Economic costs of lower respiratory tract infections among hospitalized patients in southern Sri Lanka: a prospective cohort study

Lower respiratory tract infections (LRTIs) are the fourth leading cause of death worldwide and, in Sri Lanka, were the third and fourth leading causes of hospital deaths and hospitalization, respectively, in 2022–2023. No prior study has quantified the episode-level economic burden in Sri Lanka. Although the public healthcare system provides services free of charge, patients still incur substantial out-of-pocket (OOP) and productivity costs. We estimated the direct and indirect costs of hospitalized LRTI episodes in southern Sri Lanka from a societal perspective, by phase of care and age group. We conducted a prospective cohort study of 1,268 patients (median age 58.0 years; interquartile range [IQR]: 32.0–69.0) hospitalized with LRTIs at a public tertiary care hospital in Galle, Sri Lanka, from April 2018 to March 2021. Standardized questionnaires at enrollment and approximately four weeks after the date of admission captured direct OOP costs (consultations, medications, laboratory tests, transportation) and indirect costs (productivity losses from missed work or school) across three phases: pre-hospitalization (prior costs related to the current illness), hospitalization, and post-hospitalization (illness-related costs from discharge through around four weeks after index admission). Healthcare system costs were estimated from Sri Lanka–specific World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) estimates and included in the direct costs. All costs were inflation-adjusted to 2020 Sri Lankan Rupees (LKR) and converted to 2020 United States Dollars (USD). Median total cost per hospitalized LRTI episode was USD 125.25, including median direct costs of USD 106.15 and indirect costs of USD 18.47. Before hospitalization, 69.6% of patients sought care; 23.2% sought additional care after discharge. Median length of stay was four days (IQR: 3–5), and 95.7% received antibiotics. Total costs across the cohort were USD 233,486. Median per-patient cost represented 13.2% of annual per-capita household income, with the highest median total cost among children aged 6–10 years. Hospitalized LRTIs impose a substantial financial burden on households and the public healthcare system in southern Sri Lanka despite free public healthcare. These estimates can inform economic evaluations of preventive interventions, including vaccines targeting LRTI pathogens, and support health technology assessment in Sri Lanka.