Estimating the indirect economic burden of cancer in Jordan: a retrospective observational study

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Two valuation approaches (ie, human capital approach and value of a statistical life year) were used to estimate the indirect economic burden of 22 cancers in Jordan.

  • The results were presented as a proportion of the gross domestic product to facilitate cross-country comparisons.

  • The conservative valuation approach aligns with regional policy preferences, increasing its applicability.

  • The lack of data on informal care and direct disease costs in Jordan may limit the comprehensiveness of the analysis.

Introduction

The Hashemite Kingdome of Jordan, a middle-income country situated in the Middle East that has experienced significant economic challenges and stagnant economic growth in recent years; the COVID-19 pandemic, regional conflicts and the large influx of refugees have all had negative impacts on Jordan’s national economy.1 Health is a major contributor to a country’s national economy, and cancer in particular is a significant health concern in Jordan, with a growing burden that requires calculated government interventions in light of the current stringent economic liquidity.2 3 The high proportion of chronic diseases (including cancer) among refugees, has placed a significant economic burden on Jordan’s healthcare system.2 The United Nations High Commissioner for Refugees reported that breast cancer was the most common cancer among refugees in Jordan between 2011 and 2012.2 Moreover, the International Agency for Research on Cancer reported that in 2020, there were 11 559 new cancer cases in Jordan; the most common types of cancer were breast cancer, accounting for 20.8% of all cases, followed by colorectal cancer (10.9%), lung cancer (9.1%), bladder cancer (4.9%) and leukaemia (4.9%).4

One way to understand the national burden of a disease is by looking at how it affects a person’s quality of life, also known as health related quality of life, which combines mortality and morbidity into one overall score.5 Disability adjusted life years (DALYs) is one of these measures which was first coined by Murray and Lopez6; DALYs represent the total years of life lost (YLLs) due to dying early from a disease and the proportion of ‘healthy life years’ lost because of living with a disease.

Understanding the burden of disease is crucial not only for assessing the impact on an individual’s health, but also for evaluating the economic implications at a national level.7 The economic burden of a disease can be substantial, encompassing both direct costs (such as medical expenses) and indirect costs (such as productivity loss due to disability or premature death).8 The indirect economic burden, in particular, represents a significant portion of the total cost of illness (COI); it includes the forgone value of economic output lost due to disease-related work absences (absenteeism), reduced productivity while at work (presenteeism) and premature death (mortality).9 Therefore, by monetising the disease burden in terms of DALYs, we can estimate the potential productivity loss due to that specific disease. This information is invaluable for policy makers when establishing financing priorities for healthcare, as it provides a comprehensive view of the disease’s impact on society.10

In the context of this study, understanding and quantifying the disease burden of various cancers in Jordan will provide insights into the forgone economic productivity due to these cancers; Hence, the aim of this work is to estimate the indirect economic burden of 22 cancer types in Jordan to aid in establishing cancer financing priorities from a national economic perspective. Moreover, time series analysis was applied for the time period 1990–2019 and the indirect economic burden was forecasted for the years 2020–2025, while presenting the results as a proportion of total gross domestic product (GDP) to facilitate international comparisons and transferability.

Methods

Many methods have been adopted by health economists to value the economic burden due to disease. Two main methods are often employed11 12; first is value of a statistical life (VSL) approach which is based on the willingness-to-pay (WTP), where it estimates the disease burden by weighing the tradeoffs that individuals would be willing to make to reduce their chances of dying. The VSL approach often estimates the upper bound of the indirect economic burden.13 The second (and the more commonly used) method is the human capital (HC) approach (HCA), or the forgone output approach, which is partial to the COI approach, where the forgone productivity of premature mortality and morbidity are monetised based on the projected economic output per capita.7 13 In theory, the HCA should provide the lower bound estimates of the economic burden compared with the VSL approach; this is attributed to that the VSL further captures the utility derived from intangibles such as being alive and spending time with loved ones in addition to economic consumption, in contrast to the HCA where only tangible economic output is considered.13

Owing to the data scarcity of informal care and direct disease costs of cancer in Jordan, the analysis in this work was restricted to the financial value of lost productivity (indirect costs) from cancer patients due to premature mortality and morbidity from a national perspective. This is done by using country specific, age-adjusted DALYs reported by the Global Burden of Disease study 2019 estimates for Jordan.14 When it comes to calculating the economic value of DALYs, it is generally better to use more cautious valuation methods. In this work, the most conservative estimation approach was always employed as policy makers in the region are still reluctant to consider indirect cost estimates in their reimbursement decisions. Using age-standardised DALY estimates provide more conservative estimations of the national economic loss compared with normal DALY values.15

Age standardised DALY rates for 22 cancers (ie, bladder cancer; brain and central nervous system cancer; breast cancer; cervical cancer; colon and rectum cancer; oesophageal cancer; gallbladder and biliary tract cancer; kidney cancer; larynx cancer; lip and oral cavity cancer; liver cancer; nasopharynx cancer; non-melanoma skin cancer; other pharynx cancer; ovarian cancer; pancreatic cancer; prostate cancer; stomach cancer; testicular cancer; thyroid cancer; tracheal, bronchus, and lung cancer; and uterine cancer) were used in this analysis along with their corresponding YLL (mortality) and year lived with disability (YLD) (morbidity) estimates. All values were provided with upper and lower estimates, in addition to the mean estimate value.14 To model the indirect costs of the aforementioned cancers in Jordan, we further used population size and GDP per capita (GDPpc) data from the World Bank Group,16 while life expectancy and gross national income (GNI) per capita (GNIpc) were extracted from the WHO.17 Sources were selected based on the data availability for Jordan for the years 1990–2019.

Forgone economic loss estimates (indirect costs) were calculated for the year 2019 using same year current international dollars (Intl$), adjusted for purchasing power parity (PPP). The PPP approach allows for a more accurate comparison of economic data between countries by accounting for differences in cost of living and inflation rates.18 This is particularly important in health economics where costs can vary significantly between countries due to differences in healthcare systems, wage levels and general price levels.19 Hence, using PPP-adjusted international dollars would align the methodology with established practices in the field of health economics, enhancing the credibility and comparability of the results. Total DALYs were calculated for each corresponding year and cancer type by multiplying the DALY rate by the population estimates for the same year. Additionally, since the economic value of DALYs is influenced by the GDPpc, results were also expressed as a percentage of total GDP to provide a more useful measure in comparison to other countries. Time series analysis was conducted to investigate the overall cancer situation over the past 30 years. Following are the detailed methodologies used in this work for both the HC and the VSL approaches in addition to the time series analysis.

Human capital approach

Multiple researchers have implemented the use of GNIpc as a proxy for the monetary value of a DALY.20–22 As with previous studies, PPP approach was used instead of Atlas method for determining GNIpc. The PPP method is more accurate for cross-country income per capita comparisons as it accounts for differences in price levels among countries, facilitating cross-country comparison. For this work, and provided the conservative approach adopted, each DALY lost was valued as one GNIpc, although values of one, two and three times the GNIpc were suggested as proxies for each DALY.23 24 For instance, in 2019, the total mean DALY estimate for breast cancer was 29 418.6843 DALYs, multiplied by the GNIpc Intl$, PPP value of 9940 gives the estimated forgone monetary value of 292 421 722 Intl$, PPP, noting that the numbers in the table have been rounded to enhance readability. The same approach was used to calculate the monetary value of the YLDs and YLLs.

VSL year approach

The VSL represents the maximum amount an individual is prepared to pay to reduce their risk of death; this approach is frequently employed by government bodies to assess the potential economic benefits of investments in areas with limited resources.15 20 25 In countries where specific VSL studies have not been conducted, it is possible to use estimates from other countries after adjusting based on the GDP or GNI.26 27

Income-elasticity factor plays a crucial role in adjusting monetary estimates between countries with different income levels; as individuals in higher-income countries are generally willing to pay more to reduce their risk of death compared with individuals in lower-income countries reflecting the WTP.28 29 In the context of this work, it is employed to adjust the VSL estimated from a high-income country (ie, USA) to a middle-income country (ie, Jordan). Provided that healthcare is a necessity rather than a luxury, and that its consumption does not increase proportionally with income, and owing to the conservative estimation approach adopted in this work, an income-elasticity factor of 0.85 was used to enhance the reliability of the VSL estimate, following Miller’s recommendation.30

Estimates show that the VSL for the USA is US$7.2 million.31 This number has remained constant over the past 5 years31 32; hence, no inflation adjustment was employed. After adjusting for the GNIpc following Kotagal et al
27; the VSL for Jordan in 2019 amounts to US$1.157 million using an elasticity factor of 0.85 adopted from Miller.30 On the other hand, a recent study by Sweis31 reported that the world average VSL is estimated to be US$1.3 million. This estimate is also in line with another study where the VSL was estimated to be US$1.3 million for upper-middle income countries.32

It can be seen that both VSL estimates ($1.157 million and $1.3 million) are close to each other, validating the utility of the GNI transferability approach in calculating national VSL estimates. However, in this work, the VSL for Jordan was assumed to be US$1.3 million following Sweis31 and Viscusi and Masterman.32 Consequently, the VSL year (VSLY) can be derived from the VSL by dividing the VSL by the life expectancy,22 which was 76.04 years in Jordan for 2019; this calculation resulted in a VSLY value of $17 096 in Jordan, which will be used to assign a monetary value to each DALY in this work. For instance, in 2019, the total mean DALY estimate for breast cancer was 29 418.6843 DALYs, multiplied by the calculated value of VSLY 17 096.26512 gives the estimated forgone monetary value of $292 421 722, noting that the numbers in the table have been rounded to enhance readability. The same approach was used to calculate the monetary value of the YLDs and YLLs.

Time series analysis and forecasting

DALY rates from 1990 to 2019 were used as the base case for the time series analysis. Using both the HC and VSLY estimates, the total annual cancer indirect economic burden was summed for all 22 cancers and is further used for the analysis. DALY rate and the total economic burden were investigated against time using Excel. Changes in the annual DALY rate and cumulative total economic burden were also highlighted. Forecasting was done using SPSS V.23 expert modeller module for indirect economic loss estimates up to the year 2025 using the HCA.

Patient and public involvement

This research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient relevant outcomes or interpret the results. The data used in this study are anonymised and were obtained from publicly available databases, which means they do not contain any information that could be used to identify individual patients. However, the results of this study can help inform public health policies and set national cancer spending priorities, which could indirectly benefit patients and the public in Jordan.

Results

Table 1 shows the detailed indirect economic burden for each investigated cancer type in Jordan for the year 2019 using two approaches: The HCA and the VSLY approach. The mean estimates, along with their corresponding lower and upper bounds are presented for each type of cancer (a summary of total DALYs, YLLs and YLDs for all cancer types is available in online supplemental table 1). The mean total economic burden for all cancers is estimated to be $1.82 billion using HCA and $3.13 billion using VSLY approach. The cancers contributing most to the total burden are ‘tracheal, bronchus and lung cancer’ ($359.5 million HCA, $618.3 million VSLY), followed by ‘colon and rectum cancer’ ($300.6 million HCA, $517.1 million VSLY) and ‘breast cancer’ ($292.4 million HCA, $502.9 million VSLY). These three cancers alone account for over 50% of the total indirect economic burden in Jordan.

Supplemental material

Table 1

Indirect economic burden of cancers in Jordan for the year 2019 using two estimation approaches; HCA and VSLY, along with their upper and lower bounds (international $, purchasing power parity (PPP))

In terms of morbidity, ‘breast cancer’ stands out with the highest contribution from total cancer morbidity ($17.6 million HCA, $30.2 million VSLY), followed by ‘prostate cancer’ ($7.8 Million HCA, $13.5 million VSLY) and ‘colon and rectum cancer’ ($8.6 million HCA, $15.1 million VSLY). On the other hand, ‘non-melanoma skin cancer’ has the lowest morbidity contributions, ($57 081 HCA $98 175 VSLY). Conversely, mortality costs are highest for tracheal, bronchus and lung cancer ($355.9 million HCA, $612.3 million VSLY), colon and rectum cancer ($291.9 million HCA, $502 million VSLY) and breast cancer ($274.9 million HCA, $472.7 million VSLY).

The per cent contribution of different types of cancers from the total indirect economic burden cancer are also presented in table 1. Each type of cancer is listed with its corresponding percentage contribution out of that total specific measure. In terms of morbidity; ‘breast cancer’ has the highest contribution with 29.8% of total cancer morbidity burden, followed by ‘prostate cancer’ at 13.3% and ‘colon and rectum cancer’ at 14.8%. On the other end of the spectrum, ‘non-melanoma skin cancer’ and ‘other pharynx cancer’ have the lowest disability contributions, both less than 1% of the total disability burden. On the other hand; ‘tracheal, bronchus and lung cancer’ contribute the most to mortality with 20.2% of total cancers mortality, followed by ‘colon and rectum cancer’ at 16.6% and ‘breast cancer’ at 15.6%. This underscores the severe health impact of these cancers which consequently reflects on the economic burden. When considering both morbidity and mortality (ie, total burden); ‘tracheal, bronchus and lung cancer’ contribute the most to the total cancer measure with 19.8%, followed by ‘colon and rectum cancer’ at 16.5% and ‘breast cancer’ at 16.1%. Interestingly, while testicular cancer has a relatively low total cost, it has a high disability contribution (13.3%), indicating a significant impact on patients’ quality of life despite its lower prevalence or mortality rate.

Table 2 shows the indirect economic burden due to each cancer type as a per cent of GDP in Jordan for the year 2019. The total economic burden of all cancers, when considering both the HCA and the VSLY approaches, accounted for a significant portion of Jordan’s GDP where the indirect economic burden ranged from 1.4% to 2.1% of the GDP using the HCA, and from 2.3% to 3.6% of the GDP using the VSLY approach.

Table 2

Indirect economic burden due to each cancer type as a per cent of GDP in Jordan* for the year 2019

Time series impact of cancer burden in Jordan for the years 1990–2019 is depicted in figures 1 and 2. Figure 1 illustrates the annual DALY rate attributed to cancer in Jordan; although the graph showcases fluctuations in DALY rate, yet overall, the burden seems to be going in a downward direction with a total of 11% reduction in total DALYs over the investigated 30 years. On average, DALYs decreased by 0.37% annually. Conversely in figure 2, we observe an interesting trend. Despite the decrease in the burden of disease in terms of DALYs, the indirect economic impact of cancer has more than doubled, increasing from $80.85 HCA per capita (HCApc) to $169.98 HCApc. This represents a total increase of 210% over the investigated 30 years, with an average annual increase in the total cancer economic burden per capita of 2.43%. This increase can mostly be attributed to the tripling of the per capita income in Jordan over the past 30 years. However, when we consider the total cancer economic burden as a percentage of the total GNI, an interesting trend emerges. Figure 3 shows that the relative economic burden of total cancer has actually decreased, from 1.9% to around 1.7% (ie, 11.1% decrease). This suggests that while the absolute economic impact of cancer has increased, the relative economic burden, when considered as part of Jordan’s overall economic output, has slightly decreased, reflecting the improvement in overall DALYs.

Figure 1
Figure 1

Total disability adjusted life year (DALY) rates of the 22 in Jordan 1990–2019.

Figure 2
Figure 2

Indirect economic burden per capita of the 22 cancers in Jordan 1990–2019 in (Intl$, purchasing power parity). HCA, human capital approach.

Figure 3
Figure 3

Indirect economic burden of the 22 cancers in Jordan as a per cent of gross national income (GNI) 1990–2019.

Table 3 shows the forecasted estimates for total economic cancer burden for the investigated 22 cancers in billion Intl$, PPP along with their lower and upper estimates using both the HC and the VSLY approaches; for the HCA, the total economic burden increases from 1.9 billion Intl$ in 2020 to 2.3 billion Intl$ in 2025. Similarly, for the VSLY approach, the total economic burden increases from 3.2 billion Intl$ in 2020 to 3.5 billion Intl$ in 2025.

Table 3

Indirect economic burden forecast due to the 22 cancers in Jordan for the years 2020–2025 in billion Intl$, purchasing power parity

Discussion

This analysis highlights the significant indirect economic burden associated with various types of cancer in Jordan, emphasising the urgent need for effective prevention, early detection and calculated treatment strategies on a national level. These findings provide a comprehensive picture of the economic burden of different types of cancers, offering valuable insights for policymakers, healthcare providers and researchers in prioritising resources and strategies in cancer control. Moreover, the significant economic burden of these cancers provides a strong economic argument for investing in cancer control, both in terms of healthcare costs and the broader impact on society.

The results indicate that in Jordan, the three cancer groups contributing most to the total indirect costs are tracheal, bronchus and lung cancer; colon and rectum cancer; and breast cancer, respectively. These three cancer groups combined account for over half of the total indirect economic burden cause by cancer in Jordan, indicating their substantial national economic impact. In terms of absolute morbidity costs, the results show that the highest morbidity costs were associated with tracheal, bronchus and lung cancer, followed by colon and rectum cancer, breast cancer and prostate cancer. A global investigation reported significant international disparities for tracheal, bronchus and lung cancer.33 Moreover, a systematic review reported that the indirect costs of breast cancer in women, were significantly high.19 Breast cancer high morbidity proportion highlights the long-term impact of these cancers on patients’ quality of life and the importance of specific supportive care and rehabilitation in cancer management strategies. Conversely, non-melanoma skin cancer’s low morbidity contributions can be an indication of relatively lower severity/prevalence or better management of these cancers. The mortality costs are highest for tracheal, bronchus and lung cancer; colon and rectum cancer; and breast cancer, underscoring the urgent need for effective interventions to reduce mortality from these cancers. Testicular cancer, despite its relatively low total cost, has a high disability contribution, indicating a significant impact on patients’ quality of life despite its lower prevalence or mortality rate. Given the above, it is important to note that the costs associated with cancer are multifaceted and can vary widely depending on numerous factors such as the stage of cancer at diagnosis, the patient’s overall health, the specific treatments used, and the country’s healthcare system; hence, each country should design its own management programme not influenced by general international guidelines.

Regarding the time series analysis, it was obvious that the DALY rate has been decreasing over the years, indicating a reduction in the overall burden of cancer in terms of mortality and morbidity. While a decreasing DALY rate might suggest fewer people are suffering from cancer, those who do get cancer might be living longer due to improved treatments.34 This could lead to increased direct costs over time as patients require ongoing treatment. However, from a societal perspective, and due to the increase in mortality age, the additional direct costs are easily offset by the indirect benefits achieved. Fluctuations in cancer DALY rate over this three-decade period can be attributed to various factors; for instance, changes in cancer incidence rates, influenced by factors like lifestyle, genetics and environmental exposures, can lead to fluctuations in DALYs.35 Also, improvements in cancer screening and early detection programmes may have reduced DALYs by diagnosing cancer at earlier, more treatable stages.36 37 Moreover, advances in cancer treatments, better healthcare infrastructure, and increased access to medications have contributed to improving cancer survival rates and reducing the YLDs.38 The interplay of these factors reflects the dynamic nature of cancer’s burden on the Jordanian population’s overall health over time.

A similar recent global study39 employed a unique methodology, using a decision analytical model that incorporates economic feedback. This model assessed health outcomes associated with changes in labour force supply and investment diversions. The study’s findings for upper-middle-income countries indicated that the economic burden of cancer was 0.535% (0.353%–0.779%) of the GDP. This figure is nearly half of the estimates for Jordan using the HCA. This discrepancy can be primarily attributed to differences in methodology, the incorporation of broader economic factors such as labour supply and investment diversion, the types of cancer considered, and the scope of the study. However, if we adjust the HCA used in the Jordan study to incorporate the unemployment rate, the estimates become more aligned with the global study. Further incorporation of the investment diversion may bring the results even closer. Moreover, the forecasted increase in the economic burden of cancer in the Jordan study aligns with the global study’s projection of an increasing economic toll of cancers, underscoring the need for continued research and investment in cancer prevention and treatment.

To mitigate the indirect productivity losses associated with cancer, several policy strategies could be considered. Implementing return-to-work programmes can expedite the process of cancer survivors rejoining the workforce, thereby reducing productivity losses.40 Expanding coverage for supportive care services can address physical and mental health impairments that contribute to disability costs.41 Investing in research to reduce long-term disability can help lower productivity losses by minimising the long-term effects of cancer and its treatment.42 Promoting early detection and prevention can lead to higher survival rates and lower long-term disability, as many cancers are more manageable when detected early.43 Finally, transitioning to value-based reimbursement models can incentivise healthcare providers to focus on long-term outcomes and quality of life, which can ultimately reduce indirect productivity losses.44 45 These strategies aim to lessen the economic burden of cancer, but their effectiveness would need to be evaluated in the context of Jordan’s healthcare system and patient population.

The economic burden presented in this study represents the indirect costs associated with cancer in Jordan. These costs, quantified in terms of DALYs, reflect the lost economic productivity due to premature death and disability from cancer. Policymakers could use this information in a cost-benefit analysis when considering different interventions. For instance, if an intervention could reduce the total cancer burden by 5%, this could potentially result in a 5% reduction in these indirect costs. By investing in effective interventions, policymakers have the opportunity to significantly reduce the economic impact of cancer, thereby promoting both public health and economic productivity.

While this work provides comprehensive estimates for indirect economic burden for 22 types of cancer in Jordan, it does not cover all types of cancers. Notably, cancers such as leukaemia, non-Hodgkin’s lymphoma, endometrial cancer, melanoma and skin cancer are not discussed in this paper. These exclusions are a limitation of the current study and suggest an opportunity for future research. Also, national non-gender specific estimates were used for calculating the economic burden of cancer. This approach could potentially introduce bias, particularly for gender-specific cancers. Future research should aim to incorporate gender-specific estimates to enhance the accuracy of the economic burden calculations. Moreover, it is important to note that each type of cancer has unique characteristics and challenges, and the findings of this paper may not be applicable to the excluded types. it is also important to note that while these methods are widely used, they do have limitations; the VSL method assumes that individuals have perfect information about risks and that they can trade off wealth for risk in a frictionless market. Similarly, furthermore, the use of the HCA excludes non-market productivity which can underestimate the burden. On the other hand, while the DALY metric has been extensively used in burden of disease studies, it is important to acknowledge its limitations. One significant critique is that the disability weights used in DALY calculations are not adjusted to reflect regional or cultural variations in health perceptions and values.46 This lack of adjustment may lead to potential biases in the estimated burden of disease, as the same health state may be perceived differently across different cultures or regions.47 Moreover, the DALY method assumes that a year of healthy life is equally valuable at all ages, hence age-standardised DALYs were used instead to minimise the value difference across age groups. Finally, it is worth noting that the data used is up to the year 2019, that is before COVID-19, hence forecasting estimates for the next 5 years may be conservative provided the COVID-19 comorbidity.

Conclusion

This study highlights the significant indirect economic burden of cancer in Jordan amounting to 1.4%–3.6% of total GDP, with tracheal, bronchus and lung cancer; colon and rectum cancer; and breast cancer contributing most to the total costs. Despite a decrease in the DALY rate over the years, the economic impact of cancer on Jordan’s economy is still growing. Further research is needed to explore the cost-effectiveness of different cancer control strategies and to update these estimates as new data becomes available. Collaborative efforts are needed on a global scale to tackle this issue, including sharing research, knowledge and best practices, while working collectively to advocate for policies that will reduce the global cancer burden.

Data availability statement

Data are available in a public, open access repository. GBD estimates are available for download from the Global Health Data Exchange and are available freely for non-commercial users under the Open Data Commons Attribution License (https://ghdx.healthdata.org/gbd-2019).

Ethics statements

Patient consent for publication

Ethics approval

Not required.

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