Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study.

BACKGROUND: Inclusive universal health coverage requires access to quality health care without financial barriers. Receipt of palliative care after advanced cancer diagnosis might reduce household poverty, but evidence from low-income and middle-income settings is sparse. METHODS: In this prospective study, the primary objective was to investigate total household costs of cancer-related health care after a diagnosis of advanced cancer, with and without the receipt of palliative care. Households comprising patients and their unpaid family caregiver were recruited into a cohort study at Queen Elizabeth Central Hospital in Malawi, between Jan 16 and July 31, 2019. Costs of cancer-related health-care use (including palliative care) and health-related quality-of-life were recorded over 6 months. Regression analysis explored associations between receipt of palliative care and total household costs on health care as a proportion of household income. Catastrophic costs, defined as 20% or more of total household income, sale of assets and loans taken out (dissaving), and their association with palliative care were computed. FINDINGS: We recruited 150 households. At 6 months, data from 89 (59%) of 150 households were available, comprising 89 patients (median age 50 years, 79% female) and 64 caregivers (median age 40 years, 73% female). Patients in 55 (37%) of the 150 households died and six (4%) were lost to follow-up. 19 (21%) of 89 households received palliative care. Catastrophic costs were experienced by nine (47%) of 19 households who received palliative care versus 48 (69%) of 70 households who did not (relative risk 0·69, 95% CI 0·42 to 1·14, p=0·109). Palliative care was associated with substantially reduced dissaving (median US$11, IQR 0 to 30 vs $34, 14 to 75; p=0·005). The mean difference in total household costs on cancer-related health care with receipt of palliative care was -36% (95% CI -94 to 594; p=0·707). INTERPRETATION: Vulnerable households in low-income countries are subject to catastrophic health-related costs following a diagnosis of advanced cancer. Palliative care might result in reduced dissaving in these households. Further consideration of the economic benefits of palliative care is justified. FUNDING: Wellcome Trust; National Institute for Health Research; and EMMS International.

Cigarette affordability in the Eastern Mediterranean Region.

BACKGROUND: The World Health Organization Eastern Mediterranean Region is the only WHO region with increasing male prevalence of smoking tobacco products observed and predicted. There is no regional analysis of cigarette affordability in the literature. AIMS: This study aimed to compare the affordability of the cheapest, most sold and premium brands of cigarettes between countries of the Eastern Mediterranean Region (EMR) and countries in the rest of the world by income group in 2008 and 2018. METHODS: Affordability was defined as the percentage of GDP per capita needed to purchase 2000 cigarette sticks. A simple average and 95% confidence interval of affordability was calculated by income group for EMR countries and for the rest of the world. RESULTS: Historically, the cheapest, most sold and premium brands of cigarettes have on average been more affordable in the EMR compared to the same brands in the rest of the world in every income group. This pattern persists despite some convergence between the affordability of cigarettes in the EMR and in countries in the rest of the world. CONCLUSION: The historic and persisting higher affordability of cigarettes in the EMR relative to the rest of the world could offer an explanation to the tobacco prevalence trends in the region. Continued implementation of Article 6 of the WHO Framework Convention on Tobacco Control is needed.