COST ANALYSIS OF DIAGNOSIS AND TREATMENT OF TOBACCO RELATED

CANCER
IN SELECTED HOSPITALS OF NEPAL
2019
Submitted to
Nepal Health research council
Ramshahpath, Kathmandu,Nepal

Submitted by
Principal investigator: Dr.Devi Prasad prasai
Co-investigator: Anand Bahadur Chand
Mohit singh Thagunna
Bharat Bikram Shah

Action Nepal
With the financial support of the Union
Kathmandu/Nepal
2019

1
ACKNOWLEDGEMENTS
Cost analysis of diagnosis and treatment of tobacco related cancer patients of selected hospitals
of Nepal is the result of earnest effort put forth by different individuals and organizations. The
survey was conducted after getting ethical clearance from Nepal health research council NHRC.
The International Union against Tuberculosis and Lung Disease (The Union) provided financial
support through its mission in Nepal. The survey was implemented by Action Nepal, a local
organization which has been playing significant role to make media advocacy & policy
communication for an urgent need on effective implementation of tobacco control law in Nepal
having wide experience in conducting such surveys in the past.

We express our deep sense of appreciation to Dr. Devi Prasad Prasai, health economist for
valuable input during the various phases of the survey, including the development of Proposal,
training of field staff review of draft tables. We would like to extend our sincere gratitude to Mr.
Anand Bahadur Chand chairperson Action Nepal for guidance and support to complete the
survey.

We would like to thank Dr. Murari Man Shrestha Director, Division of Preventive Oncology,
Nepal Cancer Hospital (NCH) Harisiddhi, Dr. Shivaji Poudel, Academic Co-ordinator BP
Koirala Memorial Cancer Hospital (BPKMCH) Bharatpur Chitwan, Mr RajaRam Tajale
Administrator Bhaktapur Cancer Hospital (BCH), and other staff of Nepal Cancer Hospital
Harisiddhi, (BPKMCH) and Bhaktapur Cancer Hospital for their continuing efforts in successful
implementation of the survey.

We would like to extend our appreciation to The International Union against Tuberculosis and
Lung Disease (The Union) for funding the survey. We would particularly like to thank the
Monitoring & Evaluation Officer, Mr. Mohit Singh Thagunna, for continuous support to improve
the quality of the survey. Our special thanks go to Mr. Bharat Vikram Shah Administrative
officer for capacity strengthening and valuable technical assistance and coordination throughout
the survey. We also like to thank Mr. Amit Kumar Bom Program Officer for his technical
support throughout the survey, quality control team members, and other field staff for their
valuable contribution towards the successful completion of survey. We would also like to thank
all the contributors to the report.

The survey was made possible through the cooperation we received from the hospitals & hospital
staffs, their support has been highly appreciated. Finally, we extend our deepest gratitude to all
the respondents for their time and patience during interview.

2
Acronyms/Abbreviations

BPKMCH BP Koirala Memorial Cancer Hospital

GBD Global burden of diseases

NCH Nepal Cancer Hospital

MoHP Ministry of Health and Population

NHRC Nepal Health research Council

NPR Nepali Rupee

WB World Bank

WHO World Health organization

DALYs Disability Adjusted Life Years

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Executive summary

Rationale: Non communicable disease are the leading cause of deaths globally for Nepal
accounting 66% of all deaths (2016 WHO) Cardiovascular diseases (CVD), Chronic non-
infectious respiratory diseases (like COPD), Cancers ,diabetes, and mental health. Behavior like
tobacco smoking is main risk factor for the country and region .The burden of tobacco related
diseases on society is enormous. According to the WHO, the economic burden of tobacco is
particularly high in the developing world and by 2030 four out of five tobacco-related deaths will
occur in less developed countries. Cigarette smoking harm nearly every organ of the body. The
economic costs of smoking extend beyond the direct costs of smoking-health care costs related to
diseases in both active and second hand smokers. And also contribute to loss of earnings and
reduced workplace productivity. Use of tobacco has multiple consequences; it damages the
health and pushes the household below the poverty line. The economic burden of tobacco related
cancer has not been measured in Nepal.

Objectives:
The overall objective of the study is to determine direct medical, nonmedical costs, and wage
loss (productivity) due to absenteeism. The specific objectives are: 1) to assess the socio
demographic characteristics of patients of tobacco related cancers, 2) to determine direct medical
costs of diagnosis and treatment of tobacco related cancers, 3) to determine direct nonmedical
costs of diagnosis and treatment of tobacco related cancers and to measure indirect cost of
productivity losses due to illness, and those resulting from non-healthcare payments for
caregivers.

Method:
It is a hospital based descriptive, cross sectional, quantitative study conducted in one public and
two private hospitals (one for profit other one not for profit). A total 103 cases who had ever
smoked tobacco, were randomly selected for the study purpose. Every even case was selected for
the study. Data were analyzed in SPSS version 22 and summarized in percent, mean, median and
standard deviation.

Major findings:
Total cost of tobacco related cancer has been estimated NPR 981,370.00 in 2019. The direct
medical cost accounts for 60% and direct nonmedical 13% of the total cost. The average direct
medical cost of a patient is estimated NPR 588740 (Std 449567) and the average direct non-
medical cost is estimated NPR 123147.3. The absenteeism/ wage loss due to sickness accounted
for 27% of the total cost which amounts to NRS 269482.3.

4
Recommendations:
Based on the findings of the study, 1) provide 50% treatment subsidy to a poor patient who has
been suffering from tobacco related cancer, 2) Raise the tobacco tax up to (70%) of the retail
price as recommended by WHO and World Bank. 3) Strengthen the cancer registry system and
conduct population based the socio economic study to identify the groups who are hard hit by
tobacco related diseases.

5
Contents
Acronyms/Abbreviations .......................................................................................................................... 3
Chapter I ....................................................................................................................................................... 8
Introduction ................................................................................................................................................... 8
1.1 Background ......................................................................................................................................... 8
1.2 Rationale ............................................................................................................................................. 8
1.3 Objective ............................................................................................................................................. 9
1.4 Conceptual framework ...................................................................................................................... 10
1.5 Limitations of the study .................................................................................................................... 11
1.6 Broad assumptions ............................................................................................................................ 11
Chapter II .................................................................................................................................................... 12
Methodology ............................................................................................................................................... 12
2.1 Study design ...................................................................................................................................... 12
2.2 Sample size ....................................................................................................................................... 12
2.3 Sampling procedure .......................................................................................................................... 12
2.4 Defining the costing perspective ....................................................................................................... 13
2.5 Inclusion and exclusion..................................................................................................................... 13
2.6 Identification of cost items ................................................................................................................ 14
2.7 Study Site .......................................................................................................................................... 14
2.8 Questionnaire .................................................................................................................................... 14
2.9 Data analysis ..................................................................................................................................... 14
Chapter III ................................................................................................................................................... 15
Socio economic and demographic characteristics....................................................................................... 15
3.1 Age of patient.................................................................................................................................... 15
3.2 Educational attainment...................................................................................................................... 15
3.3 Religion ............................................................................................................................................. 16
3.4 Occupation ........................................................................................................................................ 16
3.5 Source of income and management of expenses............................................................................... 17
Chapter IV................................................................................................................................................... 19

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Cost analysis ............................................................................................................................................... 19
4.1 Summary of costs.............................................................................................................................. 19
4.2 Medical costs .............................................................................................................................. 20
4.3 Non medical costs ............................................................................................................................. 21
4.4 Absenteeism/wage loss due to sickness ............................................................................................ 21
4.5 Extrapolation of cost for the diagnosis and treatment of tobacco related cancer .............................. 22
Chapter V .................................................................................................................................................... 24
Discussion and recommendations ............................................................................................................... 24
5.1 Increasing the subsidy to poor patients ............................................................................................. 24
5.2 Rising the tax on tobacco .................................................................................................................. 24
5.3 Strengthen the cancer registry system ............................................................................................... 24
References ............................................................................................................................................... 25

7
 Chapter I

Introduction

1.1 Background
Tobacco epidemic is one of the biggest public health threats the world has ever faced responsible
for approximately 22% of cancer deaths (WHO, 2018) around 80% of the 1.1 billion smokers
worldwide live in low- and middle-income countries, where the burden of tobacco-related illness
and death is heavies. Tobacco users who die prematurely deprive their families of income, raise
the cost of healthcare and hinder economic development (WHO, 2018). Tobacco use is the most
important risk factor for cancer and responsible for approximately 22% of cancer deaths (WHO,
2018). Cancer is the second leading cause of death globally, and it is responsible for an estimated
9.6 million deaths in 2018. Globally, about 1 in 6 deaths is due to cancer (WHO, 2018). The
economic impact of cancer is significant and is increasing due to the increasing the risk factors.
The total annual economic cost of cancer in 2010 was estimated at approximately US$ 1.16
trillion in the World. The leading causes of deaths due to cancer worldwide were highest for
lung cancer, followed by colorectal cancer, stomach cancer, liver cancer and breast cancer
(WHO, 2018). Smoking was ranked among the five leading risk factors by DALYs in 109
countries and territories in 2015, rising from 88 geographies in 1990 (GBD,2015).

In Nepal, the estimated prevalence of the cancer is 26.7 per 100,000 population in 2016 but
incidence rate has increased to 37.1 per 100,000 for males and 39.9 for females in 2019 (Paudel
et al, 2017). The proportion of tobacco related cancers (oral cavity, pharynx, esophagus, larynx,
lung and urinary bladder) relative to all cancers was 43.8% in males and 18.8% in female
(BPMCH, 2017). Among the cases, leading cancer was related to bronchus & lung, it accounts
for 43.5% of all cancers in males and 55.7% in females (BPKMCH, 2017). The most risk factor
of cancer is the tobacco use.

1.2 Rationale
The hospital based cancer registry was established in Nepal since 2003 and most recently
available report from 2003-2012 AD showed that lung cancer was the major cancer among
males between 2003-2012) throughout country (Poudel et al, 2017& BPKMCH, 2017). The
economic burden of tobacco related cancer has not been measured in Nepal. Therefore, it is
imperative to assess the economic cost of tobacco related cancer.

8
1.3 Objective

The objectives of the study is to determine direct medical costs, nonmedical costs, wage loss
(productivity) of tobacco related cancers.

The specific objectives of the Study are as follows:

• To assess the socio demographic characteristics of patients of tobacco related
cancers.
• To determine direct medical costs of diagnosis and treatment of tobacco related
cancers.
• To determine direct nonmedical costs of diagnosis and treatment of tobacco
related cancers.
• To determine indirect cost of productivity losses due to illness, and those resulting
from non-healthcare payments for caregivers

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 1.4 Conceptual framework

Cost analysis of diagnosis and treatment of cancer

Direct Medical Costs Direct Non-Medical Costs Indirect cost (Productivity

loss due to morbidity)
(Diagnosis and Treatment) - Travel,
- Food,
-Wage loss of patient
- Inpatient - Accommodation -Wage loss of caregivers
- Outpatients
- Emergency

Economic

Burden

Productivity
loss
Public

Hospitals Private

-For profit

-Not for
profit
hospitals
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1.5 Limitations of the study

 It is a hospital based analysis therefore, does not assess the wealth status of patients.
 It excluded the productivity loss (cost) due to the premature death.
 It has excluded intangible costs such as pain, nausea and other discomforts.
 The estimated cost of tobacco related cancer diseases is indicative because of small
sample size (n=103) and the recall errors and high standard deviation. Though, it
provides the insights to the policy makers.
 It assesses the cost of tobacco related cancer patients who were ever smokers.
 Those who went abroad for the treatment of tobacco related cancer are excluded.

1.6 Broad assumptions

Following assumptions were made while doing the cost analysis of the patients.

1. Patients are rational.

2. Assume that there is no seasonal variability of tobacco related cancer.
3. The price of consultation, drugs and medical supplies remains unchanged during the
interview period.
4. Patients report the out of pocket spending only. They do not report the subsidy given by
the Government of Nepal.

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 Chapter II

Methodology

2.1 Study design

It is a hospital based descriptive, cross sectional quantitative study conducted at one public and
two private hospitals (1 for profit and 2 not for profit). The economic costs of tobacco-related
cancer were calculated as medical, nonmedical and productivity loss due to morbidity.

2.2 Sample size

The sample size calculation was done by using the following formula.

Z2*p (1-p)
n= ----------------
d2
n= required sample size
Z= Confidential level 1.96
p= percentage of patients who come to the hospital for treatment 0.5
1-p= (1-0.5)=0.5
d = 0.1
n=96
Minimum sample size=96

2.3 Sampling procedure

There are three major cancer specialized hospitals in Nepal two are in the private sector and one
is in the public. Nearly, half of the patients were selected from public (48%) and other half
(52%) were from private hospitals based on the client load. Because of the low number of
discharges every even number of patient who has met the inclusion criteria, was selected for
interview. The distribution of samples is given in table 2.3

Table 2.3: Distribution of samples

Hospital Numbers Percent
BPKMCH, Bharatpur 47.57
Chitwan 49
Bhaktapur Cancer
Hospital 28 27.18
NCH, Harisiddhi 26 25.25
Total 103 100

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2.4 Defining the costing perspective
It is a patient perspective cost analysis of tobacco related cancer. It was conducted as a part of
economic burden of tobacco. It also assesses the affordability of treatment services of tobacco
related cancer. Therefore, only patient perspective costs are taken into account. Cost includes
medical, nonmedical, and productivity loss due to illness. But it has excluded the productivity
loss due to premature deaths.

2.5 Inclusion and exclusion

Following patients are included and excluded from the study:

Inclusion criteria:
 Cancer patients recorded in the registry,
 Patient who have cancer on Lip, tongue , gum, floor of mouth palate, unspecified of
mouth , tonsil, Oropharynx, nasopharynx, pyriform sinus, hypopharynx, oral cavity,
esophagus, larynx, trachea, bronchus & lung, and urinary bladder as defined by national
cancer registry report of 2003-2012,
 Patients admitted and discharged from the selected hospital,
 Age 18-70 years &
 Patient has the history smoking (ever smoker)

Exclusion criteria
 Cancer other than tobacco related.
 Having other health problems,
 Covered by health insurance and reimbursement mechanism,
 Cost of traditional medicine &
 Age below 18 and above than 70 years

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2.6 Identification of cost items
Following costs were identified and included in the patients perspective cost.

Medical Non –medical Productivity loss due to morbidity

Diagnosis Transportation
Consultation fee Lodging Wage loss of patient
Laboratory test cost Fooding Wage loss of care giver
Radiological cost
Other related cost
Treatment
Doctor fee
Bed or room charge
Surgery charge
Chemotherapy charge
Radiotherapy charge
Supportive treatment charge
Other cost
Follow up
Follow up consultation
Follow up test
Follow up others

2.7 Study Site

The study covered three sites (one public and two private hospitals). It was conducted at
BPKMCH, Bharatpur Chitwan a public hospital, Bhaktapur Cancer Hospital a private not for
profit, and Nepal Cancer Hospital Harisiddhi a private for profit hospital.

2.8 Questionnaire
A structured close ended questionnaire was developed and used to collect the cost related
information from the patients. It includes the all patient perspective costs (given under the
heading 2.6) including the wage loss (productivity loss) due to illness.

2.9 Data analysis

Data were summarized in mean, median and ratio as per the need. This is a descriptive study
therefore no relationship was observed between the variables.

14
 Chapter III

Socio economic and demographic characteristics

3.1 Age of patient

Table 3.1 showed that mean years of patients who belong to tobacco related cancer has been
estimated 53 years. Nearly, over one fourth 28% of the patients are between 55-59 years groups
followed by 60-64 group 23% and 18 % people are between 50-54 age group respectively .
Three- fourth 73% of the patients were above than 50 years of age group. The mean year of
patients was 53 years (Std 9.17).

Table 3.1 Age of the patients

Age groups N Percent
65 and above 3 2.91
60-64 24 23.30
55-59 29 28.16
50-54 19 18.45
45-49 13 12.62
40-44 7 6.80
less than 40 8 7.77
Total 103 100
Mean 53.17
Std 9.17

3.2 Educational attainment

The education attainments showed that over one -fourth 27% of the patients were Illiterate and
one fifth 19% has attended only informal education. Table 3.2 showed that nearly half 44% of
the patients were either illiterate or completed only primary level of education.

3.2 Educational status of the patients

Educational status Frequency Percent

Illiterate 28 27.2
Non-formal 20 19.4
Primary level 18 17.5
Lower secondary 10 9.7
Secondary 17 16.5
Higher secondary 8 7.8
University 2 1.9
Total 103 100.0

15
3.3 Religion
Overwhelming majority 82 % of the patients belongs to Hindu followed by Buddhist 10% and
Christian 5%. Patients belong to Islam religion accounted only 2 percent.

Table 3.3: Religion of patient

Religion Frequency Percent

Hindu 84 81.6
Buddhist 10 9.7
Islam 2 1.9
Christian 5 4.9
Others 2 1.9
Total 103 100.0

3.4 Occupation
Agriculture is the major occupation 41% of the patient followed by housework 17%, business
13%, government service 11%, and non-government 5%. If we merged the house work and
agriculture, it accounted More than half 57% of the total patients.

Table 3.5: Occupation of patients

Occupation Frequency Percent

House work 17 16.5
Business 13 12.6
Govt. service 11 10.7
Non-govt. service 5 4.9
Agriculture 42 40.8
Daily wages 9 8.7
Foreign employment 4 3.9
Others 2 1.9
Total 103 100.0

16
3.5 Source of income and management of expenses
Major source of income for the treatment of cancer is the agriculture 43% followed by business
22% and daily wage 12% , government services 9% and foreign employment 9%.

Table 3.4: Source of income

Source Frequency Percent

Business 23 22.3
Govt. service 9 8.7
Non-govt. service 4 3.9
Agriculture 44 42.7
Daily wages 12 11.7
Foreign employment 9 8.7
House rent 1 1.0
Others 1 1.0
Total 103 100.0

Over one fourth 27% of the household managed the expenses from household saving, other one
fourth 27% borrowed from the relatives. Only 14% of the patients have managed the expenses
from his or her income. Others have managed the expenses through mixed sources.

Table 3.6: management of expenses

Management of expenses Frequency Percent

Own income 14 13.6
Help from relatives and borrowed 1 1.0
Own income and support from
2 1.9
relatives
House hold and support from relatives
3 2.9
and borrowed
Relatives, borrowed and self -income 4 3.9
Self, house and borrowed 3 2.9
Household income 28 27.2
Help from relatives 3 2.9
Borrowed 28 27.2
Own income and house Income 3 2.9
Own income and help from relatives 1 1.0
Own income and borrowed 5 4.9
House income and help from relatives 1 1.0
House income and borrowed 7 6.8
Total 103 100.0

17
About 16% of the households have sold their land and building for the treatment of cancer. They
have fell below the poverty line due to cancer.

3.7 Sold any property due to sickness

Sold property Frequency Percent

Yes 16 15.5
No 87 84.5
Total 103 100.0

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 Chapter IV

Cost analysis

4.1 Summary of costs

The figure 4.1 showed that total cost of tobacco related cancer has been estimated NPR
981,370.00 in 2019. The medical cost accounts for 60% of the total cost. The nonmedical cost
and absenteeism/ wage loss due to sickness accounted for 13% and 27% of the total cost
respectively.

Fig.4.1: Summary of costs of tobacco cancer diseases.

Total cost
NPR 981,370

Wage loss
27%

Medical cost
Non medical
60%
cost
13%

The Table4.1 showed that medical cost is the major component of the patient perspective cost. It
accounts for 60% of the total cost. The estimated medical cost was NPR 588740 in a year. Wage
loss was estimated NPR 269482.3 in a year. Wage loss accounted only 27% of the total cost.
Table 4.1: Summary of cancer related costs
Summary cost Cost Percent
Medical cost 588740 60.0
Non-medical cost 123147.3 12.5
Wage loss 269482.3 27.5
Total 981370 100.0

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 4.2 Medical costs
The low spending group spent on an average of NPR 214772.21 compared to medium spending
(NPR 452684.80) and high spending groups (NPR 1102765.71). The medium spending group
(NPR452684.80) spent more than double compared to low spending group (NPR 214772.21) and
the high spending group (NPR 1102765.71) spent 5 time more compared to low spending group.
Details are given in table 4.2.

Table 4.2a: Medical cost by high, medium and low spending groups

Total medical
Mean medical cost cost
Low cost N=34 Mean 214772.21
Standard Deviation 68382.83
Medium cost N=35 Mean 452684.80
Standard Deviation 90089.38
,High cost N=34 Mean 1102765.71
Standard Deviation 419186.99
Mean 588740.35
Standard Deviation 449567.99
Total N=103

Table 4.2b shows that chemotherapy was the major component of the tobacco related cancer
cost, it accounts for 28.15% of the total medical cost. The second biggest component was the
laboratory cost, it accounts 12.70% of the medical cost followed by radiological cost 11.66% of
the total medical cost. The radiotherapy cost accounts for 5.48% of the total medical cost. High
standard deviation has seen due to high variability of severity of illness, used technology and
type of the hospital (public and private).

Table 4.2b: Mean cost of diagnosis and treatment (n=103)

Costs Mean Percent

Diagnosis consultation fee 3797.39 0.65
laboratory test cost 74763.07 12.70
Radiology cost 68662.67 11.66
Other related cost 18144.37 3.08
Doctor fee 11045.17 1.88
Bed or room charge 31552.84 5.36
Surgery charge 34818.11 5.91
Chemotherapy charge 165716.95 28.15
Radiotherapy charge 32280.49 5.48
Supportive treatment charge 33356.89 5.67

20
 Other cost 73651.58 12.51
Follow up 4785.86 0.81
Follow up test 24900.30 4.23
Follow up others 11264.66 1.91
Total 588740 100
Std 449568

4.3 Non medical costs

The food accounts for 38.6% of the total nonmedical cost. Transport accounts for 30.4% of the
total nonmedical cost. The nonmedical cost of patient accounts for nearly half 47.6% and other
half accounts for care givers 52.4%. High standard deviation has seen due to high variation of
hospital visits, length of hospital stay and price of goods and services.

Table 4.3: Nonmedical cost of tobacco related cancer

Costs Mean Percentage Std

Patient
Transport 19570.0 15.9 22198.2
Lodging 11022.3 9.0 31426.7
Fooding 21198.9 17.2 35598.0
Others 6850.2 5.6 19981.3
Sub total 58641.4 47.6
Care giver
Transport 17861.4 14.5 19076.5
Lodging 12334.5 10.0 36479.8
Fooding 26322.3 21.4 24460.0
Others 7987.7 6.5 20076.8
Sub total 64505.8 52.4
Total 123147.3 100

4.4 Absenteeism/wage loss due to sickness

Existing methods use wages as a proxy value of productivity loss due to absenteeism of patient
and his or her care giver. The wage loss due to the sickness accounts for 28% of total cost. Total
wage loss due to illness of patient and caregiver estimated NPR 269482.30 in a year. Bigger
amount of wage lost was due to the illness of patient. It accounts for 68% of the total
absenteeism/ wage loss. Caregivers' wage loss accounts for 32% of the total wage loss.

21
Figure 4.4: Absenteeism /wage loss due to tobacco related sickness

181594.8

80154.0

7733.6

Patient Care giver 1 Care giver 2

Table 4.5: absenteeism /wage loss due to sickness (tobacco related cancer)

Number
of days
Wage loss unable to Per day Total income loss
(productivity loss) work wages due to illness
Patient 232.2 782.1 181594.8
Care giver 1 109.9 729.4 80154.0
Care giver 2 10.5 734.8 7733.6
Total 269482.3

4.6 Extrapolation of cost for the diagnosis and treatment of tobacco related
cancer
The prevalence of tobacco related cancer was estimated based on the projection made in 2017.
The estimated prevalence of cancer for 2019 was 37.1 per 100,000 males and 39.9 per 100,000
Female populations. The estimated cases of cancer based on the above prevalence were 2487
cases in 2019.

Table 4.6: Estimated cases of tobacco related cancer.

Description Male Female

Population>=15 10582560 10,167,557
Incidence rate
per/100000 37.1 39.9
Estimated total cases 3926 4057
Tobacco attributed 43.80% 18.90%
Cases 1720 767
Total cases 2486.4
Source: Paudel et al, 2017, ,BPKMCH 2017

22
Figure 4.7: Extrapolated total cost of tobacco related cancer in NPR billion.

2.44

1.46

0.67
0.31

Medical cost Non medical cost Wage loss Total cost

The figure 4.7 shows that total cost incurred by households due to tobacco related cancer was
NPR 2.44 billion. The estimated cost may go up if all tobacco related cancers that went abroad
for the treatment are taken into account. The medical cost accounts alone estimated NPR 1.46
billion followed by 0.67 billion due to absenteeism /wage loss.

23
 Chapter V

Discussion and recommendations

5.1 Increasing the subsidy to poor patients

The treatment cost of cancer is relatively high, the medical cost alone accounted for NPR 470277.00 and
about 15% of the households have sold their property for treatment of tobacco related cancer. The
Government of Nepal has provided subsidy NPR 100000.00 to the poor for the treatment of cancer which
is less than one fourth of the total medical cost. The insurance benefit package hardly covers the treatment
cost of cancer. Therefore, government of Nepal should increase the rate of subsidy to the poor patient
who has been suffering from tobacco related cancer in order to protect them from falling down below the
poverty line.

Recommendation 1: Provide 50% subsidy to a patient who has been suffering from tobacco
related cancer.

5.2 Rising the tax on tobacco

At present, the tax on tobacco is very low in Nepal. It accounts only 26% of the retail price of the
cigarettes which is much lower than the recommended 70% by WHO and World Bank. The
increased additional revenue could be used to subsidize the medical expenditure of the patient.

Recommendation 2: Raise the tobacco tax up to 70% of the retail price as recommended by
WHO and World Bank.

5.3 Strengthen the cancer registry system

Many of hospitals have been covered by the cancer registry system, however, many cases are
still underreported by the sites. The cases that had undergone treatment in abroad should be
covered. And Population based socio economic study should be conducted to identify the groups
that are hard hit by tobacco related cancer.

Recommendation 3: Strengthen the cancer registry system and conduct population based
the socio economic study to identify the groups who are hard hit by tobacco related
diseases.

24
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