The Contribution of Nontherapeutic Expenses Toward Financial Toxicity in Free Health Care Setting: A Cross-Sectional Survey in a Tertiary Care Hospital in India

Abstract The financial burden caused by the long-term treatment of cancer is a harsh reality in low- to middle-income countries due to the vicious cycle of poverty, lack of health insurance, and illiteracy. In addition to the cost of diagnostic tests and therapy, it also includes the money spent on travel to and living in a new city owing to the lack of health care facilities near one's own residence. Several studies have highlighted the impact of this financial strain; however, studies evaluating its effect in background of free health care are lacking. We sought to estimate “financial toxicity” and its contributing factors in a specific population with access to free health care. This cross-sectional survey was conducted at the oncology center of a tertiary care hospital in India. The survey consisted of (1) demographic, cancer, and therapy-related details; (2) the COST-FACIT (Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy) questionnaire determining the financial toxicity score; and (3) an additional questionnaire with information about expenditure breakup, present financial condition, and quantification of monetary impact on the family. A total of 300 patients who had received or were currently on treatment completed the survey. All patients in our study were immediate family members of government employees (current or retired). As a fully government-funded hospital, all patients at our institute were eligible to receive free treatment, inpatient management, and medication. Of the respondents, 61.3% were female. The average treatment duration in our survey was 8.03 months, with a mean patient age of 43.14 years. The most common causes of expenditure were travel, accommodation, and food-related expenses (75.7%). This finding was despite the availability of subsidized facilities. In addition, 34.5% spent money on unanticipated therapy-related costs (additional diagnostic tests, drugs unavailable in the hospital, or alternate therapies). The mean COST-FACIT score was 21.38 (range: 20–24), indicating mild financial toxicity. Predictors of high financial toxicity were rural residence, older age, and higher additional expenses after cancer diagnosis. Financial toxicity is a problem faced by almost all oncology patients, even with the availability of free health care. Although financial toxicity was measured as mild, a significant number of families had to dip into their savings or sell assets to support their treatment.