The global demographic transition towards an older age structure represents one of the most significant public health challenges of the twenty-first century.3 Globally, the proportion of individuals aged 60 years and above is projected to nearly double from 12% in 2015 to 22% by 2050, with the most rapid growth occurring in low- and middle-income countries.4 India also adheres to this demographic trend; the elderly population, currently estimated at approximately 140 million, is projected to constitute nearly 20% of the total population by 2050.5 This demographic shift is paralleled by an accelerating epidemiological transition characterized by a rising burden of non-communicable diseases (NCDs), multi-morbidity, and functional disabilities, all of which necessitate long-term pharmacological management.3,6,7 According to the Longitudinal Ageing Study in India (LASI)8, nearly one in five elderly individuals in India suffers from multimorbidity, significantly increasing long-term medication dependence and healthcare expenditure.

Geriatric patients often present with multiple concurrent chronic illnesses, a clinical reality that inevitably translates into complex, multi-drug therapeutic regimens. In the Indian healthcare context, where the financing of outpatient services is predominantly dependent on household out-of-pocket expenditure (OOPE), the cumulative cost of long-term medications imposes an inequitable economic burden on elderly households, especially in rural areas. 9 Earlier studies have consistently demonstrated that OOPE on medicines constitutes the major driver of catastrophic health expenditure in India, precipitating poverty and negatively influencing health-seeking behaviours and adherence to prescribed medications.9

NEED OF THE STUDY

Pharmacoeconomics, as a scientific discipline, provides a systematic framework for the systematic evaluation of the costs, benefits, and outcomes of pharmaceutical interventions, thereby facilitating evidence-based resource allocation decisions. 10 While the criteria for Polypharmacy differed across various research studies, this study operationally defined it as the as concurrent use of 4–5 medications, whereas the term excessive polypharmacy was described as the simultaneous use of 6 or more medications.

In the context of an Indian healthcare system characterized by resource constraints, pharmacoeconomic evaluations conducted at the community level serve as essential instruments for the formulation of health policy. However, there exists a dearth of empirical data that quantifies the real-world pharmacoeconomic burden experienced by rural geriatric populations in Telangana. Rural communities face additional barriers to efficient medication management, which include limited literacy levels, low income, inadequate awareness regarding generic drug alternatives, and poor penetration of organized health insurance.

With this background, the present study was undertaken with the following objectives: (i) to determine the socio-demographic profile of the geriatric population in a rural community of Karimnagar district, Telangana; (ii) to assess the prevailing morbidity profile and medication utilization patterns; (iii) to estimate the monthly medication expenditure and perceived financial burden; and (iv) to identify the cost-reduction strategies that are employed by the study population.

Study Design and Setting A community-based cross-sectional study was conducted in Annaram village, which serves as a field practice area of the Department of Community Medicine, Chalmeda Anand Rao Institute of Medical Sciences (CAIMS), Karimnagar district, Telangana, India. Karimnagar is a semi-urban district in northern Telangana. Study Period The study was carried out over a duration of three months, from April 2025 to July 2025. Study Population The target population comprised permanent residents of Annaram village aged between 60 and 80 years. Sample Size Calculation The sample size was determined using the standard formula for estimating a proportion in a cross-sectional study: n = Z² × p × q / d² Where: Z = 1.96 (two-tailed, at 95% confidence interval); p = assumed prevalence of chronic morbidity among elderly as 50% (maximum variability) with 95% confidence level and 5% absolute precision; q = 100 − p; d = 5% (allowable margin of error). After adjustment for anticipated non-response, the minimum required sample size was determined to be 196 participants. Sampling Method Participants were selected using simple random sampling. A complete list of residents aged 60–80 years was obtained from the village health register and the electoral roll, which served as the sampling frame. Random numbers were generated to select the required sample from this list. Inclusion Criteria Permanent residents of Annaram village aged between 60 and 80 years. Individuals willing to provide informed consent. Exclusion Criteria Individuals below 60 years of age or above 80 years of age. Individuals who were unconscious, critically ill, or cognitively impaired to the extent that valid interview responses could not be obtained at the time of data collection. Data Collection Data were collected through structured face-to-face interviews conducted at the participant’s household by trained investigators. A pre-designed, pre-tested, semi-structured questionnaire was employed, which consists of the following domains: (i) socio-demographic characteristics (age, sex, educational status, occupation, and socio-economic status); (ii) morbidity profile and clinical diagnosis; (iii) medication utilization patterns including number of daily drugs, prescribing source, and use of generic versus branded formulations; (iv) monthly medication expenditure; (v) perceived financial burden; and (vi) strategies employed to mitigate medication costs. Data were systematically recorded in a digital format using a structured data entry template. Statistical Analysis All collected data were cleaned, coded, and entered into SPSS (Version 20). Descriptive statistical analysis was performed, with results expressed as absolute frequencies (n) and proportions (%). Chi-square analysis is done to find-out the association between polypharmacy and perceived financial burden among study participants. Ethical Considerations Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC) of Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. Written informed consent was obtained from all participants prior to their enrolment into the study. For individuals who were unable to read or write, the consent form was explained in the local language (Telugu), and thumb impression consent was obtained in the presence of an impartial witness. Participants were informed regarding the objectives of the study, voluntary nature of participation, the confidentiality of their information, and the right to withdraw from the study at any stage without any consequences. Strict confidentiality and anonymity of all participant data were maintained throughout the duration of the study.

Socio-demographic Profile

A total of 196 participants were enrolled in the study. The socio-demographic characteristics of the study population are summarized in Tables 1. The distribution across age groups revealed that the largest proportion of participants (38.3%, n=75) belonged to the 65–69-year age cohort, followed by the 70–74-year group (29.6%, n=58) and the 60–64-year group (27.6%, n=54). The oldest age category, 75–79 years, constituted 4.6% (n=9) of the sample. Males constituted the majority (57.1%, n=112) compared to females (42.9%, n=84). Regarding educational attainment, illiteracy was strikingly prevalent, documented in 77.0% (n=151) of participants, while only 2.6% (n=5) had received education beyond the secondary level.

Table 1: Socio-demographic profile of Study Participants (n = 196)

Morbidity Profile

The distribution of primary morbidities among the study participants is presented in Table 2. Hypertension was the most prevalent chronic condition, documented in 40.8% (n=80) of participants. Osteoarthritis was the second most common morbidity (24.5%, n=48), followed by diabetes mellitus (18.9%, n=37). Other comorbidities including chronic obstructive pulmonary disease (COPD), ischaemic heart disease, and miscellaneous conditions accounted for the remaining proportion.

Table 2: Morbidity Profile of Study Participants (n = 196)

* Multiple morbidities were present among participants; percentages may exceed 100%

Medication Utilization Patterns and Monthly Medication Expenditure

The daily medication utilization pattern is depicted in Table 4. Majority of participants (74.5 %, n=146) were prescribed one to three medications per day, indicating predominantly low-grade polypharmacy in this rural cohort. A moderate number of medications (four to five drugs per day) were utilized by 24% (n=47) of participants. Excessive polypharmacy, defined in this study as the concurrent use of six or more medications per day, was observed in only 1.5% (n=3) of the study population.

Table 3: Daily Medication Utilization and Monthly Medical Out-of-Pocket Expenditure among Study Participants (n = 196)

The monthly out-of-pocket expenditure on medications is illustrated in Table 3. Expenditure in the range of less than ₹500 per month was reported by 41.3% (n=81) of participants, with an equal proportion (41.3%, n=81) spending between ₹500 and ₹1,000 per month. Thus, 82.6% of the study participants spent no more than ₹1,000 per month on medications. However, 10.7% (n=21) incurred monthly medication costs between ₹1,000 and ₹2,000, and 6.6% (n=13) spent more than ₹2,000 per month. Despite the seemingly modest absolute expenditure figures, 66.3% of participants subjectively perceived their medication costs as a significant financial burden on household finances.

Table 4: Association Between Polypharmacy and Perceived Financial Burden (n = 196)

Table-4 depicts a significantly higher proportion of elderly individuals (40 out of 50) with polypharmacy reported financial burden (80.0%) compared to those without polypharmacy (90 out of 146 = 61.6%). Chi-square analysis demonstrated a statistically significant association between polypharmacy and financial burden (χ² = 5.73, p = 0.017).

Cost-Reduction Strategies

The strategies adopted by participants to mitigate medication expenditure are presented in Figure-1. Government drug subsidies were the predominant cost-reduction mechanism, utilized by 68.9% (n=135) of participants. Health insurance coverage was reported by 15.8% (n=31) of the study population. Other strategies included attending regular government health check-up camps (7.7%, n=15), purchasing generic formulations (6.6%, n=13), and utilizing doorstep drug delivery services (1.0%, n=2).

Figure -1: Cost-Reduction Strategies Utilized by Study Participants (n = 196)

This current cross-sectional study provides an insight into the pharmacoeconomic picture that challenges the geriatric population in a rural community of Karimnagar district, Telangana. The findings collectively highlight the convergence of high chronic disease burden, low medication complexity, inadequate government health insurance coverage, and significant perceived financial distress in this vulnerable population subgroup.

The predominance of hypertension (40.8%) as the leading morbidity in this cohort is consistent with the established national trend indicating a rising burden of non-communicable diseases (NCDs) among the elderly population in India. Published data from the National Family Health Survey NFHS-5 and various community-based geriatric studies lend support to these prevalence estimates, with hypertension consistently identified as the most prevalent chronic ailment among rural elderly.¹¹ The substantial prevalence of osteoarthritis (24.5%) in the present cohort warrants particular attention, as its high burden has direct pharmacoeconomic implications, necessitating long-term analgesic and anti-inflammatory treatments.¹² The prevalence of diabetes mellitus (18.9%) in this rural cohort, although lower than urban estimates, remains epidemiologically significant and is consistent with the increasingly recognized ruralization of the diabetes epidemic in India.^{12, 13}

The alarmingly high illiteracy rate of 77.0% recorded in this study has extensive public health implications. Low health literacy is a significant predictor of poor medication adherence, limited understanding of generic drug alternatives, reduced ability to navigate health financing systems, and suboptimal management of chronic diseases.¹⁴ This low literacy level also renders the elderly population particularly susceptible to inappropriate polypharmacy and simultaneously reduces their capacity to effectively utilize government health programs and insurance schemes. These findings are consistent with the observations reported by Brinda E et al., who identified significant gender and educational disparities in health outcomes among rural elderly populations in India.¹⁴

While majority of the study population (74.5%) uses 1 to 3 drugs per day, the documented prevalence of polypharmacy (25.5%) in this study stands in consistence with report polypharmacy rates in the study conducted by Nithya. S et al in 2021.³ Although the morbidity profile shows the presence of multimorbidity in more than half of the study population, it suggests that the relatively low drug count may possibly indicate under-treatment or financial self-rationing of prescribed medications, wherein patients selectively discontinue or reduce medication dosages in an effort to manage the out-of-pocket expenses.⁹ The observation that 66.3% of participants perceived their medication-related expenditure as a significant financial burden, despite 82.6% spending less than ₹1,000 per month, strongly supports this interpretation. A markedly higher proportion of elderly individuals with polypharmacy reported financial burden (80.0%) in comparison to those without polypharmacy.¹⁵ In rural household economies characterized by irregular agricultural income and absence of pension support, even a minimal monthly expenditure on medication can constitute a substantial proportion of available disposable income.¹⁶

The predominant dependence on government pharmaceutical subsidies (68.9%) as the primary cost-mitigation mechanism highlights the critical role of public health programmes in ensuring medication access for the rural elderly population. State-specific initiatives in Telangana, including the “Aasara” social pension scheme and “Telangana Aarogyasri” medical insurance for severe health conditions, and subsidized drug distribution through government healthcare facilities, appear to constitute the primary safety net for this population. These findings are consistent with those of Brinda E et al., who demonstrated the essential function of government health schemes in mitigating economic burden faced by the elderly in rural India.¹⁴ However, the persistently low health insurance penetration rate of 15.8% remains a major structural gap in the pharmacoeconomic safety net, leaving the vast majority of the study population financially vulnerable to catastrophic out-of-pocket expenditure in the event of acute illness or hospitalization requiring high-cost therapeutic interventions.¹⁴ The limited uptake of generic drug procurement (6.6%) despite the availability of Jan Aushadhi Kendras in the district further highlights a critical need for community-level interventions regarding cost-effective pharmacotherapy alternatives.^12,16

The public health implications of these findings are complex. At the policy level, they highlight the urgent need for universal coverage of outpatient geriatric medications under state health insurance schemes, rather than the current hospitalization-centric model. At the systems level, ensuring the consistent NCD drug supply at primary health centres (PHCs) and sub-centres, the strategic establishment of Jan Aushadhi Kendras in rural areas, along with the community pharmacist-led medication counselling, could substantially reduce the pharmacoeconomic burden on the rural geriatric population.^3,10        

The cross-sectional study design limits the establishment of temporal or causal relationships among the identified variables. The study's focus on a single village in Telangana may restrict the applicability of findings to broader rural populations in India.

Medication expenditure data relied on self-reported recall, which poses a risk of recall bias. Clinical diagnoses were not consistently verified against medical records. Further, objective verification of medication adherence was not done.

Financial burden was assessed subjectively based on perceived burden rather than a validated threshold, potentially leading to measurement variability. Future longitudinal studies utilizing validated pharmacoeconomic tools across diverse rural populations are needed to mitigate these limitations.

This community-based cross-sectional study demonstrates that the rural geriatric population of Karimnagar district, Telangana, experiences a significant perceived pharmacoeconomic burden resulting from chronic medication expenditures, notwithstanding the comparatively low absolute monthly pharmaceutical costs. The high prevalence of illiteracy, dependence on government drug subsidies, and markedly limited health insurance coverage collectively characterize a population that remains structurally vulnerable to catastrophic health expenditures. Hypertension, osteoarthritis, and diabetes mellitus constitute the dominant morbidity contributors, while the low observed prevalence of polypharmacy may indicate financial self-rationing rather than truly optimized prescribing. Addressing these multifaceted challenges requires a comprehensive policy response that includes the strengthened non-communicable diseases (NCD) drug supply chains, generic medicine promotion, implementation of community health literacy programmes, and the expansion of geriatric-inclusive health insurance coverage to outpatient chronic care. The following steps are necessary to reduce the avoidable pharmacoeconomic burden on the rural elderly population in India: 1. Strengthen the supply chain of essential NCD medications at PHCs and sub-health centres in rural Telangana to enhance access and minimize OOPE. 2. Expand operational reach of Jan Aushadhi Kendras' and community awareness in rural areas to encourage economical pharmacotherapy for the elderly. 3. Extend the coverage of state health insurance schemes (e.g., Ayushman Bharat – PMJAY, Telangana Arogya Sri) to explicitly include outpatient management of chronic NCDs in elderly populations, moving beyond the existing hospitalization-only coverage model. 4. Integrate structured medication counselling including guidance on generic drug use and cost-reduction strategies into the routine home visits conducted by Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs), with a specific focus on illiterate elderly individuals. 5. Conduct regular pharmacoeconomic surveillance studies across various rural districts of India to generate representative, longitudinal evidence for policy planning.

1. Singh VJ, Roy V, Singhal S, Daga MK. Pharmacoeconomics of medicines used for geriatric individuals in a tertiary care hospital in Delhi. Indian J Med Res. 2024 Feb;159(2):143–152. doi: 10.4103/ijmr.ijmr_2507_21.
2. Lazarus A, Sahasrabudhhe A, Arora VK. A cross-sectional study of health seeking behaviour and out-of-pocket expenses among elderly in the rural population in Indore. Int J Med Biomed Stud. 2020;4(2):254–256. doi: 10.32553/ijmbs.v4i2.989.
3. Nitya S, Ramya G, Kiruthika S, Meenakshi R, Nalini Devi J, Suganya G, et al. Drug utilization pattern and factors associated with polypharmacy and excessive polypharmacy in geriatric medical out-patients at a rural health training centre in India. J Family Med Prim Care. 2021;10(7):2636–2641. doi: 10.4103/jfmpc.jfmpc_2417_20.
4. Das S, Gnanavel P, Smanla S, et al. Polypharmacy and self-medication among older adults in Indian urban communities – a cross-sectional study. Sci Rep. 2025;15:4062. doi: 10.1038/s41598-024-84627-2.
5. Government of India, National Statistical Office. Elderly in India [Internet]. New Delhi: Ministry of Statistics and Programme Implementation; 2021 [cited 2025 Apr 10]. Available from: https://www.mospi.gov.in/
6. Kwak M, Chang M, Chiadika S. Healthcare expenditure associated with polypharmacy in older adults with cardiovascular diseases. Am J Cardiol. 2022;169:156–158.
7. Sahoo H, Govil D, James KS, Prasad RD. Health issues, health care utilization and health care expenditure among elderly in India: thematic review of literature. Aging Health Res. 2021;1(2):100012. doi: 10.1016/j.ahr.2021.100012.
8. Bloom, D.E., Sekher, T.V. & Lee, J. Longitudinal Aging Study in India (LASI): new data resources for addressing aging in India. Nat Aging 1, 1070–1072 (2021). https://doi.org/10.1038/s43587-021-00155-y
9. Sinha A, Mukherjee S, Tripathi S, Dutta S. Issues and challenges of polypharmacy in the elderly: a review of contemporary Indian literature. J Family Med Prim Care. 2021;10(10):3544–3547. doi: 10.4103/jfmpc.jfmpc_2581_20.
10. Ahmad A, Patel I, Parimilakrishnan S, Mohanta GP, Chung H, Chang J. The role of pharmacoeconomics in current Indian healthcare system. J Res Pharm Pract. 2013;2(1):3–9.
11. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019–21: India: Volume I. Mumbai: IIPS; 2021.
12. Singh SK, Pandey P. Morbidity profile, healthcare utilization and associated out-of-pocket expenditure on health among elderly population of Lucknow district, northern India. Trop Med Surg. 2016;4:210. doi: 10.4172/2329-9088.1000210.
13. Lakra K, Pandey M, Meher S, et al. Economic burden of multimorbidity and polypharmacy among geriatric patients: a single-centre experience from Odisha, India. Cureus. 2024 Nov 29;16(11):e74752. doi: 10.7759/cureus.74752.
14. Brinda EM, Rajkumar AP, Enemark U, Prince M, Jacob KS. Nature and determinants of out-of-pocket health expenditure among older people in a rural Indian community. Int Psychogeriatr. 2012;24(10):1664–1673.
15. Vikram Jit Singh, Vandana Roy, Shubha Singhal, M.K. Daga. Pharmacoeconomics of medicines used for geriatric individuals in a tertiary care hospital in Delhi. Indian Journal of Medical Research. February 2024; 159(2): p 143-152,.DOI: 10.4103/ijmr.ijmr_2507_21
16. Pathak V, Haldar P, Kant S, et al. Predictors of out-of-pocket expenditure on health incurred by elderly persons residing in a rural area of Faridabad district. Cureus. 2023;15(4):e37626. doi: 10.7759/cureus.37626.