The cost of acute respiratory infections in Northern India: a multi-site study

BACKGROUND Despite the high mortality and morbidity resulting from acute respiratory infections (ARI) globally, there are few data from low-income countries on costs of ARI to inform public health policy decisions We conducted a prospective survey to assess costs of ARI episodes in selected primary, secondary, and tertiary healthcare facilities in north India where no respiratory pathogen vaccine is routinely recommended. METHODS Face-to-face interviews were conducted among a purposive sample of patients with ARI from healthcare facilities. Data were collected on out-of-pocket costs of hospitalization, medical consultations, medications, diagnostics, transportation, lodging, and missed work days. Telephone surveys were conducted two weeks after medical encounters to ask about subsequent missed work and costs incurred. Costs of prescriptions and diagnostics in public facilities were supplemented with WHO-CHOICE estimates of hospital bed costs. Missed work days were assigned cost based on the national annual per capita income (US$1,104). Non-medically attended ARI cases were identified from an ongoing community-based ARI surveillance project in Faridabad. RESULTS During September 2012-March 2013, 1766 patients with ARI were enrolled, including 451 hospitalized patients, 1056 outpatients, and 259 non-medically attended patients. The total direct cost of an ARI episode requiring outpatient care was US$4- $6 for public and $3-$10 for private institutions based on age groups. The total direct cost of an ARI episode requiring hospitalized care was $54-$120 in public and $135-$355 in private institutions. The cost of ARI among those hospitalized was highest among persons aged > = 65 years and lowest among children aged < 5 years. Indirect costs due to missed work days were 16-25% of total costs. The direct out-of-pocket cost of hospitalized ARI was 34% of annual per capita income. CONCLUSIONS The cost of hospitalized ARI episodes in India is high relative to median per capita income. Data from this study can inform evaluations of the cost effectiveness of proven ARI prevention strategies such as vaccination.