Catastrophic out-of-pocket healthcare expenditures among cancer patients receiving systemic therapy and/or radiation...

Cancer imposes a growing health and economic burden in low-resource settings. In Bangladesh, gaps in universal health coverage, inadequate financial protection and substantial reliance on out-of-pocket payments expose cancer-affected households to catastrophic health expenditure (CHE). This study quantified CHE across alternative thresholds, examined associated socioeconomic and clinical factors, and described the financial coping strategies used by cancer-affected households.

We conducted a facility-based cross-sectional study involving 607 adults receiving systemic therapy and/or radiotherapy at one public and one private tertiary cancer hospital in Dhaka, Bangladesh. Using the budget-share approach, CHE was defined as out-of-pocket expenditure on cancer care exceeding 10%, 15%, 25%, or 40% of total household income. Separate multivariable logistic regression models accounting for hospital-level clustering were fitted for each threshold to estimate adjusted associations with CHE. The 40% threshold was used for the primary multivariable analysis, while the lower thresholds provided complementary estimates of financial burden. Household coping strategies were assessed through structured interviews.

Among 607 participants, 55% were women, and 88% lived in rural areas. CHE affected 97% of participants at the 10% threshold, 95% at the 15% threshold, 86% at the 25% threshold, and 75% at the 40% threshold. In the primary 40% threshold model, participants from low-income households had more than 7 times the odds of experiencing CHE compared with those from high-income households (adjusted odds ratio [AOR] 7.31; 95% confidence interval [CI] 4.33-12.33), indicating a pronounced socioeconomic gradient in financial hardship. Participants receiving treatment at the private hospital had more than 3 times the odds of CHE compared with those treated at the public hospital (3.30; 1.45-7.48), consistent with greater financial exposure among patients receiving private-sector care. Physically inactive participants also had more than twice the odds of experiencing CHE compared with physically active participants (2.33; 1.38-3.92). To finance cancer care, households frequently depleted savings (53%), sold assets (39%), and borrowed informally (33%), reflecting reliance on potentially unsustainable coping strategies.

Patients receiving systemic therapy and/or radiotherapy experienced substantial financial hardship, with more than half of the study participants experiencing CHE at the highest threshold examined. Lower household income and treatment at the private hospital were associated with greater odds of CHE. The frequent use of savings, asset sales, and informal borrowing underscores the limited financial protection against cancer treatment costs. These findings support financial risk-protection policies, including expanded public coverage of systemic therapy and radiotherapy, targeted assistance for low-income households, and measures to improve the affordability of private-sector cancer care.

The high level of catastrophic health expenditure across all thresholds examined, together with the greater financial burden among low-income households and patients treated at the private hospital, indicates substantial gaps in financial protection for cancer care in Bangladesh. National priorities should include explicit coverage of clinically appropriate essential systemic therapies and radiotherapy within publicly financed health benefit packages, supported by pooled and prepaid financing. Means-tested subsidies, fee exemptions, or co-payment caps should prioritise economically vulnerable households. Where public-sector capacity requires patients to use private oncology services, strategic purchasing arrangements should incorporate accredited providers, standardised tariffs, transparent prices, controls on additional patient charges, and monitoring of service quality and expenditure. Hospitals should also provide financial-vulnerability screening, financial navigation, and formal referral pathways to government, non-governmental, and donor-supported assistance programmes. Targeted travel and accommodation assistance should be considered for eligible rural patients required to access tertiary cancer services in Dhaka.