). If outpatient and medicines could be provided free, only 0.5% people fall into poverty due to health expenses. The study concluded that insurance schemes covering only inpatient or hospital expenses are unlikely to protect the poor from catastrophic health-care expenses. Correct identification of the vulnerable population and how to spend resources continues to be a challenge.

Both the life expectancy and per capita GDP of our country are increasing. With increasing life expectancy and changing lifestyle, the incidence of cancer in India is increasing though still less than the West. As urologists, we are witnessing a very rapid change in the drugs available to treat advanced and metastatic cancer. This gives a new hope where none existed for patients. Public health is unlikely to fund the use of these medications except for the fortunate few. The drugs are as a rule costly, toxic, and most of the time adds a few months to overall survival. New end-points such as biochemical recurrence-free survival and progression-free survival have been popularized to show the efficacy of these medications. The cost of the additional scans/investigations to measure these surrogate end-points also is never questioned. For a given patient, the ultimate goal is disability-free survival or survival with a good quality of life which unfortunately has never been used as an end-point.

Recently, the CARMENA trial[2] on patients with metastatic renal cell carcinoma with good performance status and a resectable primary tumor was published. The results of the trial show that sunitinib treatment was stopped in 86% (67.1% due to disease progression, 13% due to toxic effects, and 6.2% because of death). In addition, the mean duration of drug treatment was 6.7 and 8.5 months in the two groups (4 weeks on and 2 weeks off the drug so only during 66% of the time the patient was on the medication). Thirty percent patients required a dose reduction. About 38% had Grade 3 and 4 complications. It is obvious that the treatment was toxic and usually not continued for long. These data though provided are easily overlooked as they are not the primary end-points or part of the aims and conclusion of the articles. In making decisions on treatment of terminal malignancies, apart from the costs involved which are mostly to be paid by the patient off the pocket, the risks and the benefits have to be weighed before these options are prescribed to our patients. It is time to tread cautiously with use of newer evidence in view of the health economics.

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Conflicts of interest

There are no conflicts of interest.


1Shahrawat R, Rao KD. Insured yet vulnerable: Out-of-pocket payments and India's poor. Health Policy Plan 2012;27:213-21.
2Méjean A, Ravaud A, Thezenas S, Colas S, Beauval JB, Bensalah K, et al. Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma. N Engl J Med 2018;379:417-27.