Article
SciPaps c i e n t i f i c p a p e r s I
The Financial Burden of Acute
Nasopharynx and Acute Bronchitis
of Children from Different
Perspectives: The Cost-Of-lllness
Study in the Czech Republic
Dominika Tothova
Masaryk University, Department of Regional Economics and Administration, Czech Republic
Jana Soukopova
Masaryk University, Department of Public Economics, Czech Republic
Abstract
Acute nasopharyngitis and acute bronchitis are common childhood diseases. The problem is that the cost of these
different subjects in the economy is unknown. This article aims at estimating the cost of acute nasopharyngitis and
acute bronchitis per incidence from the perspective of society, employers, state budget, system of healthcare and
households in children aged 4-15 years in the Czech Republic. We used an incidence-based Cost-Of-lllness study
based on the typical course of disease. We estimated the mean societal cost per episode of acute nasopharyngitis at
EUR 613 (children 4-10 years) and EUR 610 (children 11-15 years) and 1 episode of acute bronchitis at EUR 963
(children 4-10 years) and EUR 960 (children 11-15 years). Overall, the state budget and employers bear the highest
costs in the Czech Republic. We estimated the share of cost from the perspective of the state budget at 47.3-49.7%
and from the perspective of employers at 66.4-67.8%. The majority of these costs arise in indirect costs in connection
with parents' absenteeism from work.
Keywords
Cost-Of-lllness, Acute nasopharyngitis, Acute bronchitis, Children Perspective
JEL Classification
H51, 113, 114, 118, 131
Introduction
Acute nasopharyngitis and acute bronchitis are common childhood diseases. An integral part of these diseases is
their economic burden, which is closely related to the treatment of the disease. The results of the National
Institute of Public Health (NIPH, 2017) showed that 18.82% of children aged 5 to 17 suffer from recurrent
nasopharyngitis (at least five times a year) and 8.67% of children suffer from frequent, repeated acute bronchitis
(more than three times a year). Air pollution (NIPH, 2016) has a significant impact on disease prevalence.
In this paper, we estimate the cost of morbidity for these two common respiratory diseases using the Cost-Oflllness
method (COI). We evaluate costs from a social perspective, as well as from the perspective of the health
care system, the state budget and households in 2020 prices. We are convinced that it is very important from a
social point of view to look at the individual cost burden for the public sector and households. Although these are
common non-serious diseases, which mainly appear in children during winter, they can represent a significant
financial burden on public budgets.
The aim of this article is to estimate the costs of morbidity for acute nasopharyngitis and acute bronchitis in
children aged 4 to 15 years using the Cost-Of-lllness method from the various perspectives of those who bear the
costs. We will identify risks that the high prevalence of these diseases can bring to individual subjects. No similar
study has been conducted in the Czech Republic. We consider it important to calculate the cost of common
respiratory disease from different perspectives in order to know the main cost factors and the burden on the
national economy subject.
The article is structured as follows: the first part contains a detailed description of the methodology used and the
procedure for calculating direct and indirect costs, including data sources. The second part of the article presents
the results of the economic evaluation of sickness costs from the individual perspectives of the bearers of the
costs. The results are then discussed further, in particular the limitations of the study.
Scientific Papers of the University
of Pardubice, Series D: Faculty of
Economics and Administration
2021, 29(3), 1414.
©The Author(s) 2021. This is
an open access article under
the CC-BY 4.0 license.
DOI: 10.46585/sp29031414
editorial.upce.cz/SciPap
Corresponding author:
Dominika Tóthová, Lipová 48a, 602 00 Brno, Czech Republic
Email: dominika.tothova@econ.muni.cz
2 SciPap29(3)
Literature Review
The Cost-Of-lllness method is quite commonly used to assess morbidity costs for various diagnoses. COI studies
tend to be conducted for more severe diseases, such as cancer (Luengo-Fernandez et al., 2013), locomotive
organs (Vargas et al., 2018), bowels (Bassi et al., 2004), asthma (Weiss et al., 2000), diabetes (de Lagasnerie, et
al., 2018). These results were confirmed by a summary study by Brodzsky et al. (2019), which identified Cost-Oflllness
studies in the countries of Central and Eastern Europe. For common respiratory diseases, the cost of
morbidity is rarely estimated. E.g. Srivsatava and Kumar (2002) calculated the direct and indirect costs of
bronchitis in Mumbai, and Quah and Boon (2003) calculated them for lower respiratory diseases in Singapore.
Most studies then evaluate the financial burden of the disease from a social perspective, but only a few evaluate
from an individual perspective. E.g. Hollinghurst et al. (2008) estimated the cost of one episode of acute cough
and the annual costs for UK preschool children from the point of view of national health services and caregivers.
The economic implications of treating lower respiratory tract infections in children aged 0-36 months in Germany
were evaluated by Ehlken et al. (2005) from a social, parental and third-party payer perspective. Schot et al.
(2019) focussed on assessing the costs of respiratory tract infection from the perspective only of parents. The
mean cost of acute respiratory disease was calculated by O'Grady et al. (2004). Also, they focussed on the main
cost drivers of illness and the proportion of cost borne by the family. However, in the Czech Republic, a Cost-Oflllness
study for acute nasopharyngitis and acute bronchitis has not yet been undertaken. It is essential to assess
the costs within the specific circumstances of the country, because as shown by the study by Brodzsky et al.
(2019), in which Cost-Of-lllness studies in nine Central and Eastern European countries were identified, the
results differ significantly in the methodology used, the publication practice and the clinical areas. Because of this
diversity, it is difficult to transfer the results between countries.
Methods
The conception of the Cost-Of-lllness study and its Perspective
The Cost-Of-lllness method estimates all treatments in monetary terms and thus represents an estimate of the
overall burden on society (Jo, 2014; Byford et al., 2000). It is, therefore, one of the forms of economic evaluation
in health care. It assesses the economic burden on society in terms of the consumption of health care resources
and production losses (Tarricone, 2006), while the traditional approach includes the analysis of direct costs,
which mainly consist of health care costs, and indirect costs or loss of productivity related to morbidity. The
resulting costs can be considered a conservative estimate and a lower limit to the real costs (e.g. Abdullah et al.,
2017; Hoagland et al., 2009; Ried, 1996).
The estimation of direct and indirect costs is based on a predetermined model of the disease that reflects its
standard course without complications or co-morbidities. In this study, direct costs include health costs that are
the result of illness. They include expenditure on medical care, in particular expenditure on diagnosis, treatment
and medicines. The valuation of indirect costs is based on the traditional human capital approach (HCA), which
estimates the value of the potential loss of production (wages) due to illness. HCA assesses the disease burden
in terms of lost opportunities, and it measures productivity loss in terms of expected future income (Tarricone,
2006). HCA looks at lost production from the worker's perspective, counting every hour that was not worked by
them.
The COI study can be conducted from several perspectives, through which the burden on different subjects can
be assessed. The social perspective is the most comprehensive because it involves both direct and indirect costs
for all members of society and thus provides a complete analysis useful in e.g. Cost-Benefit Analysis, CostEffectiveness
Analysis and Cost-Utility Analysis. Comprehensive studies such as these, which analyse costs
from all perspectives, provide the most relevant basis for decision-making in public policy (Weissman and
Rosselli, 2017; Clabaugh and Ward, 2008; Dolan and Edlin, 2002; Segel, 2006). It should be added here that for
these cost bearers, which include costs covered, the resources are not used but rather redistributed (e.g. transfer
payments).
The social costs in this article include only those costs that actually pass through the market and that are directly
attributable to the diseases in question. In case of direct costs, we did not include for example, health and public
health research expenditure, health programmes, preventative programmes, administrative costs, capital
(infrastructure, machinery) (Health Canada, 2002) are not included in the evaluation. Costs for the state budget,
such as indirect taxes, are also not included. For those, it would be very problematic and inaccurate to estimate
the company's lost production due to the absence of 1 worker. In case of indirect cost we conducted an
assessment only for mothers inside the labour market, also the mothers of children over four years of age, which
is the highest age limit in the Czech Republic for receiving a parental allowance. Overall calculation of cost show
following formulas:
3 SciPap29(3)
[1 ] Total social cost = direct social cost + indirect social cost
[2] Direct social cost = treatment cost + cost of medication
[3] Indirect social cost = loss of value of work + sickness insurance benefits +
compulsory insurance paid by the employer
. r i i (averaqe monthly waqe\ , r , r ...
a. Loss of work value = I x number of days of illness
V 21 working days )
b. Sickness insurance benefits =
60% of daily assessment base for caring for a sick person x number of days of illness
c. Compulsory insurance paid by employer = (% social insurance +
% health insurance) x ( a v e r a g e m o n t h l
y wage\ ^n u m ^ e r Qf days of illness
V 21 working days /
The following tables (Table 1, Table 2) show the basic calculation of Cost-Of-lllness including data sources from
individual perspectives. The chapter Methods and Data introduces a specific procedure of calculation of
individual types of costs in the Czech Republic.
Table 1. Direct costs - calculation and data.
Perspective Direct Costs Source
Household Medication State Institute for Drug Control
Employer Not relevant Not relevant
System of Healthcare Medical procedures and medication
Decrees of the Health Ministry, State
Institute for Drug Control
State Budget Not relevant Not relevant
Table 2. Indirect costs - calculation and data.
Perspective Indirect Costs Source
Household
(Daily net salary - daily care allowance)
x number of days of illness
Average gross wage in the Czech
Republic by the Czech Statistical Office
Employer
Hourly labour costs x 8 working hours
per day x number of sick days
Labour costs by the Czech Statistical
Office
System of Healthcare
(13.5% health insurance x average
gross wage) / 21 working days x
number of sick days
Average gross wage in the Czech
Republic by the Czech Statistical Office
State Budget
(31.5% health insurance x average
gross wage) / 21 working days x
number of sick days
Average gross wage in the Czech
Republic by the Czech Statistical Office
Characteristics and treatment of the disease
We estimated the direct and indirect costs associated with a given disease based on a model course of the
disease including diagnosis, outpatient care, medication and disease duration. The description of the disease
(manifestations, limitations and duration) is based on Scasny et al. (2005) and adjusted after consultation with
pediatricians. Information on the health care process and related medical interventions we established in
consultation with G P s for children and adolescents. We anticipated the classical course of the disease, without
complications, other comorbidities (on the topic more Cortaredona and Ventelou, 2017), and therefore without
hospitalization. Furthermore, we anticipated only the regular procedures of the doctor with which the pediatric
patient is registered.
Acute nasopharyngitis is an infection of the mucosa which does not affect the tonsils. We consider an
uncomplicated course not requiring antibiotic treatment. The child has a cough, a cold, an elevated temperature,
is tired, has a headache and has enlarged and painful lymph nodes on the neck. S/he does not go to school for a
maximum of five working days, and the mother or another relative is at home for five working (seven calendar)
days. The elevated temperature, difficulty breathing and other symptoms last for seven days. As it is a rather
common examination for a disease which is not too difficult to diagnose, the doctor usually performs a
stethoscope examination to determine the auditory finding, a palpation examination of cervical lymph nodes, or a
throat swab, and less often nasal swabs when there are persistent problems or an otoscopy for ear pain. For
these reasons, only essential cultivation examinations of material from the respiratory tract we included in the
4 SciPap29(3)
estimation of specially reimbursed operations (this is a reimbursement to the laboratory, but it is still a payment
within public health resources). The direct health costs for households are not relevant. The check-up included in
the capitation payment is performed once. The treatment of this disease does not require further special
outpatient care, and mainly includes the use of medicines. Commonly prescribed medications are nasal drops,
cough drops or syrup and temperature-reducing drugs. The doctor also usually recommends the use of serum to
cleanse the nasal mucosa.
Acute bronchitis is an infectious disease of the respiratory system (lower respiratory tract). It manifests itself with
a strong and constant cough. The child has difficulty breathing and wheezes. At first s/he has a dry cough, then
coughs up mucus and has chest pain. S/he has a headache and fever with chills. The child takes antibiotics and
other supportive medications. The mother or another close person is at home with the child for at least ten days
(eight working days). The child should not take part in any sports activities for another fourteen days. Diagnosis
of this disease includes a stethoscope examination to determine the auscultation finding, a palpation examination
of the cervical nodules, and a swab from the throat and nose. To differentiate between viral or bacterial infection,
the physician performs a C-Reactive Protein (CRP) test or a blood sample from a vein to determine the blood
count. To estimate the costs of the classic course of the disease, which includes a performance payment, a
throat swab, a nose swab and a C R P test we included in the calculation. The direct health costs for households
are not relevant. The check-up examination, which is included in the capitation payment, is performed 1x-2x. The
treatment of this disease does not require further special outpatient care, and mainly includes the use of
medicines. Antibiotics, nasal antibiotic drops, a cough syrup, symptom relief and temperature-reducing drugs are
usually prescribed. Probiotics should be taken with antibiotics. The most commonly used drugs for one course of
the disease we took into consideration.
Direct Costs
Direct costs comprise health costs resulting from illness and include medical costs, including costs of diagnosis,
treatment and check-ups, and expenditure on medicines used. In the Czech Republic, a system of
reimbursement of health care is used to finance health care costs, which varies according to the type of health
service provider. The basis of the system is to determine the number of points for specific procedures, for which a
value is given in CZK through a public regulation each year (hospital care works on a different principle).
Procedures include direct, overhead costs and an increase in the personal costs of those who carry them out.
The direct costs are the sum of the personal costs of those who carry out the procedure, the cost of the
equipment used in the procedure, the cost of the medical materials used in the procedure, and the cost of the
medicinal products directly used in the procedure. Overheads include consumption of materials, energy
consumption, services, other personal costs, taxes and other costs. The setpoints value of the procedure is then
based on the average direct costs of such a procedure (Ministry of Health of the Czech Republic, 2021), and so
this approach can be used for economic evaluation.
A system of a combination of capitation and fee-for-service payment is used to cover the costs of health care by
general practitioners for children and adolescents. Physicians in the Czech Republic are remunerated through
capitation payments with a fixed monthly rate for each registered patient. The other part of their reimbursement
consists of a fee-for-service component, which includes health procedures not included in the capitation payment,
for which the point value for 2020 was set at CZK 1.20 (EUR 0,041
) (Decree No. 268/2019 Coll. on the
determination of point values, the level of reimbursement of paid services and regulatory restrictions for 2020).
Most medical procedures, however, relate to laboratory examinations, where the point value for 2020 was set for
the field of expertise 802 - medical microbiology, at a point value of CZK 0.85 (EUR 0,03) (Decree No. 268/2019
Coll.). For this reason, it is not possible to ascertain the exact healthcare costs, but only an approximate estimate,
due to this reimbursement mechanism based on a fixed payment, but also due to further regulatory measures in
the healthcare sector.
The first step to quantify the direct costs of morbidity is to determine the corresponding medical interventions
according to Decree No. 268/2019 Coll., which publishes a list of medical interventions with point values, as
amended, and then to multiply this value in CZK. As the combined capitation/fee-for-payment system
remunerates general practitioners for children and adolescents, not all payments are covered by the
reimbursement payment, but the vast majority of them are included in the capitation component. The capitation
component is not taken into account in the calculation of direct costs because it applies to each registered
patient, regardless of the number of visits to the health centre.
Treatment of the disease is based primarily on the use of medicines. After consultation with doctors, for each
disease, the most often prescribed specific products were chosen. In the case of food supplements, where there
are many product variants on the market, we chose products which have been certified and are commercially
available, with an appropriate package size for the length of use and a reasonable price, to avoid overestimating
the costs. We included the full cost package to the estimation of direct costs, as recommended by Rozan (2001).
1
Average rate of the Czech National Bank in 2020 - 1 EUR = 26.444 CZK.
5 SciPap29(3)
Indirect Costs
We calculated indirect costs resulting from absence from work for parents caring for sick children. From a social
perspective, we calculated indirect costs by the sum of the loss of value of work, sickness insurance (caring)
benefits and the amount of mandatory statutory health and social insurance. All of which were based on the
average gross wage in the Czech Republic of EUR 1,346 for 2020 (Czech Statistical Office, 2021a). The average
gross wage we calculated by the average daily income divided by the average number of working days (21 days
per month). The total indirect costs we calculated by multiplying the average daily income by the length of
absence from work, which is given by the average duration of illness according to the model (classical) course of
the illness. This average gross daily wage also includes taxes and statutory insurance paid by the employee.
Another component of productivity loss is sickness insurance benefits, which are an essential part of the total
social loss due to a child's illness. In the absence of (or reduction) of pollution and thus a corresponding impact
on health, these transfer payments could be allocated differently, e.g. for increasing other benefits or indeed to
decrease the insurance premium of this payment, leading to an increase in real wages and hence the growth of
social well-being (Scasny, 2005). The amount of the care allowance we calculated from average gross wages.
However, the care allowance is not paid to all people but is intended primarily for employees participating in
sickness insurance2
. The last component of social costs consists of mandatory statutory social and health
insurance, which we calculated at 25% of the gross salary for social insurance and 9% of the gross salary for
health insurance.The estimation of indirect costs from various perspectives of economic subjects, is based mainly
on the average gross wage. Table 3 shows the calculation of the individual cost component, the losses of which
due to illness of a child we assigned to individual economic entities.
Table 3. Calculation of cost components from average gross wage (EUR, 2020).
Cost components Calculation Sum (EUR)
Average gross wage 1,346
Social insurance paid by employer 25% 337
Health insurance paid by the employer 9% 121
Super gross wage Gross wage + soc. and health insurance paid by the employer 1,804
Advance tax on super gross wage 15% 271
Reduction for a taxpayer EUR 79 / month 78
Tax reduction per dependent child EUR 42 / month 48
Advance tax after deduction of
discounts
Super gross wage tax advance payment - taxpayer discount dependent
child reduction
144
Employee social insurance 6.5% 88
Employee health insurance 4.5% 61
Net monthly wage
Gross wage - advance payment after deduction of discounts social
insurance paid by the employee
- employee health insurance
1,054
Daily net wage Net monthly wage / 21 50
From the perspective of households, indirect costs we expressed as lost income due to caring for a sick child.
The resulting amount is an estimate of the loss of the average net daily income, which we obtained after
deducting social and health insurance expenditure and may differ in the amount of tax relief applied. The starting
point of the estimate is the application of the basic tax relief to the taxpayer and the deduction of the non-taxable
amount per dependent child. The calculation was based on an estimate of the average gross wage in the Czech
Republic in 2020. The daily net wage is estimated at EUR 50, according to the Czech taxation and insurance
system. The amount of care allowance is EUR 24 for one day of caring for a sick family member and is deducted
from the net daily income. The loss of the net daily income after the deduction of the care allowance is EUR 26
per working day. The total loss of household income, i.e. the total loss of productivity from a household
perspective, is obtained by multiplying the number of working days spent caring for the child. As the care
allowance is also paid for non-working days, EUR 48 is deducted from the resulting amount as the amount of the
care allowance for two non-working days.
The costs from the perspective of the employer are the value of the employee's work expressed in wages for
work performed, including wage compensation, which is an average of EUR 10 (2020 prices) (Czech Statistical
2
According to the Czech Social Security Administration (2021), an employee who is unable to work because of nursing a sick member of the
household is entitled to a carer's benefit from the first day of illness for 9 calendar days (16 calendar days for a single employee). The amount
of the carer's benefit from the first calendar day is 60% of the reduced daily assessment base per calendar day.
6 SciPap29(3)
Office, 2021b). We obtained the total costs by multiplying the 8-hour working time by the number of days of
illness. The loss expressed from the perspective of the employer and the employee reflects a partial loss of
wages, including actually the same 'money', only from a different perspective.
The perspective of the health care system includes loss of income from compulsory health insurance
payments paid by both the employer at 9% of the gross salary and the employee at 4.5%, which due to absence
from work is not paid to health insurance companies and is therefore a cost (loss) for the health care system. We
calculated the resulting expense as a monthly levy divided by the number of working days in the month
(assuming 21 days) and multiplied by the number of days of illness.
Costs from the perspective of the state budget include unpaid statutory social insurance payments (EUR 2 /
day at a gross wage of EUR 1,346), which include sickness insurance, pension insurance and contributions to
the state employment policy. These payments of 25% (employers) and 6.5% (employees) are made into the
budget through the Czech Social Security Administration. Another component of the state budget expense is tax
losses calculated from super-gross wages (EUR 7 / day). Those payments of statutory social insurance and
taxes are two significant items that do not flow into the budget because of absence from work. Thus there is a
lower assessment base from which these transfers are calculated. Also, the state budget will lose other
resources in the form of care allowance, which is paid to parents as compensation for wages when caring for a
sick child (EUR 21 / day at a gross wage of EUR 1,346).
Results
Direct Costs
Table 4 summarizes all the direct costs associated with the treatment of the disease, including the GP's medical
interventions and medications used from individual perspectives. The health care system (costs of health
insurance companies) includes the redistribution of funds within public health insurance, while household costs
show their expenditures for the purchase of medication.
Table 4. Direct costs of treatment of respiratory diseases (EUR, 2020).
Medical procedures Medication Total
Perspective System of healthcare System of healthcare Household costs Social costs
Acute nasopharyngitis
4-10 years 2 0 14 16
11-15 years 2 0 11 13
Acute bronchitis
4-10 years 10 6 20 36
11-15 years 10 6 17 33
The cost of treating acute nasopharyngitis and acute bronchitis does not depend on age. Diagnosis involves
identical examinations for children of all ages. Although drug consumption may increase as children get older, the
cost always involves purchasing the entire packet of medication. The difference in the cost of households in the
age category results from the fact that the cost of a packet of medication for smaller children is usually higher
than for older children.
Table 5 includes all direct costs from all different perspectives. The results show that the burden in terms of direct
costs is significant, especially for households. Medicines for these relatively common, non-serious diseases are
not reimbursed (apart from antibiotics) by the health insurance company; these are often classic medications to
relieve problems such as high temperature, runny nose and cough or recommended dietary supplements.
7 SciPap29(3)
Table 5. Direct costs of treatment of respiratory diseases from different perspectives (EUR, 2020).
Perspective Social
Healthcare
system
State
budget
Employers
Households
EUR % EUR % EUR % EUR % EUR %
Acute nasopharyngitis
4-10 years 16 100 2 12.5 - - 14 87.5
11-15 years 13 100 2 15.4 - - 11 84.6
Acute bronchitis
4-10 years 36 100 16 44.4 - - 20 55.5
11-15 years 33 100 16 48.5 - - 17 51.5
Indirect costs
Indirect costs include several economic entities. Households, employers, but also the budget and health care
system all bear part of the total social cost. The social costs reflect the total costs of all entities. In order to make
the most accurate estimate in the Czech Republic, which would reflect all types of costs, we worked with the
average gross wage in the Czech Republic. Based on this, we estimated the individual social cost items, such as
loss of work, loss of statutory contributions paid by employers (social and health insurance), and sickness
insurance benefits. It is therefore a matter of the total economic losses that are incurred by the various economic
entities throughout society. Table 6 shows the total social costs calculated from the above cost components.
Table 6. Total social indirect costs of the disease, (EUR, 2020).
Illness Loss of work value
Sickness insurance
benefits
Statutory insurance Social indirect costs
Acute nasopharyngitis
Acute bronchitis
320
513
168
239
109
174
597
927
Note: Carer's benefit (sickness insurance) is also calculated in the Czech Republic for non-working days (seven days for acute
nasopharyngitis, ten days for acute bronchitis).
Table 7 provides an overview of cost items from different perspectives. Indirect costs are due to parents not
being at work due to the care of a sick child. In terms of age, the costs do not show any differences, given that
they are children from 4 years of age upwards, which in the Czech Republic represents the maximum threshold
for receiving a parental allowance. The most significant burden due to people not being at work is for the
employers, as it leads to lower productivity. For the state, it is a burden in the form of lower social security
contributions and taxes, while on the other hand, there are higher costs of care benefits. In the case of
households, the costs represent the real loss of wages after deduction of care benefits.
Table 7. Indirect costs of treatment of respiratory diseases from different perspectives (EUR, 2020).
Perspective Social
Healthcare
system
State
budget
Employers
Households
EUR % EUR % EUR % EUR % EUR %
Acute nasopharyngitis
4-15 years 597 100 43 7.2 303 50.8 407 68.1 82 13.7
Acute bronchitis
4-15 years 927 100 69 7.4 456 49.2 651 70.2 160 17.3
Social costs of treatment of illness
The social cost distribution (Table 8) shows that indirect costs account for a significant majority of the total costs.
In the overall context, the costs directly linked to the treatment of the disease constitute only a part of the total
cost, although in this case, they are primarily a burden on households. The largest share is represented by
indirect costs associated mainly with a loss of wages, which reach 96.6-97.9%.
8 SciPap29(3)
Table 8. Total social direct and indirect costs of respiratory diseases (EUR, 2020).
Direct costs Indirect costs Total costs
EUR % EUR % EUR %
Acute nasopharyngitis
4-10 years 16 2.6 597 97.4 613 100
11-15 years 13 2.1 597 97.9 610 100
Acute bronchitis
4-10 years 36 3.7 927 96.3 963 100
11-15 years 33 3.4 927 96.6 960 100
If we look at the total cost of illnesses from different perspectives (Table 9), the highest burden is beared by
employers (66.4-67.8% of the total social cost) state budget (47.3-49.7% of the total social cost). This result is
caused due to the dominance of indirect cost. Absentee at work causes for employer loss from missed work and
for state budget unpaid statutory social insurance payments, tax losses and care allowance paid to parents. The
costs of households for nasopharyngitis is EUR 96 for children aged 4 to 10 years and EUR 93 for children aged
11 to 15, and for bronchitis, EUR 180 and EUR 177 per case of illness. The share for the average wage is 7% for
nasopharyngitis, and 13.2% for bronchitis. We calculated the costs per case of the disease. Given the high
incidence of illness in particularly polluted areas, where children become ill several times a year, high morbidity
can be a source of financial problems related to loss of income. However, the overall costs from different costbearer
perspectives should be considered a conservative estimate. We anticipate the classical course of the
disease, without complications, other comorbidities, and therefore without hospitalization. Furthermore, we
anticipate only the standard procedures of the doctor with which the pediatric patient is registered.
Table 9. Total costs of respiratory diseases from different perspectives (EUR, 2020).
Perspective
EUR
Social
%
Healthcare system
EUR %
State budget
EUR %
Employers
EUR %
Households
EUR %
Acute nasopharyngitis
4-10 years 613 100 45 7.3 303 49.4 407 66.4 96 15.6
11-15 years 610 100 45 7.4 303 49.7 407 66.7 93 15.2
Acute bronchitis
4-10 years 963 100 85 8.8 456 47.3 651 67.6 180 18.7
11-15 years 960 100 85 8.9 456 47.5 651 67.8 177 18.4
Discussion
Comparison of the results with other studies using the Cost-Of-lllness method is quite problematic due to the
broad generality of the method and therefore often different approaches to estimating total values, such as the
choice of variables or the method of data collection. Comparison with the cost of morbidity with other states is
then quite challenging due to the different ways in which health care is financed. Cost-of-lllness studies are also
used for symptom studies, for example the cough (Dal Negro et al., 2018; Hollinghurst et al., 2008) or the
common cold (Hellgren et al., 2010). The most significant difficulty, however, is the impossibility of comparisons
due to the absence of similar studies aimed at analysing the morbidity of similar diseases. As mentioned at the
outset, Cost-Of-lllness studies tend to focus on more serious diseases: with respiratory diseases, these are
mainly chronic bronchitis (Accordini et al., 2017; Weissflog et al., 2001), asthma (Ferreira de Magalhaes et al.,
2017; Gendo et al., 2003), chronic obstructive pulmonary disease (Ehteshami-Afshar et al., 2016; Makela et al.)
or lower respiratory tract infections (Schot et al., 2019; Ehlken et al., 2005).
However, we should look at the individual cost components from the different perspectives of their bearers.
According to the results of Lambert et al. (2008), acute respiratory infections in children represent a significant
cost burden for families and society. Indirect costs have proved to be the key cost drivers, i.e. the time spent
taking care of a child outside the usual activities. The assessment of the costs due to acute respiratory infections
with cough in Australia has been addressed by Lovie-Toon et al. (2018). Compared to the conclusions of our
study, the results showed a different structure of cost bearers. Caretakers, the public health system and
employers incurred 44, 39, and 17% of the costs per episode, respectively. The high share of household costs
was mainly due to the different way in which health care is financed. Family costs included general practice visits,
after-hours general practice visits or specialist visits, which when added to the time off work with unpaid leave
and time off non-work activities, which were not the subject of our study, contributed to the relatively high share of
9 SciPap29(3)
household costs. The significant proportion of the public health care system was mainly due to the cost of
doctors' services, which were not included in our assessment in the Czech Republic due to visits to the doctor
being part of the capitation component. Similarly, the cost estimates of Hollinghurst et al. (2008) for acute coughs
in children in the UK have shown that the cost for health service providers resulting from consultations with G P s
is particularly significant. The costs for families were mainly due to travel and expenditure on over-the-counter
preparations, suggesting that the child's illness could cause financial problems due to loss of earnings.
The cost of acute cough health care providers for preschool children is high; most of these costs result from
consultations with GPs. Parents experience certain personal costs due to travel and buying over-the-counter
products, and they can suffer greatly if they have a loss of earnings. There is scope for evaluating interventions
designed to reduce this burden. To summarise, the differences between individual studies are mainly due to
different approaches to average cost estimates and different ways of financing health care. This leads to different
proportions between the individual cost bearers.
When conducting COI studies, there are generally some methodological problems, which makes comparison
difficult. A relatively significant limit of the COI study is the lack of a generally valid methodology. How published
COI studies are conducted often differs between different diagnoses and studies. Determining the direct costs of
treating a given diagnosis also does not say anything about the effectiveness of the resources used (Larg and
Moss, 2011). Thus, COI studies can show which diseases require a higher allocation of resources for treatment
or prevention (Jo, 201), but since the method is not designed to measure benefits, it cannot be used to determine
how to allocate these resources (Drummond, 1992). The COI method only measures ex-post costs that arise in
connection with treatment. It does not take into account any changes in defensive costs (market goods
purchased by individuals to improve health) (Dickie and Gerking, 2002). Maca (2005) considers the complicated
compilation of an incidence profile, such as the number of asthma attacks, to be a major negative. He also points
out that it is impossible to determine the cost of healthcare accurately. Another drawback that can make it more
difficult to compare results and can also lead to the costs being underestimated is that some costs that are not
directly health expenses but are directly related to treatment are not included.
These are e.g. expenditures on health and public health research, health and preventative programmes,
education, construction, administration, infrastructure. However, these costs are often omitted from COI studies
because of the difficulty or rather the inability to assign partial costs to specific diseases. Another reason is that
expenditures in one period are not necessarily associated with the disease in that period. For example,
equipment built, research and training funded in one year will only bring benefits in the years to come (Health
Canada, 2002; Hodgson and Meiners, 1982).
Other costs that may be included in some studies are travel costs or the loss of leisure time. However, these
costs were omitted from this study. Finally, we have to conclude, that the costs are estimated on the basis of our
methodology based on a predetermined model of the disease, its course, treatment and use of medication. For
this reason, the resulting estimates can be sensitive to a change in the individual cost types included.
Conclusion
This article analyses the health cost of common respiratory diseases in pediatric populations aged 4 to 15 from
the different perspectives of economic subjects. The results are based on the Cost-Of-lllness method, which
includes the direct costs of treating the disease and the indirect costs of absenteeism due to caring for a sick
child. We found that the costs directly linked to the treatment of the disease are of marginal importance, with
indirect costs being the most significant contributor to the total cost. Overall, the state budget and employers
bear the highest costs in the Czech Republic. Given that the total cost for households per case of acute
nasopharyngitis is about 7% of the average monthly wage and about 13.2% for acute bronchitis, repeated
incidences of the analysed diseases may lead to an excessive burden on households. Since 2021, the supergross
wage has been abolished in the Czech Republic, which will lead to a particular reduction in the financial
burden on households, on the other hand, even more significant tax losses for the state budget.
Acute nasopharyngitis and acute bronchitis are common respiratory diseases that affect the majority of the child
population (especially in the winter months) and which cannot be avoided altogether, especially when in contact
with children. As these diseases recur more frequently by up to 10% in areas with deteriorated air quality,
reducing pollution and research related to it is key to reducing disease incidence and the associated financial
costs. We see effective preventive measures as a significant solution for reducing these costs, especially in
cities and other areas with unsatisfactory air quality. These may include, for example, vitamin use, outdoor
recovery programmes, installation of air purifiers inside buildings, road cleaning. Further research into the
prevention of these common respiratory diseases would be desirable to reduce the overall economic burden for
all economic entities.
The policy implications of the research could involve pointing out the importance of main cost factors and the
burden on the national economy subject to the decision-making process in health policy or social policy. Many
studies were conducted for more serious illnesses, but very little for mild illnesses. But as we showed, the
10 SciPap29(3)
significant financial burden was confirmed on common respiratory illnesses such as acute nasopharynx and
acute bronchitis.
Acknowledgement
This contribution was supported by the Technology Agency of the Czech Republic within the Environment for
Life Program No. SS02030008, "Center for Environmental Research: Waste and Circulation Management and
Environmental Safety (CEVOOH)."
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