Volume 71, Issue 2_suppl
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Ill-health contributes to impoverishment, a process brought into sharper focus by the impact of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic. This paper reviews studies that have measured the economic costs and consequences of illness for households, focusing on malaria, tuberculosis (TB), and HIV/AIDS. It finds that in resource-poor settings illness imposed high and regressive cost burdens on patients and their families. Direct and indirect costs of illness for malaria were less than 10% of the household income, but still significant when combined with the costs of other illnesses. The costs of TB and HIV/AIDS were catastrophic for households (more than 10% of the income). Health service weaknesses in many countries, including low coverage, user charges, and poor quality of care, contributed to high costs. Poor households in developing countries with a member with TB or HIV/AIDS struggled to cope, highlighting the urgent need for a substantial increase in health sector investment to expand access to preventive and curative health services. Government and non-governmental interventions should also be broadened to encompass measures that reduce the substantial indirect costs associated with diseases such as malaria, TB, and HIV/AIDS.


Article metrics loading...

Loading full text...

Full text loading...



  1. Ainsworth M, Fransen L, Over M, 1998. Confronting AIDS: Evidence from the Developing World. Washington, DC: The World Bank and Brussels: The European Commission.
  2. Barnett TA, Whiteside A, Desmond C, 2001. The social and economic impact of HIV/AIDS in poor countries: a review of studies and lessons. Prog Dev Studies 1 : 151–170.
  3. World Bank, 1997. Confronting AIDS: Public Priorities in a Global Epidemic. Washington, DC: World Bank.
  4. DFID, 1999. Better Health for Poor People. International Development Target Strategy Paper. London: Department for International Development.
  5. World Bank, 2000. World Development Report: Attacking Poverty. Washington, DC: World Bank.
  6. WHO, 2002. Improving Health Outcomes of the Poor: The Report of Working Group 5 of the Commission on Macroeconomics and Health. Geneva: World Health Organization.
  7. Bloom G, Lucas H, Eddun A, Lenneiye M, Milimo J, 2000. Health and Poverty in Sub-Saharan Africa. Brighton, United Kingdom: Institute of Development Studies, University of Sussex, Working Paper 103.
  8. Sauerborn R, Nougtara A, Hien M, Diesfeld HJ, 1996. Seasonal variations of household costs of illness in Burkina Faso. Soc Sci Med 43 : 281–290.
  9. Sauerborn R, Adams A, Hien M, 1996. Household strategies to cope with the economic costs of illness. Soc Sci Med 43 : 291–301.
  10. Fabricant SJ, Kamara CW, Mills A, 1999. Why the poor pay more: household curative expenditures in rural Sierra Leone. Int J Health Plann Manag 14 : 179–199.
  11. Gallup J, Sachs J, 2000. The Economic Burden of Malaria. Cambridge, MA: Center for International Development, Harvard University, CID Working Paper No. 52.
  12. Malaney P, 2003. Micro-Economic Approaches to Evaluating the Burden of Malaria. Cambridge, MA: Center for International Development, Harvard University, CID Working Paper No. 99.
  13. Russell S, 1996. Ability to pay for health care: concepts and evidence. Health Policy Plann 11 : 219–237.
  14. Russell S, 2001. Can Households Afford to Be Ill? The Role of the Health System, Material Resources and Social Networks in Sri Lanka. PhD thesis. London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom.
  15. Wilkes A, Hao Y, Bloom G, Xingyuan G, 1997. Coping with the Costs of Severe Illness in Rural China. Brighton, United Kingdom: Institute of Development Studies. IDS Working Paper No. 58.
  16. Berman P, Kendall C, Bhattacharyya K, 1994. The household production of health: integrating social science perspectives on micro-level health determinants. Soc Sci Med 38 : 205–215.
  17. Sauerborn R, Ibrango I, Nougatar A, Borchert M, Hien M, Benzler J, Koob E, Diesfeld HJ, 1995. The economic costs of illness for rural households in Burkina Faso. Trop Med Parasitol 46 : 54–60.
  18. Prescott N, 1999. Coping with Catastrophic Health Shocks. Washington, DC: Inter American Development Bank. Conference on Social Protection and Poverty.
  19. Ranson K, 2002. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujurat, India: current experiences and challenges. Bull World Health Organ 80 : 613–621.
  20. Pryer J, 1989. When breadwinners fall ill: preliminary findings from a case study in Bangladesh. IDS Bull 20 : 49–57.
  21. Chima RI, Goodman C, Mills A, 2003. The economic impact of malaria in Africa: a critical review of the evidence. Health Policy 63 : 17–36.
  22. McIntyre D, Thiede M, 2003. A Review of Studies Dealing with Economic and Social Consequences of High Medical Expenditure with a Special Focus on the Medical Poverty Trap. Cape Town, South Africa: Health Economics Unit, University of Cape Town.
  23. Worrall ES, Basu, S, Hanson K, 2003. The Relationship between Socio-economic Status and Malaria: A Review of the Literature. Background paper for the meeting “Ensuring that Malaria Control Interventions Reach the Poor.” London: London School of Hygiene and Tropical Medicine. September 5–6, 2002.
  24. Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L, McIntyre D, Pannarunothai S, Prieto A, Ubilla G, Ram S, 2000. Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition. Bull World Health Organ 78 : 55–65.
  25. Onwujekwe O, Chima R, Okonkwo P, 2000. Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities. Health Policy 54 : 143–159.
  26. Pannarunothai S, Mills A, 1997. The poor pay more: health-related inequality in Thailand. Soc Sci Med 44 : 1781–1790.
  27. Ensor T, San PB, 1996. Access and payment for health care: the poor of Northern Vietnam. Int J Health Plann Manag 11 : 69–83.
  28. Ettling MB, McFarland DA, Schultz LJ, Chitsulo L, 1994. Economic impact of malaria in Malawian households. Trop Med Parasitol 45 : 74–79.
  29. Evans PJ, 1994. Community Knowledge, Attitudes and Practices: Urban Mosquitoes and Sustainable Mosquito Control. PhD Thesis. University of Exeter, Exeter, United Kingdom.
  30. Zandu A, Malengreau M, Wery M, 1991. Methods and expenses for protection against mosquitoes in households in Kinshasha, Zaire. Ann Soc Belg Med Trop 71 : 259–266.
  31. Louis JP, Trebucq A, Gelas H, Fondjo E, Manga L, Toto JC, Carnevale P, 1992. Malaria disease in Yaounde-City, Cameroon: financial charges and anti-vector control at the family level. Bull Soc Pathol Exot 85 : 26–30.
  32. Desfontaine M, Gelas H, Cabon H, Goghomou A, Bemba DK, Carnevale P, 1989. Evaluation of practice and cost of vector control at family level in central Africa I, Yaounde-City, Cameroon. Bull Soc Pathol Exot 82 : 558–565.
  33. Desfontaine M, Gelas H, Cabon H, Goghomou A, Bemba DK, Carnevale P, 1990. Evaluation of practice and cost of vector control at family level in central Africa II, Douala-City, Cameroon. Ann Soc Belg Med Trop 70 : 137–144.
  34. Guiguemde TR, Coulibaly N, Coulibaly SO, Ouedraogo JB, Gbary AR, 1997. A precise method for estimating the economic costs of malaria: application of the method in a rural area in Burkina Faso (West Africa). Trop Med Int Health 2 : 646–653.
  35. Guiguemde TR, Dao F, Curtis V, Traore A, Sondo B, Testa J, Ouedraogo JB, 1994. Household expenditure on malaria prevention and treatment for families in the town of Bobo-Dioulasso, Burkina Faso. Trans R Soc Trop Med Hyg 88 : 285–287.
  36. Attanayake N, Fox-Rushby J, Mills A, 2000. Household costs of ‘malaria’ morbidity: a study in Matale district, Sri Lanka. Trop Med Int Health 5 : 595–606.
  37. Asenso-Okyerea WK, Dzatorb JA, 1997. Household cost of seeking malaria care. A retrospective study of two districts in Ghana. Soc Sci Med 45 : 659–667.
  38. Konradsen F, van der Hoek W, Amersinghe PH, Amerasinghe FP, Fonseka KT, 1997. Household responses to malaria and their costs: a study from rural Sri Lanka. Trans R Soc Trop Med Hyg 91 : 127–130.
  39. Kamolratanakul P, Sawert H, Kongsin S, Lertmaharit S, Sriwongsa J, Na-Songkhla S, Wangmanee S, Jittimanee V, Payandana V, 1999. Economic impact of tuberculosis at the household level. Int J Tuberc Lung Dis 3 : 596–602.
  40. Rajeswari R, Balasubramanian R, Muniyandi M, Geetharamani S, Thresa X, Venkatesan P, 1999. Socio-economic impact of tuberculosis on patients and family in India. Int J Tuberc Lung Dis 3 : 869–877.
  41. Wyss KP, Kilima P, Lorenz N, 2001. Costs of tuberculosis for households and health care providers in Dar es Salaam, Tanzania. Trop Med Int Health 6 : 60–68.
  42. Croft RA, Croft RP, 1998. Expenditure and loss of income incurred by tuberculosis patients before reaching effective treatment in Bangladesh. Int J Tuberc Lung Dis 2 : 252–254.
  43. Needham DM, Godfrey-Faussett P, Foster SD, 1998. Barriers to tuberculosis control in urban Zambia: the economic impact and burden on patients prior to diagnosis. Int J Tuberc Lung Dis 2 : 811–817.
  44. Mann G, Squire S, Nhlema B, Luhanga T, Salaniponi FML, Kemp J, 2002. Expanding DOTS? Time for Cost-Effective Diagnostic Strategies for the Poorest in Malawi. Paper presented at the 33rd World Conference on Lung Health, October 2002, Montreal, Canada.
  45. Nair D, George A, Chacko KT, 1997. Tuberculosis in Bombay: new insights from poor patients. Health Policy Plann 12 : 77–85.
  46. Ngalula J, Urassa M, Mwaluko G, Isingo R, Ties Boerma J, 2002. Health service use and household expenditure during terminal illness due to AIDS in rural Tanzania. Trop Med Int Health 7 : 873–877.
  47. Bechu N, 1997. The Impact of AIDS on the Economy of Families in Cote d’ Ivoire: Changes in Consumption among AIDS-Affected Households. Washington, DC: World Bank. Confronting AIDS: Public Priorities in a Global Epidemic.
  48. Pitayanon S, Kongsin S, Janjaroen W, 1997. The economic impact of HIV/AIDS mortality on households in Thailand. Bloom D, Godwin P, eds. The Economics of HIV and AIDS: The Case of South and South East Asia. Delhi: Oxford University Press.
  49. Johnson S, Schierhout G, Steinberg M, Russell B, Hall K, Morgan J, 2002. AIDS in the household. South African Health Review 2002. Cape Town, South Africa: The Health Systems Trust.
  50. Rugalema G, 1999. Adult Mortality as Entitlement Failure: AIDS and the Crisis of Rural Livelihoods in Buhaya Village, Bukoba District, Tanzania. PhD thesis. Institute of Social Studies, The Hague, Netherlands.
  51. Williams A, 1988. ‘Abantu Abaafa’ People Are Dying: Old Age in Contemporary Uganda. PhD thesis. University of Queensland, Brisbane, Queensland, Australia.
  52. Needham DM, Bowman D, Foster S, Godfrey-Faussett P, 2003. Patient seeking care barriers and tuberculosis programme reform: a qualitative study. Health Policy 67 : 1–15.
  53. Mishra DK, Pandey GD, Sinha PK, 1993. Use of and spending on curative health care in a tribal block of Madhya Pradesh. Berman P, Khan ME, eds. Paying for India’s Health Care, London: Sage Publications.
  54. Mongkolsmai D, 1993. Survey data from the research project “Public Sector Health Financing in Thailand.” Bangkok, Thailand: Faculty of Economics, Thammasat University.
  55. Rannan-Eliya R, 2001. Strategies for Improving the Health of the Poor: The Sri Lankan Experience. Paper prepared for the Health Systems Resource Centre, Department of International Development, United Kingdom, by the Institute of Policy Studies, Colombo, Sri Lanka.
  56. Shepard DS, Ettling MB, Brinkmann U, Sauerborn R, 1991. The economic cost of malaria in Africa. Trop Med Parasitol 42 : 199–203.
  57. Ettling MB, Shepherd DS, 1991. The economic cost of malaria in Rwanda. Trop Med Parasitol 42 : 214–218.
  58. Jayawardene R, 1993. Illness perception: social cost and coping-strategies of malaria cases. Soc Sci Med 37 : 1169–1176.
  59. Konradsen F, van der Hoek W, Amerasinghe PH, Amerasinghe FP, 1997. Measuring the economic cost of malaria to households in Sri Lanka. Am J Trop Med Hyg 56 : 656–660.
  60. Leighton C, Foster R, 1993. Economic Impacts of Malaria in Kenya and Nigeria. Bethesda, MD: Abt Associates. U.S. Health Financing and Sustainability Project, 6.
  61. Lonnroth KL M, Tran T, Thuong Quy HT, Diwan VK, 2001. Can I afford free treatment? Perceived consequences of health care provider choices among people with tuberculosis in Ho Chi Minh City, Vietnam. Soc Sci Med 52 : 935–948.
  62. Menon RMJ, Wawer, Konde-Lule JK, Sewankambo NK, Li C, 1997. The economic impact of adult mortality on households in Rakai district, Uganda. Ainsworth M, Fransen L, Over M, eds. Confronting AIDS: Evidence from the Developing World. Washington, DC: The World Bank and Brussels: The European Commission.
  63. Bachmann M, Booysen F, 2003. Health and economic impact of HIV/AIDS on South African households: a cohort study. BMC Public Health 3 : 14.
  64. Rugalema G, 1998. It is not only the loss of labour: HIV/AIDS, loss of household assets and household livelihoods in Bukoba District, Tanzania. Paper presented at the East and Southern Africa Regional Conference on responding to HIV/AIDS. Harare, June 8–12, 1998.
  65. Hansen K, Woelk G, Jackson H, Kerkhoven R, Manjonjori N, Maramba P, Mutambirwa J, Ndimande E, Vera E, 1998. The cost of home-based care for HIV/AIDS patients in Zimbabwe. AIDS Care 10 : 751–759.
  66. Knodel J, VanLandingham M, Saengtienchai C, Imem W, 2001. Older people and AIDS: quantitative evidence of the impact in Thailand. Soc Sci Med 52 : 1313–1327.
  67. Tibaijuka AK, 1997. AIDS and economic welfare in peasant agriculture: Case studies from Kagabiro village, Kagera region, Tanzania. World Dev 25 : 963–975.
  68. Rugalema G, 2000. Coping or struggling? A journey into the impact of HIV/AIDS in Southern Africa. Rev Afr Political Economy 86 : 537–545.
  69. Booth D, Milimo J, Bond G, Chimuka S, Nabanda M, Liywalii K, Mwalusi M, Mwanamwalye M, Mwanza E, Peme L, Zulu A, 1995. Coping with Cost Recovery: A Study of the Social Impact of and Response to Cost Recovery in Basic Services (Health and Education) in Poor Communities in Zambia. Report to SIDA, commissioned through the Development Studies Unit, Department of Social Anthropology, Stockholm University.
  70. Fabricant SJ, 1992. Community Financing in Sierra Leone: Affordability and Equity of Primary Health Care Costs. PhD thesis. University of London, London, United Kingdom.
  71. Kanji N, Jazdowska N, 1993. Structural adjustment and women in Zimbabwe. Rev Afr Political Economy 56 : 11–26.
  72. Lucas H, Nuwagaba A, 1999. Household Coping Strategies in Response to the Introduction of User Charges for Social Services: A Case Study on Health in Uganda. Brighton, United Kingdom: Institute of Development Studies. Working Paper No. 86.
  73. Lundberg M, Over M, 2000. Transfers and Household Welfare in Kagera. Durban, South Africa: IAEN Economics of AIDS Symposium.
  74. Tungaraza F, 1993. Social networks and social care in Tanzania. Soc Policy Admin 27 : 141–150.
  75. Waddington C, Enyimayew K, 1989. A price to pay: the impact of user charges in Ashanthi-Akim district, Ghana. Int J Health Plann Manag 4 : 17–47.
  76. Needham DM, Foster S, Tomlinson G, Godfrey-Faussett P, 2001. Socio-economic, gender and health services factors affecting diagnostic delay for tuberculosis patients in urban Zambia. Trop Med Int Health 6 : 256–259.
  77. Nhlema B, Kemp J, Steenbergen G, Theobald S, Tang S, Squire SB, 2003. A Systematic Analysis of TB and Poverty. London: TB and Poverty Advisory Committee.
  78. Mutyambizi V, 2002. An Exploratory Study of the Resources and Coping Strategies of Poor Urban Households Affected by HIV/AIDS in Harare. Cape Town, South Africa: School of Economics, University of Cape Town.

Data & Media loading...

  • Received : 03 Oct 2003
  • Accepted : 28 Jan 2004

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error