Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries

Background: One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region – the Asean CosTs In ONcology (ACTION) study – to assess the economic impact of cancer. Methods: The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30 % of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model. Results: The mean age of participants was 52 years; 64 % were women. A year after diagnosis, 29 % had died, 48 % experienced financial catastrophe, and just 23 % were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95 % confidence interval, 4.76–7.23) and death (5.52; 4.34–7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05–1.52) and die (1.51; 1.21–1.88) than participants with insurance. Conclusions: A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75 % of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness. Background The Association of Southeast Asian Nations (ASEAN) region consists of ten countries – Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam – and is home to over half a billion people. The burden of cancer is increasing in the ASEAN region, due to population ageing and growth and the adoption of cancer-associated lifestyle behaviours [1]. In 2012, there were estimated to be over Correspondence: [email protected] The George Institute for Global Health, Level 10, King George V Building, 83–117 Missenden Road, Camperdown, NSW 2050, Australia © 2015 The ACTION Study Group Open Acce Attribution 4.0 International License (http:// distribution, and reproduction in any medi source, provide a link to the Creative Comm Public Domain Dedication waiver (http://cr available in this article, unless otherwise sta 750,000 new cases of cancer, and incidence is expected to rise to 1.3 million per year by 2030 [2]. Survival rates for most cancers are poor and quality of life is greatly impaired [2–4]. In addition to this significant disease burden, cancer can have a profound economic effect on individuals and their households, especially among the poor and under-insured [5]. Most studies examining the economic burden of cancer have, however, been conducted in high-income settings. Little is known about its economic impact in lowand middle-income settings, where the financial implication of a cancer diagnosis may not be equitable because out-ofpocket (OOP) payments are the principal means of ss This article is distributed under the terms of the Creative Commons creativecommons.org/licenses/by/4.0/), which permits unrestricted use, um, provided you give appropriate credit to the original author(s) and the ons license, and indicate if changes were made. The Creative Commons eativecommons.org/publicdomain/zero/1.0/) applies to the data made ted. The ACTION Study Group BMC Medicine (2015) 13:190 Page 2 of 11 financing health care [6]. This not only relates to primary treatment, but may include long-term costs of adjuvant therapy and follow-up care [7–9]. Hence, a cancer diagnosis can quickly result in catastrophic payments for a household; that is, spending a disproportionate amount of household income on cancer treatment [10]. Furthermore, patients may be unable to continue working due to the burden of their symptoms, treatment, or side-effects, leading to poorer economic circumstances [11]. Health insurance is seen as an important means in offering households protection from catastrophic payments for illness. However, the extent of financial protection through insurance depends on which health services are covered and the level of subsidy offered. In the ASEAN region, while population coverage varies between 8 % (Laos) and 100 % (Malaysia), all countries – including those with universal health coverage – rely heavily on OOP financing [12, 13]. Despite the risk of a cancer epidemic overwhelming the region, governments have been slow to react to the health consequences of socioeconomic and demographic changes. Hence, in 2011, two regional initiatives were launched to increase cancer awareness and inform priority setting. First, a series of roundtable meetings of key stakeholders and experts were organised to generate knowledge and interest through engagement with the media [14, 15]. Second, a study of new cancer patients in eight countries in the ASEAN region (Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Thailand, and Vietnam) was instigated – the Asean CosTs In ONcology (ACTION) study – to assess the economic and health impact of cancer. This paper presents the main results.