Costs and Affordability of COVID-19 Testing and Treatment in India
Authors: Selvaraj Sakthivel , Kumar Preeti , Bharali Ipchita , Hasan Habib , Mao Wenhui , Ogbuoji Osondu , Hussain Suhaib 
Published: July 2021

Abstract
BackgroundThe COVID-19 pandemic has triggered several underlying vulnerabilities with potentially far reaching consequences in low- and middle-income countries (LMICs) like India. Evidence of physical and socio-economic vulnerabilities caused by the pandemic are emerging rapidly, but one area that has received limited attention so far, is the financial vulnerability COVID-19 causes for households and the government. This paper aims to assess the financial burden imposed on governments and households and the ability of households to afford the required medical costs. Methods and FindingsUsing publicly available data, we computed per-episode mean costs for COVID-19 diagnosis and curative care by government and households. The curative costs included per-episode expenditure for (i) home isolation, (ii) hospital isolation and (i) ICU support. Expenditure was estimated based on mean costs derived from government capped package rates set for private facilities. Households’ affordability was assessed by comparing costs per episode to the estimated household income. The number of days required to pay for the cost of testing and treatment served as a proxy for households’ ability-to-pay. Work-days and wages/salaries for different types of workers were estimated based on Periodic Labor Force Surveys (PLFS, 2017-18) – a national level survey, with a sample size of 102,113 households and 433,339 persons, sampled through a stratified multi-stage random sampling approach. The mean cost for COVID-19 testing was Rs. 2,229 per test (Min-Max: Rs. 2200 – 2500) in a private facility and free in public facilities. The average cost of home isolation was Rs. 829 (Min-Max: Rs. 164 – 2743), while a 10-day episode of hospital isolation in a private facility was Rs. 67,470 (Min-Max: Rs. 2700 – 12600), and admission to the intensive care unit (ICU) cost Rs. 128,110 (Min-Max: Rs. 82500 – 200,000). To afford hospital isolation, regular employees would need to spend the equivalent of 124 days of wages while self-employed and casual workers would spend 170 days, and 257 days respectively. For ICU hospitalization, casual workers, regular employees, and self-employed workers would require 481 days, 318 days and 232 days of work respectively. Thus, affordability of COVID-19 services is far worse among casual workers, wherein annual wage falls short of ICU hospitalization cost for 90% of workers and hospital isolation costs for 48% of workers. Among self-employed workers, the proportions whose annual wages could not afford ICU hospitalization and home isolation were 66% and 27% respectively. For regular employees, we found that for 51% and 15% of them, their annual salaries could not afford to pay for ICU admission or hospital isolation respectively. ConclusionsBesides the financial burden associated with economic costs of COVID-19 lockdowns and other containment measures, the direct medical cost of seeking treatment by households is enormous and unsustainable. Our study has shown that households are subject to considerable financial burden rendering a sizeable segment unable to afford COVID-19 services. Future research must pay attention to measurements that can capture catastrophe and impoverishment inflicted by COVID-19 conditions. A deep dive to measure unaffordability must focus on what other basic needs are sacrificed while paying for COVID-19 conditions and treatments foregone.