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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 416-423

Out-of-pocket expenditure for diabetes mellitus and its determinants in recent times in India: A narrative review

1 Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health (AIIH&PH), Kolkata, India
2 Department of Community Medicine, IQ City Medical College, Durgapur, West Bengal, India

Date of Submission01-May-2021
Date of Decision07-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Pritam Ghosh
Gents Hostel, All India Institute of Hygiene and Public Health, 50, Colootolla Street, Kolkata 700073.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_59_21

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Introduction: Diabetes is one of the major disease burdens in the world. Globally around 463 million people (at a prevalence of 9.3%) suffered from diabetes recently. Apart from morbidity and mortality, diabetes poses high economic burden on healthcare systems, especially on national economies in developing countries like India. Estimation of the cost burden of diabetes can help decision-makers to understand the magnitude of the problem, prioritize research efforts and interventions, and plan resource allocation, especially in resource-poor settings. The focus of our review was to summarize cost burden of diabetes and its determinants from existing literature in the last 10 years in India. Materials and Methods: All literatures published in the period 2010–2020 were accessed through two databases: PubMed and Google Scholar. Reference lists of the article were again searched for further literatures. Cost calculated in different times was converted to current price in 2020 for ease of comparison. Results: Studies reported a wide range of expenditures in different settings of care. Inequity of expenses across income quintiles among patients was found. Complication of diabetes, insulin therapy, treatment in private facility, and events of hospitalization were the factors associated to high expenditure burden. Conclusion: Financial risk protection for vulnerable people and control over medicine market price will reduce out-of-pocket expenditure for diabetes. Comprehensive strategy to delay onset of complication as well as its early detection can be an opportunity to cut down diabetes-related economic burden.

Keywords: Cost of illness, diabetes, health expenditure, India, OOP

How to cite this article:
Ghosh P, Dasgupta A, Paul B, Roy S, Ghose S, Yadav A. Out-of-pocket expenditure for diabetes mellitus and its determinants in recent times in India: A narrative review. J Diabetol 2021;12:416-23

How to cite this URL:
Ghosh P, Dasgupta A, Paul B, Roy S, Ghose S, Yadav A. Out-of-pocket expenditure for diabetes mellitus and its determinants in recent times in India: A narrative review. J Diabetol [serial online] 2021 [cited 2022 Sep 25];12:416-23. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/4/416/335595

  Introduction Top

Globally around 463 million people (at a 9.3% prevalence) suffered from diabetes in 2019.[1] Rapid transition to urbanization precedes global diabetes epidemic as a consequence of population explosion, unhealthy diet, and sedentary lifestyle.[2] Diabetes prevalence has been rising more rapidly in low- and middle-income countries than in high-income countries.[3] India holds second position globally in the prevalence (10.4%) of diabetes.[1] Keeping the rising trend in mind, the National Programme for “Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)” launched by Government of India focusses on strengthening infrastructure, human resource development, health promotion, early diagnosis, management, and referral of diabetes patients.[4] Diabetes poses high economic burden on healthcare system. Cost of care is high because diabetes needs lifelong care. It also leads to various complications with multi-organ involvement. Loss of economic productivity is another important attribute, making diabetes an expensive disease. Such lifelong expenditure imposes a significant economic loss for the individuals, families, society, and countries.[2] Moreover, the spending on diabetes by various countries is not equitably distributed as more expenditure on diabetes is spent in developing countries. In India, each diabetic patient has to pay $165 every year for diabetes care.[1]

Sustainable Development Goals (SDGs) state to achieve universal health coverage, including financial risk protection and access to safe, effective, and affordable essential medicines for all.[5] India experiences high out-of-pocket (OOP) expenditure burden which constitutes over 60% of country’s current health expenditure. Patient’s compliance to treatment may be suffered, and it can lead to development of complications, ultimately a vicious cycle of financial catastrophe. Previous studies showed various demographic and clinical factors such as age, gender, duration of disease, insulin, presence of complication, and occurrence of hospitalization to have impact over expenditure due to diabetes.[6]

Estimation of the cost burden of diabetes can help decision-makers to understand the magnitude of the problem, prioritize research efforts, and plan resource allocation and prioritize interventions, especially in resource-poor settings. Efforts to find out epidemiological factors associated with excessive expenditure on the disease can mitigate the OOP expenditure burden associated with diabetes. Here, an effort was made to sum up the findings of previous study available as published literature. The focus of our review was cost burden of diabetes and its determinants in India.

  Materials and Methods Top

Information sources and search

The review was conducted for 3 months from January 2020 to March 2020. Literature search was conducted in January 2020. Our search was restricted to studies published in the last 10 years (January 1, 2010 to October 1, 2020) as National Programme for Diabetes (NPCDCS) came in 2010. The first date of literature search from database was January 5, 2020. After completing the analysis, finally, literature search was re-run and updated in the same way on March 25, 2020.

All the available studies were searched from two electronic database; PubMed and Google Scholar. The three terms “Health expenditure,” “Diabetes,” and “India” were used as MeSH words in PubMed accessed through the website https://www.ncbi.nlm.nih.gov. Google Scholar was searched in the browser https://scholar.google.com. A filter was applied for human studies only. In Google Scholar, advanced search was conducted using keywords “Diabetes,” “Diabetic,” “Diabetic Complication,” “Cost,” “Expenses,” “Expenditure,” “Economic burden,” “OOP,” and “India.” Quotation marks were used for phrases. Boolean operators such as “AND” and “OR” were used in search engines. Any stop word like adverb, preposition, and conjunction was avoided. Terms were searched not only in title but also anywhere in article. All types of files were accepted. Reference lists of identified articles were searched for additional resources.

Eligibility criteria and study selection

Articles written in English were included. Original research findings based on both primary data and secondary data were explored irrespective of the study design. Case series and gray literatures were excluded. After completing the literature search, merging the search results from different sources and removal of duplicate studies were done. All titles and abstracts were examined to remove irrelevant studies or documents. In the next step, the available full texts of the selected studies were retrieved filtering the abstract-only papers. Articles under the same research project were linked together. During selection, Author 1 and Author 5 were the main reviewers. Author 4 was consulted for any dispute.

Data items and operational definition

The cost implications of diabetes are direct and indirect. The direct costs are only part of the total expenditure, which include medical costs comprising physician consultation, laboratory investigations, pharmaceutical interventions, hospitalization (short- and long-term), and treating complications. Non-medical costs include transportation to healthcare facilities and time utilized for diabetes care. In addition, there are indirect expenses to the community and government, which are reduction of productivity (work loss, reduced productivity, worker replacement, social security, disability payment, and depression).[2]

As different studies were conducted in different years, the cost calculated cannot be compared directly due to effects of inflation each year. Those cost values were converted to current price in 2020 using consumer price index given by the Ministry of Statistics and Programme Implementation, GoI. Calculation was done in an online tool accessed through the website https://fxtop.com/en/inflation-calculator.php?.

Monthly or 6-monthly projected data were multiplied accordingly to get annual estimation wherever needed.

Data collection and extraction

Data extraction was done from individual full text studies in a structured extraction sheet in Microsoft Excel sheet. Information such as study design, setting, year of study, author, participant characteristics, length to follow-up, and outcome data were extracted.

  Results Top

A total of 15 studies met the inclusion criteria [Flowchart 1]. Thirteen studies had analyzed primary data, whereas two were based on secondary data (one analyzed NSS 2014 and another analyzed WHO SAGE study 2007–2010). All 13 primary studies were observational studies, of which 8 were cross-sectional and 5 were longitudinal [Table 1]. The sample size in different studies varied from 88 to 809 patients [Table 2]. Most studies did not clearly define the type of diabetes considered; only one study focussed on the cost of diabetes mellitus type 1 and two study mentioned only type 2. Three studies analyzed only direct cost, but rest all the studies included indirect cost also. Most studies had taken only loss of wages as indirect expenses and incorporated transport, food, and accommodation charges into direct cost. Chandra et al.[7] took transport, food along with wage loss as indirect expenses. Akari et al. and Fernandes et al. calculated expenditure over 6 months, whereas Basu et al. figured monthly expenditure. Tripathy et al. and Javalkar et al. reported expenditure per visit. Rest of the studies estimated annual expenditure.
Flowchart 1: Selection of articles

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Table 1: Various studies according to their types

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Table 2: Distribution of studies according to brief methodology and relevant finding

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Expenditure pattern on diabetes

Studies showed wide variation in expenditure estimates even after adjustment of inflation in current year. Studies which included expenses on hospitalization episode found higher direct costs; studies which calculated only ambulatory care reported much lower cost [Table 3].
Table 3: Various studies showing details of average annual expenditure in Indian rupees (₹) per person

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Tripathy and Prasad showed that median expenditure per episode of outpatient visit due to diabetes was ₹421 (current price ₹579) in NSS.[10] Javalkar[21] found that mean expenditure on diabetes is ₹912 (₹1185 in current price) per visit. Out of that, direct cost was ₹553 (current price ₹718) and indirect expenditure was ₹359 (current price ₹466).

OOP in the study by Basu et al.[16] and Thakur et al.[9] was comparatively low probably because of free of cost refilling of medication from the study settings of government hospital OPD. Studies by Eshwari et al. and Tharkar et al. might have recall bias in self-reporting for its high hospitalization expenditure [Table 4]. Sharp difference could be found in medicine cost share when compared with others. It was beyond doubt that medicine costs major portion in direct expenditure on diabetes. Wage loss had shared maximum portion in indirect medical cost [Table 5]. Tharkar et al.[12] defined intangible cost as willingness to pay to manage their diabetes well and prevent further complications in future and it was derived as ₹2000 per month.
Table 4: Average cost for episode of hospitalization in different studies

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Table 5: Percentage of different cost categories for expenditure on diabetes and proportion of catastrophic expenditure among patients

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Catastrophic expenditure

Some studies had figured out the expenditure out of family income or individual’s capacity to pay. Only three studies had coined the term catastrophic expenditure [Table 5]. Thakur et al.[8] showed 9.3% of the subjects spent more than 20% of family income on diabetes care. Eshwari et al.[18] showed that 3% of the family income was used for outpatient services, whereas hospitalization consumed 21% of family income. Similarly, Chandra et al.[7] reported that 3.6% of average income was spent on direct cost and 1.4% was spent on indirect cost. Katam et al.[17] reported higher proportion (18.6%) of annual family income spent for type 1 diabetics.

Factors for high OOP expenditure

Age, sex, and residence

Akari et al.[22] showed that patient in higher age showed higher expenditure. Male patients were found to have significant association with high expenditure for diabetes.[8],[22] Katam et al.[17] found that patients in rural location spent greater proportion of income compared with those in urban areas.

Socio-economic class (education and income)

Higher education was associated with high expenditure in diabetes in most studies.[12],[19],[20] Tripathy and Prasad[10] showed that median OOP expenditure from hospitalization due to diabetes was higher among the richest quintile when compared with the poorest quintile. In most studies, high income class showed high expenditure.[12],[17],[19],[20],[21] But the proportion of income spent and prevalence of catastrophic expenditure were high in the low-income group.[7],[10],[17]

Duration of diabetes

Sharma et al.[13] calculated that 10 additional years of diabetes duration was significantly associated with 11% higher direct costs. Longer duration of diabetes was associated with higher expenditure in most studies.[7],[8],[14],[20],[21]

Place of treatment

Thakur et al.[8] had found higher expenses in private facilities. Tripathy and Prasad[10] also found high OOP in private facility, but indirect cost was higher in the public sector when compared with the private sector. Sharma et al.[13] showed that direct costs were greatest in the private clinic attendees followed by rural clinic and government clinic attendees. Eshwari et al.[18] noted strikingly high expenditure among subjects on ayurvedic medications, compared with subjects on oral hypoglycemic agents (OHAs).

Diabetes complication

Many studies had shown that cost of medication was high for diabetes with complication.[12],[15],[19],[21] Indirect cost was also high for complications, due to spending more episodes and attending more facilities for their management.[12] Hospitalization events were significantly associated with high expenditure in studies.[8],[12],[18] Surgical intervention was a significant factor for higher expenditure in the study by Thakur et al.[8] Few studies found macrovascular complication to increase expenditure.[15],[22]

Insulin therapy

Use of insulin had significantly increased expenses on diabetes.[8],[15],[18] Basu et al.[16] found that providing long-duration medication refills in OPD would reduce OOP expenses. Katam et al.[17] showed that compared with patients using regular insulin, patients using insulin analogs and insulin-delivery devices had higher expenses.

Glycemic status

Tharkar et al.[12] showed that patients with good glycemic control (HbA1C < 7) had high direct cost, whereas those with poor glycemic control (HbA1C > 7) had high indirect cost.

  Discussion Top

A large portion of direct cost was made for purchase of medicines. Policies regarding reduction of market price of diabetes medicines and their increased availability in government hospital need to be implemented. A multicentric study by Chow et al.[23] reported that 0.7% of households in high-income countries and 26.9% of households in low-income countries could not afford metformin. Initiatives to strengthen health systems are essential in this situation. Government of India already launched Pradhan Mantri Bhartiya Janaushadhi Pariyojana to provide generic drugs, which are available at lesser prices but are equivalent in efficacy as expensive branded drugs.[24] Moreover, insulin therapy significantly made the patient susceptible for high OOP expenditure. International Diabetes Federation estimated one in two people with type 2 diabetes does not have access to the insulin they have been prescribed. High cost of insulin would be barrier for regular treatment. Barriers can be dissolved by increased availability. Global as well as national factors such as price mark-ups within the supply chain also impact its prices. High and variable prices observed globally influence insulin affordability for both governments and individuals.[1]

Substantial amount of indirect cost (mainly wage loss for health care seeking or ill-health) was found. This high indirect cost indicated productivity loss of working population. It can affect in long term on country’s economy when people will start to get the disease at earlier age.

Longer duration of disease was seen as a significant factor for higher cost. It meant that either higher age or early onset of diabetes had impact on expenditure. Reason behind it might be that longer duration would arise complications, requirement of excess drugs, and investigation. Eventually cost of care rises.

Complications of diabetes vary from mild to severe forms. Severe forms of complication require extra care on hospital admission. Thus, complications increased expenditure. Effect of complication on high expenditure was reported by another similar review on economic burden of diabetes in India by Yesudian et al. in 2014.[6]

Lower expenditure among the low-income group may be due to poor access and affordability, but greater portion of their income was spent in treatment when compared with the high-income group. Late detection of the disease in the vulnerable population often leads to early complication and subsequently “catastrophe” in household expenses. It also pointed out absence of equity in health care, particularly in modern epidemic like diabetes. Allocation of resources in public health infrastructure is need of the hour so that poorer section can depend on government sector for their regular ambulatory care to avoid “catastrophe.”

Health seeking behavior had also significant influence on health expenditure. Patients who sought private facilities had reported more direct costs compared with those in government hospital. In government hospital and health centers, patients get free medicines and access to diagnostic procedures. But patients in the private sector have to procure medicines and purchase lot of money for various investigations. Thus, the private sector expense clearly surpasses that of the government sector.

The fragmented picture of the cost burden of diabetes in India was drawn in this review. The heterogeneity in study designs used in the literature could not make it possible to generate meaningful aggregate. Comparisons of findings should be made with caution due to the diversity in their methodology. Further review studies must be done to explore evidences with standard methodology and study design, and it will help in meaningful estimates like meta-analysis. The review could not explore proportion of the insurance coverage of the patients as well as the reimbursement from insurance scheme. Studies either were done before the popularization of recent government insurance initiatives or did not report the insurance cost (premium as well as reimbursement) into consideration. The exclusion of intangible costs causes an underestimation of cost burden. Comprehensive calculation of intangible costs can pick up actual loss due to impact of disease on quality of life.

  Conclusion Top

High burden of cost in diabetes care can be mitigated by controlling its influencing factors. In this review, some modifiable factors such as price of medicines, burden of complication, low socio-economic status, and seeking care in private facilities had been found. A comprehensive strategy must be adopted at all levels to delay onset of complication. Public health facilities in the management of diabetes must have a dominant role to pave away dependence on public facility. Strategy to reduce the inequity in expenditure on diabetes—"poor people suffer more”—must be focussed. Integrated strategy to adopt universal coverage for economically vulnerable section can ensure risk protection.


We want to convey our gratitude to the Director of All India Institute of Hygiene and Public Health to permit us to conduct this study. We also acknowledge the support of health functionaries and faculties of AIIH&PH for their untiring support.

Financial support and sponsorship

The review was not supported by any funding.

Conflicts of interest

There are no conflicts of interest.

  References Top

International Diabetes Foundation. Diabetes Atlas: Ninth Edition [Internet]. International Diabetes Foundation; 2019. Available from: https://www.diabetesatlas.org/upload/resources/material/20200302_133351_IDFATLAS9e-final-web.pdf#page=38&zoom=auto. [Last accessed on Feb 20, 2021].  Back to cited text no. 1
Pradeepa R, Mohan V. Prevalence of type 2 diabetes and its complications in India and economic costs to the nation. Eur J Clin Nutr 2017;71:816-24.  Back to cited text no. 2
World Health Organisation. Diabetes [Internet]. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes. [Last accessed on Feb 20, 2021].  Back to cited text no. 3
Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS): National Health Mission [Internet]. Available from: https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1048&lid=604. [Last accessed on Feb 20, 2021].  Back to cited text no. 4
United Nations. Goal 3: Sustainable Development Knowledge Platform [Internet]. Available from: https://sustainabledevelopment.un.org/sdg3. [Last accessed on Feb 20, 2021].  Back to cited text no. 5
Yesudian CA, Grepstad M, Visintin E, Ferrario A. The economic burden of diabetes in India: A review of the literature. Global Health 2014;10:80.  Back to cited text no. 6
Chandra P, Gogate B, Gogate P, Thite N, Mutha A, Walimbe A. Economic burden of diabetes in urban Indians. Open Ophthalmol J 2014;8:91-4.  Back to cited text no. 7
Thakur A, Ray TK, Goel MK. Determinants of expenditure on diabetes care: A community based longitudinal study in a resettlement colony of Delhi. J Assoc Physicians India 2019;67:44-7.  Back to cited text no. 8
Thakur A, Ray TK, Goel MK. Expenditure pattern on diabetes care: A community based longitudinal study in resettlement colony of East Delhi. Indian J Community Health 2017;29:209-12.  Back to cited text no. 9
Tripathy JP, Prasad BM. Cost of diabetic care in India: An inequitable picture. Diabetes Metab Syndr 2018;12:251-5.  Back to cited text no. 10
Gwatidzo SD, Stewart Williams J. Diabetes mellitus medication use and catastrophic healthcare expenditure among adults aged 50+ years in China and India: Results from the WHO study on Global Ageing and Adult Health (SAGE). BMC Geriatr 2017;17:14.  Back to cited text no. 11
Tharkar S, Devarajan A, Kumpatla S, Viswanathan V. The socioeconomics of diabetes from a developing country: A population based cost of illness study. Diabetes Res Clin Pract 2010;89:334-40.  Back to cited text no. 12
Sharma KM, Ranjani H, Zabetian A, Datta M, Deepa M, Moses CRA, et al. Excess cost burden of diabetes in southern India: A clinic-based, comparative cost-of-illness study. Glob Health Epidemiol Genom 2016;1:e8.  Back to cited text no. 13
Fernandes SD, Fernandes SDA. Economic burden of diabetes mellitus and its socio-economic impact on household expenditure in an urban slum area. Int J Res Med Sci 2017;5:1808-13.  Back to cited text no. 14
Acharya LD, Rau NR, Udupa N, Rajan MS, Vijayanarayana K. Assessment of cost of illness for diabetic patients in South Indian tertiary care hospital. J Pharm Bioallied Sci 2016;8:314-20.  Back to cited text no. 15
Basu S, Garg S, Sharma N, Singh MM, Garg S, Asaria M. The determinants of out-of-pocket health-care expenses for diabetes mellitus patients in India: An examination of a tertiary care government hospital in Delhi. Perspect Clin Res 2020;11:86-91.  Back to cited text no. 16
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Chidambaram D. Cost-of-illness analysis of type 2 diabetic patients in a multispeciality hospital at Coimbatore. Indian J Pharm Pract 2013;6:39-44.  Back to cited text no. 19
Loganathan ACV, John KR. Economic burden of diabetes in people living with the disease: A field study. J Diabetol 2013;4:5.  Back to cited text no. 20
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Akari S, Mateti UV, Kunduru BR. Health-care cost of diabetes in south India: A cost of illness study. J Res Pharm Pract 2013; 2:114-7.  Back to cited text no. 22
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Chow CK, Ramasundarahettige C, Hu W, AlHabib KF, Avezum A Jr, Cheng X, et al; PURE Investigators. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: A prospective epidemiological study. Lancet Diabetes Endocrinol 2018;6:798-808.  Back to cited text no. 23
Government of India. Pradhan Mantri Bhartiya Janaushadhi Pariyojana—National Portal of India [Internet]. Available from: https://www.india.gov.in/spotlight/pradhan-mantri-bhartiya-janaushadhi-pariyojana. [Last accessed on Feb 20, 2021].  Back to cited text no. 24


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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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