Socio-Economic Burden and Coping Strategies of Non-Communicable Disease (NCD) Patients in Below-Poverty-Line Households: A Cross-Sectional Study in Karnataka, South India

Introduction

Non-communicable diseases (NCDs), such as hypertension, diabetes, heart disease, and kidney disease, have become a major global health concern. In 2017, approximately 226.8 million disability-adjusted life years were attributed to NCDs worldwide.¹ Non-communicable diseases were responsible for 5.87 million deaths, representing 60% of all deaths in India.² Among NCD-related deaths, 22% were attributed to various respiratory disorders, 12% to cancer, and 3% to diabetes. They pose a significant burden in terms of morbidity, mortality, and socio-economic impact.³ NCDs such as cancer, obesity, and respiratory disorders disproportionately affect vulnerable populations, like those below the poverty line.⁴ In such a scenario, the interaction between disease management costs, low income, and survival strategies becomes a serious determinant of the well-being and survival of patients belonging to below-poverty-line (BPL).⁵ The financial burden of NCDs is multifaceted, encompassing direct costs such as medical treatment, diagnostics, and hospitalization,⁶ as well as indirect costs including lost income, jobs, reduced productivity, and long-term caregiving. Populations living below the poverty line are particularly vulnerable, as the onset of NCDs can accelerate the poverty cycle, forcing households to adopt coping mechanisms such as selling assets, pledging valuables, or borrowing money.¹ These measures create long-term vulnerabilities, continuously perpetuating a cycle of deprivation. Globally, it is estimated that annual economic growth declines by 0.5% for every 10% increase in NCD-related mortality.^5,7

In India, BPL households face significant challenges in accessing quality and timely healthcare due to low social security and predominance of out-of-pocket payments.² Their predicament is compounded by inequalities in health service delivery and a weak public healthcare infrastructure. India faces a double or triple whammy with the socio-demographic (SES) burden of NCDs compounded by the inequitable burden placed on women and marginalized populations that the gendered cultural lens of caregiving creates.⁴ The financial impact of NCDs is wide and varied in Indian society. In most BPL families, direct expenses such as medications, repeat hospitalizations, diagnostic tests, and prolonged treatments cannot be afforded.⁸ This is compounded by indirect costs, for example, the loss of income due to illness, caregiving responsibilities, and premature mortality. This dual burden of health expenditure and income loss may drive a family into a cycle of poverty and ill-health, which is difficult to emerge from.⁹ In India, since out-of-pocket expenditure forms a large percentage of health care, BPL population is prone to catastrophic health spending, pushing them into hardship or further indebtedness.¹⁰

The socio-economic impact of NCDs often compels BPL households to create survival strategies. This encompasses taking high-interest loans, selling productive property, withdrawing kids from school, and reducing consumption of staple products such as food, or postponing the treatment.⁷ However, these measures may yield short-term results. They eventually have long-term disastrous impact, including the perpetuation of poverty and the dilution of future resilience. Studies have found that the burden of NCDs is unevenly distributed among BPL households. Women are more likely to suffer from this phenomenon due to gender vulnerability. The dearth of effective response mechanisms also suffers from social stigma and limited awareness regarding proper management of NCDs.¹ Finally, systemic issues, including health infrastructure, high treatment charges, and low public health schemes, only add to the burden for BPL families. With this background, this study aimed to assess the socio-economic impact of NCDs on BPL households in Karnataka state, South India, by quantifying the cost of illness and revealing the survival mechanisms adopted by affected households. This study sought to contribute to policy deliberations on inclusive healthcare, social protection, and poverty alleviation in developing nations.

Materials and Methods

This study adopted a mixed-methods approach, incorporating both quantitative and qualitative techniques, to explore the socio-economic challenges faced by below-poverty-line (BPL) populations/ households in relation to non-communicable diseases (NCDs) in Karnataka State, South India. The research was conducted across selected districts of Karnataka, chosen for their diverse socio-economic and cultural contexts. A multi-stage stratified sampling method was used to select around 300 participants from four districts of Karnataka, India (Mysore, Bangalore, Hassan, and Belagavi). The participants were diagnosed with NCDs like hypertension, heart issues, diabetes, and cancer, and were drawn from households classified as Below Poverty Line (BPL) according to the Karnataka’s State Government criteria. Districts have been selected based on the National Health and Family Welfare Survey report 2024. 

For the qualitative component, purposive sampling technique was employed to select individuals in order to obtain insights into the coping mechanisms adopted. Structured questionnaires in the local language were used to collect data on, 1. direct medical costs, including diagnostics, treatment, and hospitalizations; 2. indirect costs akin to lost income, caregiving time, travel expenses, and death rituals; 3. coping strategies adopted by households, including loans, asset sales, and school dropouts; and 4. socioeconomic background and health service utilization patterns. These dimensions were derived from theoretical frameworks or previous studies that could provide more contexts.

Results

Quantitative data were analyzed using SPSS (version 21), and qualitative data using Vivo software. IEC was obtained from the institutional ethical committee (Mysore University). Structured questionnaires were pre-tested through a pilot study. All participants were informed about the nature and objectives of the study prior to data collection, and informed consent was obtained both in writing and verbally. To maintain anonymity, participant's names and identifying information were replaced with pseudonyms during analysis. Data were stored in password-protected digital formats.

The study population mainly comprised of middle-aged people, with 48% belonging to 41-60 year age group. Males constituted 51% of the sample, while females accounted for 49% (Table 1). Around 53.3% of subjects were married, whereas 20% were either divorced or widowed. Educational levels also varied: 46.7% of participants had completed secondary or higher secondary education, while 16.6% had no formal education, which may limit their awareness of health issues and access to quality health care. The economic vulnerability was obvious, as 60% of respondents earned less than ₹5,000 per month. Only 40% of the subjects had stable jobs, while 40.1% were unemployed. Hypertension emerged as the most common NCD (40%), followed by diabetes (26.6%), chronic respiratory illnesses (16.6%), heart conditions (10.1%), and cancer (6.6%). Public hospitals were found to be key healthcare providers for 60% of patients, highlighting the dependence on free public healthcare because of the limited affordability of private care. Additionally, 40% of households possessed only essential assets, while 13.3% owned valuable assets.

Logistic regression analysis (Table 2) identified the most important issues affecting the socioeconomic burden. Women were 1.40 times more likely to experience financial hardships than men. With age, the risk increased by 10% per year, indicating that burden increased with ageing. Smaller households were associated with higher financial pressure (OR: 0.85). Education was identified as a protective factor, and higher levels were associated with a lower economic impact.

Cancer patients had experienced the greatest financial burden (OR: 2.00), followed by individuals with heart disease (1.50) and diabetes. The mean direct cost for each household (Table 3) was ₹8,502, with hospitalization accounting for a sizeable portion (40%), followed by medications (23%), diagnostics (17%), consultation fees (12%), and other expenses (8%).

However, costs varied widely (₹1,000–₹10,000), highlighting the substantial financial disparities among studied households. Further, the average indirect cost was found to be ₹5,200, mainly due to income losses for patients (51%) and lost employment (35%). Next, supplementary expenses included travel costs (12.1%) and productivity losses (2%), demonstrating the monetary collision of chronic illnesses on poor families (Table 4).

Catastrophic health expenditure (CHE) is described as healthcare costs that exceed a large proportion of household income (Table 5). About 50% of the households in the study faced moderate to severe financial stress due to healthcare costs, spending more than 25% of their income on medical expenses. Around 16.7% of households were in the severe category, spending over 50% of their income on health care. In some of these cases, families spent as much as 63% of their income on treatment, pushing them deeper into poverty and making it harder to afford other basic needs, which led to more health exclusion and adversity. Bowring is the key Coping Strategies Adopted by BPL Households. (Table 6).

Discussion

The aim of the paper was to assess the socioeconomic burden and coping strategies associated with non-communicable diseases among below-poverty-line households. This study highlights significant socio-economic issues and their predictors drawing immediate attention to the related coping mechanisms. The financial strain caused by non-communicable diseases is significant, leading to job loss, reduced income, and the liquidation of assets for survival. These findings corroborate earlier research while offering fresh perspectives, especially in the Indian context, where economic discrimination, class and caste issues, and limited health care availability exacerbate poor health care choices, especially in rural parts.¹¹ The incidence of NCDs in individuals aged 41-60 years is consistent with other relevant studies, which underline that middle-aged people face heightened risk due to snowballing exposure to risk factors, such as poverty, aging, unhealthy eating habits, inactive lifestyles, and occupational pressure.¹²

According to the study, women experience greater socioeconomic difficulties than men because they are burdened with caregiving and household duties and face limited economic opportunities and healthcare access. Studies have shown that poor households incur substantial long-term health expenditures due to NCDs, often resulting in catastrophic health spending.^8,13 Further, the findings of this study support the idea that higher education levels reduce the monetary burden of chronic illnesses, indicating that education promotes health literacy and economic stability among poor people.¹⁴

The study revealed large-scale direct costs relating to NCDs, such as hospitalization and prescription expenses, in the study area. Government funded health insurance schemes may not consistently provide adequate assistance to patients. In this regard, the findings are broadly consistent with Berman et al. (2010) who reported that the greatest contributor to spending on healthcare by Indian low-income families is the expenditure of hospitalizations. The indirect costs, primarily driven by income losses for patients and caregivers, highlight the rippling impact of NCDs on household economic stability.¹⁵ The incidence of catastrophic health expenditure, with half the households spending more than 25% of their income on NCD healthcare, is consistent with global estimates for low-income populations. In a broader perspective, 16.7% of the households faced extremely catastrophic health expenditure, spending over 50% of their income, which is alarming and underscores the urgency for better financial protection mechanisms, such as low-cost health insurance.⁸

Further, logistic regression analysis (Table 2) revealed important socioeconomic predictors. Gender, age, and smaller households were associated with higher burdens, corroborating findings from studies that reported similar vulnerabilities in low- and middle-income countries.¹⁵

Cancer (OR: 2.00) and heart disease (OR: 1.50) were found to impose disproportionately high burdens, as they often require extensive and frequently protracted medical care. Additionally, more than 60% of patients relies on government hospitals, highlighting the critical role of sophisticated public health care in meeting the needs of underserved communities. However, the low utilization of private healthcare services reflects affordability and accessibility issues in low-income districts of the state.¹⁷ These disparities emphasize the requirement to improve public health infrastructure and expand affordable healthcare services in underserved areas along with economic upliftment.

The average direct cost per household was ₹8,502, but the wide range and high standard deviation highlight substantial disparities in financial burden. As per this study, most families experienced catastrophic health expenditures, due to complications, co-morbidities, or dependence on costly private healthcare services. Hospitalization alone accounted for 41.3% of the direct costs, suggesting serious gaps in early diagnosis and insufficient access to primary health care.¹⁵ This indicates that weak preventive services at the community level are pushing families toward costly tertiary care. In addition, expenditures on medications (23.2%) and diagnostics (17.2%) remain high, despite schemes like Ayushman Bharat and Jan Aushadhi, indicating limited availability and accessibility in public healthcare facilities. Non-medical costs categorized under “Others,” such as transport, food, and lodging, though smaller in percentage (6.3%), become important for rural patients who must travel long distances. These logistical costs often delay treatment or cause patients to abandon care midway.

 Indirect costs, which average around ₹5,200 and account for over 60% of direct costs, highlight some serious economic pressures that often go unnoticed. A significant portion of this burden arises from lost income, accounting for 51% for patients and 35% for caregivers. For families relying on informal or single-income sources, such financial losses can severely undermine economic stability. The often overlooked “other productivity losses” hint at even deeper issues, such as job loss, accumulating debt, or having to sell assets. The combined financial strain, both direct and indirect only worsens poverty and reveals a troubling disconnect between what policies promise and the harsh realities of health care. Currently, health programs are inadequate in providing comprehensive financial and social protection, especially for economically marginalized populations. This calls for an urgent shift away from a treatment-focused mindset to a more inclusive public health model that prioritizes financial risk protection, caregiver support, and community-based chronic care.¹²

The findings of this study are in line with research conducted in comparable socio-economic environments experiencing health disasters. It has been established that the monetary burden of non-communicable diseases (NCDs) on low-income households in India is augmented by considerable out-of-pocket expenses, leading to more deprivation.¹¹ Furthermore, it has been observed that NCDs have a considerable effect on the financial stability of households, particularly affecting women and elderly individuals. Studies in other low and middle-income nations, also highlight the important direct and indirect costs associated with chronic illnesses and their repercussions on household poverty and social exclusion.^13,17 Flagship programs such as Ayushman Bharat (Universal Health Coverage) need further reforms to specifically address the immediate needs of rural and tribal communities. The study also found that many families incur considerable treatment expenses, forcing them to sell valuable assets, take on debt, and compromise overall family welfare, including school dropouts among children and increased work demands.¹³ Structural health inequalities driven by class and caste factors in rural India further exacerbate these challenges.⁹

Furthermore, psychological distress and stigma associated with chronic illnesses are extensive, and accessibility to health care is a significant challenge, especially for the people from the rural areas. Interviews with respondents revealed that health culture and healthcare-seeking behavior has a strong influence on the coping strategies adopted by BPL households. While several health reform programs exist for these households, respondents noted various technical and administrative challenges. The resulting loss of economic stability may contribute to intergenerational poverty, as experts have observed.⁷ Additionally, studies show that poor access to healthcare facilities and delays in seeking timely medical assistance are particularly prevalent in rural areas.^2.3 In backward districts (county) such as Belagavi and Hassan, residents incur higher transportation costs to reach nearby hospitals, often losing a day’s labor. Wage loss and additional food expenditure also contribute to indirect costs. In urban areas, overcrowded public facilities and lack of modern diagnostic services drive patients to private hospitals, resulting in higher costs. Additionally, informal workers without social security in urban areas are excessively impacted by income loss during health-related events.¹⁷

Coping strategies are a critical issue in this context. High health care costs often compel individuals to rely on informal lenders, family members, or self-help groups for financial assistance. Some families resort to selling valuable possessions, including livestock, land, jewelry, or tools. As a result, families often forego essential healthcare services or delay essential surgeries. In most cases, the entire burden falls on women and children who are more likely to take informal jobs to cover the medical bills. Individuals with non-communicable diseases asymmetrically place burden on the healthcare system, often modifying their diet or lifestyle to manage their condition for financial or health reasons. In some cases, extended family, neighbors, and community organizations frequently provide both emotional and material support, including food, caregiving, and financial assistance. Unfortunately, more affordable health insurance plans often fail to provide adequate support. Furthermore, complicated paperwork, lack of awareness, and limited local services can greatly limit the effectiveness of government health programs, leaving many individuals without the assistance they need.

The effective implementation of telemedicine and digital health platforms is recommended to improve health care access and reduce costs for BPL households. Effective community-based programs and public-private partnerships in alleviating the NCD burden among economically vulnerable groups are also need of the hour. E-health initiatives should play a greater role within the National Rural Health Mission (NRHM) program. Income replacement schemes in collaboration with local NGOs are needed to mitigate the economic impact of NCDs.

The study has several limitations, including its cross-sectional design and exclusive emphasis on BPL households. Reliance on self-reported data may introduce errors or recall bias. Additionally, as the study was restricted to only four districts, it may not accurately reflect the varied socioeconomic and cultural circumstances of the entire state of Karnataka.

The absence of longitudinal data further limits the analysis of long-term impacts. Further research should focus on cost-benefit analyses of interventions like subsidized medications, health education programs, and improvements to public healthcare infrastructure.

Conclusion

The financial burden of managing non-communicable diseases among below-poverty-line households is significantly increased by inadequate access to quality healthcare, poor health literacy, and systemic injustices that are deeply entrenched in gender, caste, and class. This burden often results in loss of assets, reduced income, and high out-of-pocket expenditures, with women and the elderly disproportionately affected. Limited access to private health care contributes to low uptake of even low-cost health insurance. The high incidence of catastrophic health expenditures, where many households spend more than half their income on NCD-related issues, underscores the immediate need for affordable health insurance and strong social welfare programs. Enhancing health awareness and economic resilience through health education can help reduce health care expenses associated NCDs. Widespread public health measures are required to rectify these systemic and socioeconomic challenges. The importance of public health care in underserved areas is evident, as most families rely primarily on government hospitals, which require structural and functional reforms.

Conflict of Interest

Nil