Exploring the effects catastrophic health expenditure due to non-communicable diseases and coping strategies: A case study among households in Bangladesh

Abstract

Objectives

Non-communicable diseases (NCDs), due to their chronic nature, lead to long-term and significant health burdens that result in catastrophic expenses for individuals and communities. This study explores the socioeconomic effects of catastrophic health costs on households with family members experiencing NCDs and their coping mechanisms in rural areas of Bangladesh.

Study design

Qualitative study.

Methods

Case studies were conducted with ten NCD patients who had experienced catastrophic events and their close contacts. Purposive sampling strategies were used to recruit participants from two sub-districts in areas with a high prevalence of NCDs. In-depth interviews and observations were conducted, and documents (e.g. hospital and diagnosis bills, medicine purchase receipts) were reviewed. Data were analysed using thematic analysis.

Results

Data revealed that the treatment costs of NCDs are multifaceted and long-term. This catastrophic health expenditure has many economic effects, such as compromising food, housing, living standards and quality of life. It also has non-economic effects, including social stigmatisation, adjusting wishes and dreams, hampering children's education, disrupting family relationships and undermining social dignity. Households' adaptive strategies include loaning and borrowing, selling assets, using savings, seeking assistance from friends and relatives, reconciling living standards and even adopting alternative medicines.

Conclusions

Thisstudy highlights the socioeconomic impact of catastrophic health costs associated with NCDs and how households adapt and cope with these expenses. The results increase understanding of the impact of NCDs and the importance of managing the economic burden. Results highlight the necessity for a strategic plan to aid families affected by chronic NCDs.

1. Introduction

The prevalence of NCDs is increasing alarmingly and becoming a global health burden, especially in low- and middle-income countries (LMICs) [1]. The World Health Organization (WHO) reported that NCDs result in approximately 41 million deaths globally every year, and 77 % of these deaths occur in LMICs [2]. Noticeably, financing for NCDs is very low, representing only 2 % of all global health funding [3]. The World Bank has identified three underlying reasons for this: (1) insufficient financing (the gap being $176 billion per year); (2) inefficient spending (20–40 % is wasted); and (3) inadequate health expenses (half a trillion dollars on out-of-pocket payments [OOPP] every year in developing countries); all of these reasons hinder access to health services, especially by the poorest individuals [4]. People living in LMICs are less capable of accessing and affording quality health services. In addition, higher OOPP forces around 100 million people into extreme poverty globally [4]. The study revealed that higher OOPP in relation to inpatient care for NCDs is strongly associated with overspending and poverty across all income countries, with patients often employing coping mechanisms, such as borrowing and selling assets [5]. In LMICs, individuals are subject to higher OOPP and the total OOPP has doubled from 2000 to 2017 [6]. Moreover, there is a strong correlation between catastrophic health expenditure (CHE) and the residence status, social stratum, religion, household size and economic position of individuals [7]. However, developing countries can benefit from adopting investment policies for preventing NCDs. The WHO reported that an investment of USD 1 in stepping up efforts to address NCDs in LLMICs would produce a return of USD 7 through higher employment, productivity and life expectancy [3].

In Bangladesh, the health system is operated by four key actors: the government, the private sector, non-government organisations (NGOs) and donor agencies [7]. Public sector financing in health is declining alarmingly and currently represents only 23 % of Bangladesh's total health expenditure (previously 37 % in 1995) [8]. The government's health expenditure is only 0.7 % of gross domestic product (GDP), which is the lowest in the world; whereas, it has the highest percentage (67 %) of out-of-pocket (OOP) expenditure [8]. In addition, the unequal expenditure of government health funds results in a greater health gap because funds are unevenly allocated between poorer rural divisions and tertiary hospitals, resulting in healthcare being disproportionately provided to affluent communities [8]. Limited health insurance and high OOP creates complexities in the health system that has resulted in 5 million people in poverty having to bear healthcare costs [9]. To reduce the burden of healthcare costs, especially OOP, the budget allocation in the healthcare sector must be increased with the aim of eliminating CHE.

In developing countries like Bangladesh, the prime determinants of both CHE and impoverishment are chronic illness conditions and geographical location [10]. One study identified that CHE incidence has been increasing more among rural (16.3 %) than urban populations (8.6 %) in Bangladesh, and is more concentrated among lower socioeconomic households because of the OOP expenditure for healthcare costs [11,12]. Around 16.5 % of the poorest and 9.2 % of the richest households faced CHE, while the number of people living in poverty increased by 3.5 % (5.1 million people) due to OOPP [13]. Demographic and socioeconomic variables, like household consumption expenditures, create more vulnerability to CHE [14]. The Ministry of Health and Family Welfare (MoHFW) in Bangladesh reported that primary-level healthcare intervention has improved, but a severe crisis exists in financial risk protection [12]. NCDs have substantial socioeconomic repercussions in addition to being a health burden, a major impediment to economic growth, and one of the top causes of death [15]. In the long-term, expensive treatment, medication costs, and income erosion consequences disproportionately impact poorer individuals [2]. The people in Bangladesh also face the repercussions of receiving long-term health care at facilities. Due to the centralised treatment system, which focuses only on the big cities, the treatment cost is also embedded in the transportation, along with accommodation near the healthcare facility and expensive food, resulting in excessive expenditure for those living in rural areas of Bangladesh.

Patients pay the majority of their health treatment costs from household earnings, creating a large-scale impact on the entire household, and because of unhealthy habits, physical incapacity and lost wages, they run the risk of losing their household income [16,17]. Through CHE, NCDs can lead a household into poverty. The sum of those items could have a significant effect on national economies [18,19]. The problem is worse in LMICs since their mortality rates are nearly twice as high as high-income countries [19,20].

The majority of NCD mortality can be avoided by addressing the risk reduction factors. The hazardous use of alcohol and cigarettes, poor eating habits, and insufficient physical activity are associated with significant behavioural risk factors [18,20]. The World Bank reported on strategic choices for the prevention and treatment of NCDs [4,21]. In South Asian low-income nations, combating NCDs is seen as a development concern [22]. In India, families tend to adopt financial coping strategies since the majority of NCD patients or family members borrow money from informal sources, and family members often reduce consumption and send children to do odd jobs [23]. Although the disease burden profiles among.

LMICs may differ, there are many similarities in the problems associated with NCDs and the difficulties in coming up with effective solutions. Therefore, this study investigates the various socioeconomic effects of CHE brought about by NCDs and how these costs can lead to household impoverishment and related coping mechanisms. Investigating the various socioeconomic impacts of NCD health costs on households as well as exploring coping mechanisms, highlights the problem and the importance of developing essential strategies to address the issue.

2. Methods

2.1. Study design and settings

Adopting a qualitative self-reported approach, interviews were conducted in the following explanatory case study [24] design from February to May 2022 in the Comilla District of Bangladesh. NCD care in Comilla District was found to be influenced by a number of factors, such as an absence of treatment guidelines, an inadequate health information system and an unregulated private healthcare sector [25]. The research was carried out at five villages under two sub-districts in the Comilla District of Bangladesh. The Comilla District is located southeast of the capital city of Dhaka, about a 2-h journey and 3 h from the port city of Chattagram. All other areas in Bangladesh are well-connected to the district by bus and train. There are 17 sub-districts, all with almost similar geographic and socioeconomic characteristics. Data were collected from the villages of Sreemontopur, Sreeballavpur and Chandpur in Comilla Sadar Dakshin Upazila, as well as from Debipur and Sonapur villages in Chauddagram Upazila. First, the research team collected the NCD patient list from the two vital healthcare service centers, Comilla Medical College and Comilla Sadar Hospital. The research team then visited the patients’ local residences in these two sub-districts and included each household as a case study.

2.2. Study participants and sampling strategies

Ten case studies were carried out, with each household being considered, rather than the individual participants, to explore both the CHE and adaptive strategies of that household. Patients with different types of NCD and their close family members, including household heads, spouses and adult children, were recruited for the interviews. The study participants were recruited using the purposive sampling method to maximise the socioeconomic variations among participants. Qualitative data for this research were collected from NCD patients, their friends and families, and close contacts. The research team selected the cases to cover variations in socioeconomic status along with disease diversity to generate a comprehensive understanding of expenditure patterns, sources of expenses and different coping strategies adopted by the various households. The inclusion criteria of the case study participants included patients who faced CHE. The procedure was followed to determine the patients who were clinically diagnosed with NCDs (≥6 months ago) and had sold property, livestock or personal belongings to bear their medical costs following loss of income (Table 1). To have an overview of participants experiences, we conducted informal discussions with patients, caregivers and health service providers. Data saturation principles were followed to recruit nine case study participants [26]. This ensured that the researchers did not find any new dimensions of information, sub-themes and themes. The study team included one extra case to reach data saturation to ensure adequate data. The data collection and primary analysis procedures were conducted using an iterative process to understand the data dimensions, patterns and overlapping. The team found data saturation in eight interviews, but two extra interviews were conducted to ensure data saturation.

Table 1.

Participant selection procedures.

Selection procedure of NCD patients	Inclusion criteria	Number of cases
•Consisting of NCD unit and specialist doctors working at government health facility centers (Comilla Medical College, Comilla Sadar Hospital), initial NCD patient names and addresses were collected •Particulars were cross-checked at the respective Upazila Health complex/Union Sub-center/UHFWC/CC.	•Suffering from one or more NCDs •Chronic (on the patient list for at least 6 months) •Health expenditure burden of the household •Diverse SES of the patient's households •Sub-district representations were also considered	10 case studies were conducted to reach the data saturation point

NCD, non-communicable disease; SES, socioeconomic status.

2.3. Data collection procedures

To demonstrate the financial burden caused by NCDs, questions relating to the cost of diagnosis, hospitalisation, surgery and subsequent medicines were put to the household heads following an in-depth interview procedure. The households were found to be affected differently by CHE. A qualitative research team composed of four members (male and female) who had graduated in anthropology and trained in qualitative research conducted the interviews. AH, FN, NMRAC and SAU developed the interview guidelines in a participatory way and tested them in the field before conducting the interviews. Qualitative data were collected through the case study method with face-to-face interviews conducted with each participant and an audio recorder used to record the interviews. The researchers observed the participants’ residences, living conditions, food consumptions and other non-verbal behaviours of daily activities following an observation checklist. Additionally, the study reviewed hospital and diagnosis bills, and medicine purchases. The average length of each interview was 50–60 min. Each interview was recorded with the informed consent of each participant, and notes were also taken during the interview session. The interviews started with demographic questions and then continued with questions such as: “How long have you been suffering from NCD?“, “What barriers do you face due to treatment costs? Please explain.“, “Where do you go for your regular treatment? (Probe: Government/Public Hospitals, Private Hospitals/Clinics, or others). Why? Please explain.“, “How do you manage your medical expenses?“, “Is there any difference between your current and previous financial situation due to treatment costs? Please explain.” and “What adaptive strategies do you or your household use to manage your regular health expenditure? Please explain.”

2.4. Data analysis

Each interview was initially transcribed into the local language (Bengali) and then translated into English before importing into Atlas.ti software for further analysis. AH, FN, NMRAC, SAU and MSM read each transcript at least twice to familiarise themselves with the data and develop the code list. Coding procedures were conducted individually and shared with the research team when the code emerged. The team came to a consensus about the generated codes and clustered them into sub-themes and major themes (Fig. 1). This study employed thematic framework methods to analyse the interviews [26,27]. Data, participants and methods (IDI and observation) were triangulated to ensure data creditability and confirmability.

Fig. 1.

Catastrophic health expenditure, effects and adaptive strategies.

3. Results

Table 2 shows the case patterns of the various participants. Eight patients were male and two were female. The patients ranged in age from 35 to 59 years. The household head refers to the main income and decision maker, while the spouse and adult children share experiences before and after diagnosis and treatment. The ten case studies consisted of two patients with cardiovascular diseases (CVDs), one CVD patient with diabetes, one CVD patient with kidney disease and diabetes, two with blood cancer, two with lung cancer, one with cervical cancer, and another with CVD and chronic respiratory disease from five villages in two sub-districts of Comilla District. Participants included patients, household heads, spouses and their adult children.

Table 2.

Case and participant^a characteristics.

Area	Village	Case	Participants age (years, mean ± SD)
Comilla Sadar Dakshin	Sreemontopur	Case 1: CVD	45 ± 5
		Case 2: CVD, diabetes
	Sreeballavpur	Case 3: CVD, kidney disease and diabetes.	45 ± 10
		Case 4: Cervical Cancer
		Case 5: Blood Cancer
	Chandpur	Case 6: Chronic respiratory diseases and CVD	48
Chauddagram	Debipur	Case7: Blood Cancer	50 ± 8
		Case 8: Lung Cancer
		Case 9: Lung Cancer
	Sonapur	Case 10: CVD	59

CVD, cardiovascular disease.

a Participants included patients, household heads, spouses and adult children.

3.1. Consequences of catastrophic health expenditure

3.1.1. Economic consequences

Each household had experienced economic hardship due to their CHE. The majority of participants shared that they were forced to seek treatment and diagnosis from private clinics due to inadequate NCD healthcare facilities in government hospitals, which increased their financial burden. One patient quoted:

“I want to go to the nearest hospital to have the cheapest treatment and diagnosis. However, it was extremely difficult for me because the diagnosing equipment of that hospital did not work well and I could not reach the doctor. Consequently, I was forced to go to a private hospital, which was quite expensive for me.” Household Head, Case Study 1

The long-term economic effects on households have been identified, consistently compelling households into poverty. The findings revealed that many breadwinners of households had lost their jobs after being impacted by NCDs. One participant underwent open-heart surgery in an overseas hospital, resulting in him losing customers as the shop was closed for too long while he received treatment.

NCDs were found to have significant economic effects on the social and personal lives of household heads. Due to being diagnosed with diabetes and kidney disease with CVD, one participant lost his managerial position and a significant portion of his savings because he needed 2 months off work to recover after bypass surgery (Ring porano). Despite providing services to the company for around 15 years, he lost his job without any financial compensation or insurance payment, forcing the household into difficulties, both socially and economically.

3.1.2. Effect on household diet and nutrition

Family members of NCD patients often faced food insecurity due to treatment costs, according to the study findings, especially when the patient was the sole breadwinner of the family. One participant shared:

“I was the sole source of income for my family. I was unable to ensure my family’s food security when I had open-heart surgery in India. Going outside regularly for food was difficult for my wife and daughters because they were not used to it. Money was also another obstacle to purchasing food. All savings were spent on my treatment.” Household Head, Case Study 10

Similarly, another participant added:

“I wished I could contract cancer from him. Instead of seeing my children suffer from hunger, it would be preferable to catch the disease and pass away. My spouse was not the only one affected by cancer; our entire family has suffered as a result of the illness and treatment cost.” Wife of a Blood Cancer Patient, Case Study 5

3.1.3. Shattering of future plans, dreams and children's education

Catastrophic health expenditure on NCDs was found to have a long-term effect on all households, which was difficult to quantify. To manage the cost of treatment, family members often had to adjust the household's long-term plans. Every household member had to compromise with their plans and dreams, including the patients themselves, due to the exorbitant treatment cost.

One CVD patient shared:

“Before undergoing open-heart surgery, I dreamed of owning a duplex and having a big party for my elder daughter’s wedding. Now, there is nothing left but regret because all my savings have been spent, and I have already taken a loan for my treatment and medicine.” Case Study 1

Similarly, another participant stated:

“I was the only wage earner in the household. I hoped that our only son would become a doctor and planned to put my entire life savings toward his education. Due to lung cancer, I cannot work, and my son is struggling to continue with his studies.” Case Study 8

However, some family members reported that the children in these households were often unable to receive private lessons to support their education due to the expense involved. One CVD patient said:

“For better understanding, all my children received private tuition. However, following my treatment, I am unable to work. They were forced to cease their private lessons, and my elder daughter even returned home from Dhaka, where she was enrolled at a prestigious institution.” Household Head, Case Study 3

3.1.4. Change in the socioeconomic position of the family

Participants reported that patients suffering from NCDs often had to deal with the consequences of losing their decision-making position in the family. Data revealed that NCDs not only affected the patients’ health but also brought other difficulties to their lives. Bed rest is recommended following major surgery for the treatment of NCDs, making it difficult for patients to meet their job obligations while having to depend on other family members for caregiving. Consequently, family members did not always respond positively. One blood cancer sufferer remarked:

“I feel like I am a burden on my family. They are all suffering as a result of my cancer. It is difficult to perform tasks on my own, and my wife and children are not finding it easy to look after me.” Household Head, Case Study 7

Similarly, another participant commented:

“Since I returned home from hospital, I have seen a change in my daughter-in-law’s attitude toward me. She seemed so repulsed to be assisting me, I noticed. Then I understood that perhaps I had lost my pre-illness status in family. I decided to move in with my sister after that.” Household Head, Case Study 2

3.1.5. Adaptive strategies taken by households affected by NCDs

NCD patients struggled to afford treatment. The field data revealed that households had adopted strategies for managing the costs and coping with financial hardship. Participants shared that when their family members became ill, it was critical that they received medical attention, even if it meant borrowing money or selling land. Furthermore, families were falling below the poverty line due to the high treatment costs.

3.2. Financial management and social support

3.2.1. Loans from formal and informal sources, selling assets and community support

To deal with the financial consequences of NCDs, households borrowed money from various formal sources, such as the workplace (employer, cooperative, provident fund) and banks, and informal sources, such as relatives, coworkers, friends and local moneylenders at a high rate of interest. Due to a lack of health insurance, patients must seek healthcare from expensive private facilities. Patients or family members have been forced to borrow money for costly, long-term medical care and medication. One of the participants claimed:

“I had to pay 50–60 thousand BDT for every chemotherapy session to treat my cervical cancer. In total, I paid 1.4 million BDT for diagnosis and treatment. As a government official, I was able to secure a loan quickly and have the loan instalments deducted from my salary every month.” Case study 4

Some participants had been compelled to mortgage their jewellery and land or borrow money from moneylenders at high rates of interest condition. One participant reported:

“When my wife was in ICU, I borrowed 1.5 lakh BDT from my nephew and since I have not been able to repay that debt, we have to give land to him instead.” Household Head, Case Study 3

Similarly,

“I had to mortgage my land and borrowed 1.5 lakh BDT for blood cancer treatment.” Case Study 5

3.2.2. Social support

Some NCD patients who were unable to bear the cost of treatment or had lost their belongings were helped by social capital, whereby people in the community raised funds to help them. Social media, schools and markets were some of the fund-raising sources revealed. One participant stated:

“After losing all my belongings and the treatment was going to end for my husband, the locals paid me 1.5 lakh BDT from the community fund, and I was very fortunate to have the money for treatment and my household expenditure.” Household Head, Case Study 8

3.2.3. Support from friends and relatives

When family members refuse to take care of them, patients must rely on others. One of the female participants stated:

“Since my two sons are living abroad, my daughter-in-law refused to take care of me after a heart attack, so I moved to my sister’s house because I had no one to take care of me at my house.”

CVD Patient, Case Study 10

3.2.4. Medication adjustment and regular follow-ups

The data revealed that patients often needed to have their daily medication adjusted and attend regular follow-up appointments with the physician. Patients preferred to buy fewer drugs due to financial hardship, and this impacted medicine adherence and put their health at risk. Budgetary constraints also led to delays in follow-up care, increasing the risk of infection spread. The situation was explained by a cancer patient as follows:

“If we have less money, we tend to avoid buying and consuming medicine every day due to the monthly costs involved. Other household members have needs, too, including medication. I also tend to avoid frequent follow-up sessions at tertiary-level hospitals to save travel costs, doctor’s fees, and medicine costs.” Case Study 7

3.2.5. Dependency on alternative medicines, folk healers and self-medication

According to the data, many patients visited a kabiraj (local traditional healer) and used herbal medicine due to financial hardship. Participants found traditional healing and medicine to be cheaper. In addition, patients also self-medicated, such as using herbal or other home remedies easily available at the family level and local pharmacy. A few participants claimed:

“I do not attend regular check-ups because diabetic herbal medication is more effective and economical for controlling my diabetes.” Case Study 2

Similarly,

“I followed all prescribed medicine, chemotherapy, and radiotherapy, but the cancer came back again. Now, I am taking Ayurveda medicine and following a folk healer (jar fok) regularly.” Case Study 5

3.3. Changes in the lifestyles of the household members

Compromising food, clothing and children's tuition was found to be the main adaptive strategy. Many of the participants were trapped in a distressing situation because treatment choices were costly, and most households' savings and assets had been lost. As a result, the cost of treatment for NCDs had a direct effect on the consumption expenses and daily activities of household members.

3.3.1. Reducing expenditure on food

Households with chronic NCD patients tried to compromise on their food expenditure. One of the participants expressed:

“We can no longer afford to purchase fish, chicken, or beef on a regular basis because we are worried about whether we will be able to afford medicine at the end of the month.”

Household Head, Case Study 1

3.3.2. Effect on children's education

To reduce household expenses, children are unable to receive tuition. Financial hardship forces children to drop out of school or college, or prevents them from receiving tuition, affecting their future prospects. One of the participants stated:

“There was significant financial hardship in the family when I underwent heart surgery. My daughter studied on her own without tuition in any subject despite having HSC exams.”

CVD Patient, Case Study 2

The study also found that many children were financially and emotionally exhausted from witnessing their parents fighting against illness and treatment costs.

3.3.3. Reducing expenditure on shopping

The data revealed that prior to illness, patients and household members were generally solvent and had good employment prospects. They were able to purchase clothes and gifts for all family members and close relatives. Following his wife's cancer diagnosis, one participant commented about his inability to buy new clothes for his children to wear at a very important ceremony:

“I could not buy EID clothes for my kids after my wife’s cancer diagnosis.” Case Study 9

3.3.4. Avoiding family, social functions and programmes

Avoiding birthday and anniversary celebrations or joining relatives at social occasions was reported by many of the participants. NCDs are treatable but incurable ailments that affect households over a long period, forcing patients and their families to adapt and adjust their lifestyles. Some participants explained:

“My daughter was expecting to have a birthday celebration with her friends and gifts as usual. I had to tell her we would arrange a colourful birthday next year, but we do not know what is waiting for us.” Family member, Case Study 2

Similarly, another participant shared:

“My nephew called to invite us to his wedding. I had to say that my father’s health condition (blood cancer patient) meant he was unable to travel and could stay at home alone.” Household head, Case Study 7

4. Discussion

This study explores the socioeconomic effects of CHE for patients with NCDs and their family members, and the coping strategies adopted using a case study design. The increasing global incidence of NCDs is extremely high and world health leaders are focused on addressing, controlling and managing the burden [[1], [2], [3]]. The prevalence of NCDs is greatest in LMICs [1]. The situation in Bangladesh is alarming due to the questionable management of NCDs and the country's lack of comprehensive development. As has already been established, health is an integral part of the holistic development of any country, and Bangladesh, as a developing country, faces this NCD health burden in a crucial area of its overall development. It has become a vital barrier to the economic growth of the country. Numerous studies have shown that nations with better economic status are addressing the burden of NCDs more seriously. This qualitative study explores the patterns and processes of impoverishment along with the respective adaptive strategies adopted to cope with the CHE for serious NCDs through a case study design. The study uses households as its study unit since the whole family is affected by the CHE associated with NCDs and the need to adopt diverse strategies. The findings reveal that the treatment costs for NCDs are multifaceted and long-term. CHE has both economic effects, such as compromising on the household diet and nutrition, housing, living standards and lifestyle, and non-economic effects, like a downgrade in social status, social stigmatisation, compromising the wishes and dreams of family members, hampering children's education, disrupting family relationships and undermining social dignity. The findings of this study align with those of previous works. During and after severe health crises, households in developing countries cannot maintain their level of consumption due to rising medical costs and income deficits. Health issues impact household nutrition and schooling [23]. The study also revealed that CHE has a direct effect on household consumption in terms of food, clothing and children's education.

One study examined how Bangladeshi households manage payments for medical expenses [28]. To determine the effect of health expenditure on NCDs and adaptive strategies, this study looked at borrowing money, selling personal belongings, reducing expenses on food, etc. According to another study, patients and their families were caught in a cycle of debt and poverty [29]. However, it is interesting to note that debt also affects the social and interpersonal relationships between the families of NCD patients and their lenders since they often borrow from personal networks.

According to a previous study, having a family member with a serious disease is associated with a considerable rise in healthcare costs and a higher probability of becoming poor [30]. Female household heads are considered to be particularly vulnerable in Bangladesh and many other developing nations with patriarchal systems [31]. The data supports the claim that when the male breadwinner falls ill, the household becomes female-centred, and assistance is needed from the community.

Lack of social protection places a disproportionate cost on poor households. Families admit to taking out informal loans, using savings or selling assets to make their payments, causing long-term problems [32]. The financial and social circumstances before and after receiving a chronic NCD diagnosis differed significantly in the study.

Some of the major drawbacks of the health system include limited public facilities (service delivery) and compromised access to managing NCDs. Lack of essential commodities, unavailability of the health workforce, inadequate financial resources, political instability, lack of commitment and weak health information systems contribute to the poor management of NCDs [33]. Furthermore, Bangladesh's healthcare situation makes it more difficult for families with NCD patients to support themselves. Due to the devastating health costs associated with NCDs, practically every household experiences difficulty despite diverse socioeconomic status (SES). The situation is worse if the NCD patient is the head of the household and the only wage earner.

The current findings support previous studies that indicated major NCDs (e.g. cancer, CVD, chronic respiratory disorders) had a huge impact on vulnerable households and those below the poverty line [34]. The additional financial burden of treatment costs affects regular family expenses and income. Additionally, a systematic study revealed that households in South Asia most frequently used borrowing and asset sales as coping mechanisms for costs associated with NCDs [18]. In this study, issues such as not being able to pay the rent on time have been highlighted. In households with a history of cancer or CVD, food and nutrition for the family's children are major concerns. Due to limited or no access to formal financial sources, the majority of households relied on informal sources [23]. An alternate approach to assessing household funding options for medical expenses is through borrowing. Families have a variety of options for financing their care costs, including selling assets or borrowing money. However, over time, they found it difficult to repay the loans because the household's wage earner was no longer able to work due to suffering from NCDs.

Borrowing is a different approach to accessing household finance for healthcare purchases, according to research on coping strategies. Families have several options when paying for care, including using existing funds or savings, borrowing money or selling assets [18]. According to the study findings, households with cancer and CVD patients mostly depend on formal loans due to the large sums of money required for medication and surgery. Households have also discovered unofficial sources of borrowing from friends, neighbours and relatives. Almost all of the study participants had to borrow after a certain amount of time; their financial instability prevented them from affording the treatment.

One of the most popular adaptive strategies used by NCD-affected households during treatment was to sell assets. National studies confirm high rates of borrowing and selling to cope with financial shocks due to medical bills in the developing world [15]. To plan and manage the treatment and household living expenses, households frequently sell assets, such as animals, gold ornaments and property. Such asset sales resulted in households ultimately becoming impoverished. As a coping mechanism, patients adjust by taking a course of medication and scheduling regular check-ups with the doctor. Households also shift the position of the breadwinner, sometimes overcoming gender barriers, as an adaptive strategy when the primary or sole breadwinner of the home suffers from a major NCD and is unable to work. Nearly every household member, including children, is active in the adaptation process. Children choose to forgo tuition as a coping strategy. Others in the family make changes to the routines they had before being afflicted by the NCD.

In Bangladesh, most medical expenses are covered by individuals. There is little government assistance, and patients must bear this cost out of their own pockets, leading to the households’ ultimate impoverishment [5]. NCD treatments tend to be prolonged, bringing poverty to almost every household. Along with the various economic and social effects of NCDs and the CHE involved, it can also cause superstition among some people. Sometimes, people consider NCDs as being communicable and this produces social stigma. Therefore, further studies should focus on the perception of NCDs and the attitudes toward NCD patients for a better understanding of the situation because this kind of superstition is significant in marginalising, isolating, excluding and ultimately impoverishing NCD patients.

4.1. Conclusion

Households in LMICs should prioritise their health above everything. The CHE of NCDs greatly increases the likelihood of financial hardship and poverty for the affected family. The effect of chronic NCDs on household finances needs to receive far more attention from stakeholders and this study's findings can help to address the issues in this regard. The government should spend more on healthcare and ensure that all citizens have access to health insurance. The public's understanding of insurance options and the expansion of health insurance programmes could help households deal with the CHE. In addition, the problems require additional focus to lessen the immediate and long-term effects on the households of NCD patients. The study's conclusions highlight the necessity for a strategic plan to aid families affected by chronic NCDs.

Ethical approval

Ethical approval was granted by the Ethical Review Committee (ERC) of the Department of Comilla University, Bangladesh. An informed consent form was provided to each study participant, which included the study purpose and potential risks, with a confidentiality and anonymity statement to explain how the information provided would be securely handled. Moreover, the informed consent form also acknowledged that the participants could leave the interview at any time if they felt uncomfortable. Both verbal and written consent was obtained from all study participants prior to the interviews.

Author contributions

N. M. Rabiul Awal Chowdhury: Conceptualization, Methodology, Validation, Formal Analysis, Writing– Original Draft. Asaduzzaman Hridoy: Investigation, Data Curation, Formal Analysis. Fahima Nusrat: Investigation, Data Curation, Formal Analysis. Salma Akter Urme: Conceptualization, Methodology, Data Curation, Formal Analysis. Md. Shahgahan Miah: Conceptualization, Methodology, Formal analysis, Validation, Writing – Original draft and Editing, Revised, Supervision.

Funding

This research did not receive any research grant from any source.

Declaration of competing interest

I am declaring as corresponding author of this manuscript entitle “Exploring the Effects of Non-Communicable Diseases Induced from Catastrophic Health Expenditure and Coping Strategies: A Case Study among Households in Bangladesh” in favor of the first author and all co-authors’ that we have no conflict of interest and have consent to submit into this global reputed journal of Public Health in Practice.

Data availability

Data cannot be publicly available due to ethical issues and participant consent. Interview guidelines are available on request to: Mr. Shamim Osman (osmanshamim978@gmail.com), Department of anthropology, Comilla University, Kotbari, Comilla 3506, Bangladesh.