***Cost escalation deprives people of access tb health facilities. Poverty and poor health are closely intertwined. Poor health traps the poor into poverty and living in poverty contributes to poor health. With limited government budgeting for the health sector, any excess cost related to patients' care will compel patients to make out of pocket payment, thus inability to pay deprives the marginalised population of adequate health coverage.***

SINCE the time of Hippocrates (460 BC), the father of medicine, medicine has undergone dramatic changes from magic, mysticism, miasma and religious ritual to the 20th century modernised body of knowledge and technology which can save lives and reduce disability from diseases, which was a mere dream not far back.

The benefits reaped have invited some effects, which have compromised the very basic tenets of equity and accessibility, through the mounting costs of universal health care; many lives are saved at the cost of denial of service to many who cannot afford it.

In 2005. total national health expenditure in USA rose by 6.9 percent -- twice the rate of inflation. Total spending was $2 trillion in 2005, or $6,700 per person, which represents 16% of GDP. U.S health care spending is expected to increase at similar rate for the next decade, reaching$4 trillion in2015.

or 20% of GDP (US Health statistics. 2006).

In New Zealand, in I he 12 months to March 31, 2006, total health care cost escalation was 6.4% per annum. Escalation of surgical costs for the same period was 7.7%, while medical costs increased by 3.6% (Southern Cross Health Care, 2006). In general hospitals in China, between 1990 and 2002, nominal outpatient spending per patient increased 8.14 times (from 10.9 Yuan to 99.6

Yuan), and nominal inpatient spending per admission increased 6.6 times (from 473.3 Yuan to 3597.7 Yuan) (Qingyue Meng et al, 2004). Health care costs in UK in 1960, 1980 and 1985 were, respectively, 3.9%, 5.8% and 6.1% of GNP (SchieberandPoullier, 19891.

Despite the Bangladesh government's commitment to free health care services for the people, cost escalation has forced the rural people to incur, on average, an expenditure ofTk.342 per episode of acute illness. For major ill nesses, per episode treatment cost is estimated to be Tk.2,696, with 18%

incurring a cost of more than Tk.3,000 and 12% spending more than Tk.5,000.

Nearly 97% rural households make major expenses on health in a year, accounting for 15% of the annual expenses incurred by a household (Sharifa B. 1997). Factors influencing rising health care costs are:

General market inflation

The general rise in costs of almost all commodities and utilities has an effect on medical expenditures. There is always a rising inflationary trend in supplies, materials, fuel, food and medicines, which affect the overall health expenditure, making it costlier everyday.

Changing demographic pattern

With better living standards, health technology, nutrition, and hygienic practices, people are healthier today and are living longer than before, but geriatric diseases have become a natural phenomena, which are chronic in nature and costly as well.

Technological development

Better technology has contributed better diagnostic and therapeutic opportunities, but has also increased the cost of health care, making it available only for the privileged. There are at least four expensive technologies already, or soon to be, in the market for the treatment of heart disease: a drugeluting stent that is triple the price of earlier stents, doubling annual expenses to $4.6 billion; an improved ventricular assist device for use with patients who are not

candidates for transplantation, at an estimated cost of $16 billion a year; increased use of the implantable cardioverter defibrillator, adding 400,000 new patients at a cost of $24 billion, or $120 billion to treat the estimated backlog of 2 to 4 million patients; and the long pending artificial heart, which could add costs of $11 billion a year (Dannie! Collahan, 2007).

Unplanned health care facilities

Without appropriate need analysis and cost-effectiveness analysis, the mushrooming of health facilities, concentrated in urban areas, with most modern equipments has increased the average overhead cost and total cost in general. If an MRI machine can serve a definite number of people, having more than one machine, owned by different hospitals in the same locality, spreads the patients, which means that fewer patients than its capacity avail the facility, thus rendering the service costlier.

Inclination toward curative than preventive care Curative care is individual directed, and there is no collective benefit. Whereas preventive care is community or group oriented, from which the whole population can benefit. In curative care, there is recurrence of episodes and contin-

ued incurring of costs, whereas preventive care gives long term protection to the population against many diseases, thus, in the long run it is cost effective and cheap.

Supplier induced demand (SID)

Health is not a commodity, and there is no scope for the patients to prefer any type of care for any health situation. Due to asymmetry of information, it is the physicians who decide the need of the patients, and act as the agent of the patients. This unique characteristic in health care has allowed the physicians to prescribe more, but avoidable, medicines and laboratory investigations, making the service more expensive. It has been seen that in any hospital 8% of tests can easily be avoided without any impact on the quality of care (BM Shakharkar, 2003).

Increased proliferation of super specialists

The rate of referral to superspecialists has risen considerably, due to the attitude of the patients consulting a specialist, and a defensive attitude of the hospital itself, making the care costlier; whereas the majority of the physical ailments are curable at the general practitioner (GP) level.

Defensive attitude of outpatient departments (OPD)

A study has revealed that 65% of the patients can be sufficiently cured at the OPD level; 35% requiring referral, out of which 10% are acute in nature and 25% are chronic. If the majority of the patients from OPD are referred to specialists or advised for admission, there is unwarranted wastage of facilities, with increased cost.

Tendency for admission to hospital

If the majority of the patients who are curable at the OPD level are unwisely admitted to hospital, it leads to non-availability of beds for those who really need admission; thus depriving the society from the facility and increasing the cost for the patients who are unnecessarily admitted.

Defensive medicines

When a disease can be treated by a less expensive treatment and procedure, prescribing expensive medicines and procedures instead as a defensive approach is also increasing the costs.

Ineffective referral system Due to lack of adequate service personnel, equipments, facilities and overall lower quality of services at the peripheral health centers, patients are compelled to report directly to secondary or tertiary level hospitals, thus overburdening the facilities with minor ailments and, in effect, hampering the specialist services in terms of quality.

The most striking fact, however, is that despite many planned efforts to develop a sound health care delivery network in rural areas, the public sector performance in taking care of people’s health is appallingly poor. For acute illnesses their contribution stands only at 12%, and rises to 23% for the major ones.

Moral hazard

When there is an insurance system to cover the health care costs, there is a tendency of the consumer to over-utilise the services needlessly. In 1996, Americans spent $202

billion for physicians' services (19% of total health care spending), of which 25% were "unnecessary" visits (US hospital statistics report. 1998).

Changing pattern of diseases

In the past, we were more concerned about communicable diseases (CD), but changes in socio-economic standards have also changed the disease pattern, causing more non-communicable diseases (NCD) like heart diseases, diabetes, and cancers, which are expensive to treat and put an extra burden on already resource-starved health facilities.

Lack of efficiency

In health care systems, there is widespread lack of cost awareness among all levels and. in general, there is inefficiency in management, which also contribute to cost escalation of health care costs.

Cost escalation deprives people of access to health facilities.

Poverty and poor health are closely intertwined. Poor health traps the poor into poverty and living in poverty contributes to poor health. With limited government budgeting for the health sector, any excess cost related to patients' care will compel patients to make out of pocket payment, thus inability to pay deprives the marginalised population of adequate health coverage.

For accessibility and equity, efficient mechanisms, which will envisage cost containment, universal health insurance policy and community participation in decision making, monitoring, and evaluation of services are prerequisite. "Medical impoverishment” is a tragic consequence of cost escalation. compelling people to make a dire choice: either die without treatment, or save a life by sinking the family into poverty

Dr ZultiquBr Ahmed Amin is a physician, specialist In Public Health Administration and Health Economics.