The burden is great and the money little: Changing chronic disease management in low– and middle–income countries

Abstract

Many health conditions are chronic, and only some of those chronic health conditions are NCDs. If the interest is on cause and prevention, then NCDs should be treated separately from other chronic diseases. If the interest is on health systems and management, then NCDs should be joined with other chronic
diseases.

Full text

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www.jogh.org • doi: 10.7189/jogh.02.020301 1 December 2012 • Vol. 2 No. 2 • 020301
Agenda item 117 of the 66th session of the United
Nations General Assembly was a watershed for
global health. It marked the adoption by the Gen-
eral Assembly on the 16th of September 2011 of the politi-
cal declaration of the High–level Meeting of the General
Assembly on the Prevention and Control of Non-commu-
nicable Diseases [
1
]. The adoption placed non-communi-
cable diseases (NCDs) center stage for global health. To
reach that point required a signicant amount of scientic
and political effort, rst to convene the High–level Meeting
on NCDs, and then to have the declaration adopted by the
UN General Assembly. The historical time–line leading up
to this achievement is punctuated by reective pieces in a
number of journals, but dominated by a series in The Lan-
cet [
2-8
].
One of the interesting features identiable in the time–line
is a shift in vocabulary between late 2010 and early 2011
– a period that is bisected almost exactly by the publication
of an article, also in The Lancet, identifying “chronicity” as
the future issue for health systems [
9
]. Up until late 2011
the NCDs discussion had
more often than not used
the vocabulary of chronic
diseases rather than NCDs,
with reference to a typical
set of non-communicable
diseases that were chronic
in nature, including cardio-
vascular diseases (mainly
heart disease and stroke),
some cancers, and type 2 di-
abetes [
2,3
]. Occasionally
The burden is great and the money little:
Changing chronic disease
management in low– and
middle–income countries
Daniel D. Reidpath, Pascale Allotey
other conditions such as mental health conditions, respira-
tory conditions, injury and such like would appear in the
narrative. The main conditions, however, were those that
might be described using a nomenclature of “diseases of
lifestyle”, related to choices made about smoking, exercise,
and macro– and micro–nutritional content of food [
10-13
].
The shift in vocabulary may have just been whimsy, but it
probably reected a wish to classify the diseases of interest
by their causes rather than by their effects or health systems
consequences (long term management) [
14
]. The global
burden of NCDs is signicant, and will affect low– and
middle–income countries most [
15
]. As a strategy, there is
no doubt that the greatest future health gains in the area of
NCDs are going to be made through prevention – which
requires an understanding of causation – and might then
support the vocabulary shift. Prevention strategies will have
to be multifaceted, but may include trying to effect indi-
vidual behaviour change [
16,17
], change in industrial be-
haviour [
18
] or change in the environment [
19
]. Making
the changes is non-trivial: it will in many cases be harder
for lower income countries
to implement; it will take
time to make the changes;
and even when the interven-
tions are successful, there
will still be a substantial
number of people who will
contract non-communicable
diseases. The health burden
of NCDs will grow for the
foreseeable future; it will
have a real impact on the
Many health conditions are chronic, and only
some of those chronic health conditions are
NCDs. If the interest is on cause and preven-
tion, then NCDs should be treated separately
from other chronic diseases. If the interest is
on health systems and management, then
NCDs should be joined with other chronic
diseases.
School of Medicine and Health Sciences, Monash University, Sunway Campus, Malaysia

VIEWPOINTS
health and non-health budgets of governments; it will have
an impact on the GDP of countries; and it will have to be
managed.
Without diminishing the primacy of prevention in global
health, in this article we want to focus on the practicalities
of the management of chronic diseases. Note again the shift
from the NCDs vocabulary back to chronic diseases. This
is intentional and pointed. If one is interested in under-
standing causes and prevention strategies it is important to
separate the NCDs from other chronic diseases; however,
if one is interested in the effects of the diseases, particular-
ly on the health systems, then it is equally important to join
the NCDs with other chronic diseases [
9,14
]. Many health
conditions are chronic, and only some of those chronic
health conditions are NCDs. Even after the inclusion –
along with the core non-communicable diseases of cardio-
vascular disease, cancer, and diabetes – the respiratory con-
ditions, mental health conditions, the arthritides, and
functional loss and disability, there is a group of other dis-
eases that are all chronic in nature. These are the commu-
nicable, infectious diseases that either have no cure, simply
ongoing management (HIV/AIDS) or they have a cure, but
the cure takes an extended period of 6 months treatment
or more (tuberculosis and onchocerciasis – with some
hope, following recent trials, that a shortened 2–week
course may be feasible for tuberculosis treatment [
20
]). The
commonality is chronicity – the temporal nature of the
conditions requires an extended relationship with the
health system, including quite probably an extended nan-
cial relationship.
Most low– and middle–income health systems have been
designed for the management of maternal and neonatal
mortality, and acute phases of infectious diseases such as
malaria, respiratory tract infections, and diarrhoeal diseas-
es [
21
]. “Receive them, Revive them, and Return them”
could have been the motto emblazoned over the entrance
gates to most health services in low and middle income
countries. The system – beyond a record of immunisation
or antenatal visits – has not traditionally needed to have a
memory of the patient. For epidemiological purposes re-
cording health systems interactions is important, but not
central to the case management. For the acute diseases the
diagnosis drives most of the decision process. In the man-
agement of chronic diseases, the diagnosis is known early
in the patient–system relationship, and the ongoing strat-
egy revolves around maintenance, monitoring, encourage-
ment, and compliance (with acute services when neces-
sary). This requires that a relationship is built with the
client. However, a health system designed to deliver longi-
tudinal management of a chronic health condition is dis-
tinctly different from one designed for the management of
serial acute episodes.
The two main issues that arise when contemplating health
systems' management of chronic diseases are structure and
nancing. Unfortunately, the research base for establishing
evidence for action is thin. We return to the lack of research
shortly. There is, however, little doubt about the nancial
impact of an increasing chronic disease burden on the in-
dividual, the family, and the health system. Under current
health systems arrangements, the nancing of chronic dis-
ease management in the population is costly, and at a na-
tional level costs will increase with rising prevalence [
22
].
One possibility is that the costs will be carried by individ-
uals through out of pocket payments, which in low– and
middle–income countries will often have catastrophic con-
sequences for families [
23
]. Alternatively, costs could be
carried by government, but few low– and middle–income
countries could manage the entire nancial burden, or
some mixture of insurance, out of pocket payments, and
government support.
With respect to the individual and family impact, quotes
published in a recent article on catastrophic health care
spending related to acute coronary syndrome in Kerala pro-
vide good examples [
23
]:
“I am not sure how long I can take my medicines. I have a cred-
it account with the local pharmacy. They also help me out with
samples from medical representatives. I cannot be a charity case
forever, can I?”
and
“Right now, I am staying with one of my sisters, so that I don’t
have to pay rent, water or electricity charges. My other sister
has cut all ties with me. She fears that I will become a burden
on her and her family.”
Both these quotes came from the same 50–year–old male
patient and highlight individual and family collective nan-
December 2012 • Vol. 2 No. 2 • 020301 2 www.jogh.org • doi: 10.7189/jogh.02.020301
The two main issues that arise when contem-
plating health systems' management of chron-
ic diseases are structure and financing. Our
interest is in the observation that the manage-
ment of any chronic condition entails a com-
mitment to recurrent costs, which reduces the
flexibility of health systems to respond to new
demands. It also requires that a health system
that traditionally has a poor relationship with
the population beyond acute management
becomes more responsive to changes in the
population health profiles. Such a system will
be harder for poorer countries to manage than
richer ones.

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cial burdens. The disease reduced his daily earning from
US$ 17 per day to US$ 0.7 per day, and required an in-
crease in expenditure to cover health care (although some
was available through charity).
The impact on health systems, particularly health systems
already stretched will be marked. In Kenya, the national
government believes that the prevalence of type 2 diabetes
in the population was around 10% in 2008, although “of-
cial statistics note a diabetes prevalence of 3.5%.” [
24
].
Under some fairly loose assumptions, one can imagine that
in that 6.5% prevalence gap between what is believed and
what is ofcially acknowledged, there is a fairly large group
of people with insidious diabetes that is damaging their
eyes, kidneys, and vascular system. For this chronic disease
alone, the Kenyan government would be anticipating 10%
of their population should be under clinical management
(in 2008). Unlike treating a respiratory tract infection, the
nancing of diabetes management is a recurrent cost be-
cause of the chronic nature of the disease. Whence will that
money come?
At the moment, 61% of the total health spending in Kenya
goes to another chronic disease – HIV [
25
]. For that level
of spending, antiretroviral coverage for 61% of HIV posi-
tive people in need of treatment has been achieved; mean-
ing that 39% of people in need of treatment are missing out
[
26
]. The commitment to provision of HIV treatment to
those in need entails an expansion of services, and an in-
creasing recurrent annual nancial commitment that will
not reduce in the near future. Indeed, given some of the
evidence on antiretroviral resistance, one might imagine
the cost will rather increase [
27
]. Furthermore, the more
successful one becomes at management, the greater the
number of people under management, the longer they will
live, and the greater the recurrent costs.
The purpose here is not to pit one disease against another
and argue for the greater worthiness of one group of pa-
tients over another. The chronic communicable diseases
and the chronic non-communicable diseases often have an
interacting pathophysiology – and the management of one
supports the management of the other. Both diabetes and
HIV increase the likelihood of contracting TB [
28
]. Having
diabetes increases the likelihood of chronic kidney disease,
and chronic kidney disease increases the chance of heart
failure [
29
]. Our interest is in the observation that the man-
agement of any chronic condition entails a commitment to
recurrent costs, which reduces the exibility of health sys-
tems to respond to new demands. It also requires that a
health system that traditionally has a poor relationship with
Photo: Courtesy of Dr Kit Yee Chan, personal collection
www.jogh.org • doi: 10.7189/jogh.02.020301 3 December 2012 • Vol. 2 No. 2 • 020301

VIEWPOINTS
the population beyond acute management becomes more
responsive to changes in the population health proles.
Such a system will be harder for poorer countries to man-
age that richer ones. The World Health Organization has
suggested that [
22
]:
“In order for low– and middle–income country health systems
to expand individual health–care interventions [for chronic dis-
eases], they need to prioritize a set of low–cost treatments that
are feasible within their budgets. Many countries could afford a
regimen of low–cost individual treatments by addressing inef-
ciencies in current operations for treating advanced–stage
NCDs. Experiences from maternal and child health and infec-
tious disease initiatives show that health priorities can be rear-
ranged and low–cost individual treatments improved with only
a modest injection of new resources.”
Identifying inefciencies and cost–effective interventions
to improve health systems performance is laudable. Such
a strategy will not, however, overcome the fundamental
bottleneck. Health systems were never designed to treat
20% or more of a country's population as if they had a dis-
ease all the time. Take two middle–income countries as ex-
amples. In South Africa, the prevalence of HIV in adults is
about 18% [
30
], diabetes is about 13% [
31
], and hyperten-
sion is 10% [
32
]. In Malaysia, the prevalence of diabetes in
adults is about 15%, and 25% among one of the ethnic
groups, the prevalence of hypertension is about 32% [
33
].
It is not enough to nd cost–effective strategies for indi-
vidual management. A fundamental rethink is required
about how population health is managed when a substan-
tial and growing proportion of the population has a chron-
ic disease. We do not have the evidence base for that.
One approach to developing the evidence base is through
“community health laboratories”. Essentially, within a trac-
table, geographically dened area, such as a county or dis-
trict, health systems innovation can be tested and moni-
tored [
34
]. Assuming that the entire population has been
enumerated, and their health status and health systems in-
teraction can be followed over time, it becomes possible to
measure the impact of health systems innovations on vari-
ous dimensions of health systems performance. Using these
kinds of community settings, governments can look at im-
plementation within the contexts of real lives and function-
ing communities. This is particularly important in environ-
ments where people employ pluralistic health care engaging
multiple belief systems simultaneously, utilising both gov-
ernment and private providers. These community based
research environments are particularly well suited to low–
and middle–income countries.
In Malaysia, a new health and demographic surveillance
site, the South East Asia Community Observatory (SEACO),
is being established with the intention of being able to trial
health systems innovation relevant to chronic disease man-
agement [
35
]. There are in excess of 40 health and demo-
graphic surveillance sites in the world, mainly located in
low–income countries in sub–Saharan Africa [
34
]. They rely
on enumerating and then following–up the population over
time. The raison d'être of HDSS has been in the management
and prevention of acute health conditions associated with
vaccine trials, maternal and child health, malaria, diarrhoe-
al diseases, and HIV. Chronic diseases have emerged rela-
tively recently within the scope of HDSS, and no sites had
been established with this as a theme of interest. SEACO
has been established with chronic diseases prevention and
management as a central theme in its development. Unusu-
ally, it is also one of only two HDSS in middle–income coun-
tries.
The value of settings like SEACO is that they sit between
the unrealistically controlled setting of an experimental tri-
al – focused on the individual and uninterested in the con-
textual effects – and a completely realistic, unmonitored,
community setting in which context is everything, but the
impact of change cannot be measured or assessed. Low–
and middle–income countries, faced with a growing chron-
ic diseases problem will need to rethink how they deliver
health care – and even what it may mean to deliver health
care – but they also need an evidence base on which to
make systems changes. The evidence generated through
SEACO–like infrastructure has the potential to provide
novel, yet realistic, models of prevention and health care
management within the real life context of low– and mid-
dle–income countries. With the growing chronic diseases
problem this evidence base and new ways of thinking are
critical to making long term, sustainable systems change.
Funding: None.
Authorship declaration: DDR and PA jointly wrote the manuscript and approved the nal version.
Competing interest: The authors have completed the Unied Competing Interest form at www.icmje.
org/coi_disclosure.pdf (available on request from the corresponding author) and declare no nancial re-
lationships with any organizations that might have an interest in the submitted work in the previous 3
years; and no other relationships or activities that could appear to have inuenced the submitted work.
December 2012 • Vol. 2 No. 2 • 020301 4 www.jogh.org • doi: 10.7189/jogh.02.020301

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Correspondence to:
Daniel D. Reidpath
Global Public Health
Jeffrey Cheah School of Medicine and Health Sciences
Monash University, Sunway Campus
Bandar Sunway, Malaysia
daniel.reidpath@monash.edu
December 2012 • Vol. 2 No. 2 • 020301 6 www.jogh.org • doi: 10.7189/jogh.02.020301