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RES E AR C H Open Access
The economic burden of diabetes in India: a review
of the literature
Charles AK Yesudian
1
, Mari Grepstad
2
, Erica Visintin
2
and Alessandra Ferrario
2,3*
Abstract
Background: Diabetes and its complications are a major cause of morbidity and mortality in India, and the
prevalence of type 2 diabetes is on the rise. This calls for an assessment of the economic burden of the disease.
Objective: To conduct a critical review of the literature on cost of illness studies of diabetes and its complications
in India.
Methods: A comprehensive literature review addressing the study objective was conducted. An extraction table
and a scoring system to assess the quality of the studies reviewed were developed.
Results: A total of nineteen articles from different regions of India met the study inclusion criteria. The third party
payer perspective was the most common study design (17 articles) while fewer articles (n =2) reported on costs
from a health system or societal perspective. All the articles included direct costs and only a few (n =4) provided
estimates for indirect costs based on income loss for patients and carers. Drug costs proved to be a significant cost
component in several studies (n =12). While middle and high-income groups had higher expenditure in absolute
terms, costs constituted a higher proportion of income for the poor. The economic burden was highest among
urban groups. The overall quality of the studies is low due to a number of methodological weaknesses. The most
frequent epidemiological approach employed was the prevalence-based one (n =18) while costs were mainly
estimated using a bottom up approach (n =15).
Conclusion: The body of literature on the costs of diabetes and its complications in India provides a fragmented
picture that has mostly concentrated on the direct costs borne by individuals rather than the healthcare system.
There is a need to develop a robust methodology to perform methodologically rigorous and transparent cost of
illness studies to inform policy decisions.
Keywords: India, Diabetes, Cost of illness, Economic burden, Out-of-pocket expenditure
Background
Diabetes is one of the leading causes of morbidity and
mortality worldwide [1-3] and a major problem in India.
In 2012, 60% of all deaths in India were due to non-
communicable diseases (NCDs), including ca rdiovascu-
lar diseases (26%), chronic respiratory diseases (13%),
cancer (7%), diabetes (2%) and other NCDs (12%) [4,5].
Currently accounting for 43% of total disability adjusted
life years (DALYs), the prevalence of NCDs is expected
to increase in the coming years due to ongoing large-
scale urbanisation and increasing life expectancy [3].
The prevalence of diabetes in 2013 in India is only
slightly higher than the world average (9.1% vs. 8.3%
worldwide) [3]. However, due to its very large popula-
tion, India has the world? s largest population living with
diabetes after China. In 2013, there were 65.1 million
people between 20 and 79 years of age with diabetes and
this number was predicted to rise to 109 million by
2035. The growing epidemic of type 2 diabetes in India
has been highlighted in several studies [6-9].
Studies have shown large regional and socioeconomic
differences in the prevalence of type 2 diabetes in India.
Self-reported prevalence is lower in rural areas than in
urban areas ranging from 3.1% in rural areas to 7.3% in
* Correspondence: a.ferrario@lse.ac.uk
2
LSE Health, London School of Economics and Political Science, Houghton
Street, London WC2A 2AE, UK
3
Social Policy Department, London School of Economics and Political
Science, Houghton Street, London WC2A 2AE, UK
Full list of author information is available at the end of the article
? 2014 Yesudian et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Yesudian et al. Globalization and Health 2014, 10:80
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urban areas [10]. The disease appears to be more preva-
lent in the south of the country as compared to the
northern and eastern parts [11]. However, the absence of
large well-planned national studies on diabetes preva-
lence have led to incomplete and unreliable nationwide
data on the prevalence of diabetes in India [6].
Financing and delivery of health care in India has been
left largely to the private sector [12]. In 2012, public
health care funding was lower in India than other countries
in the region, with a general government funding for health
accounting for 33% of total health expenditure in India com-
paredtoanaverageof52%intheSouthEastAsiaregion
[13]. Nevertheless, at 4% of India? s gross domestic product
(GDP) the share of health expenditure is equivalent to the
average of the South East Asia region [14].
At the 56
th
World Health Assembly in Geneva in
2012, universal health coverage was identified as essen-
tial to consolidate public health advances [15]. While
various health programmes and policies have previously
attempted to achieve universal health coverage in India,
there is still a long way to go. In 2010, only about 19
percent of the population (240 million people) was cov-
ered by the country? s centr al and state government-
sponsored health insurance [16]. When including private
insurance and other schemes, some 25 percent of the
population (300 million people) was covered [16]. Thus,
the financial burden of health care falls heavily on indi-
viduals with the government contributing to one third of
total health spending and out-of-pocket payments repre-
senting about 58% of total health spend in 2012 [13].
The assessment of the e conomic and social impact of
diabetes in India is imp ortant for several reasons. First,
India is considered the diabetes capital of the world [17],
yet not enough is done to tackle the disease. An article
published in 2007 suggests that an estimated USD 2.2
billion would be needed to sufficiently treat all cases of
type 2 diabetes in India [18]. In comparison, health
spending per capita in 2012 was USD 61 [19]. Second,
by 2025, most people with diabetes in developing coun-
tries will be in the 45 to 64 year age group, thus threat-
ening the economic productivity of the country and the
income-earning ability of individuals [20]. Third, the
management of diabetes and its complications can be
expensive, which poses serious obstacles to the strength-
ening of the Indian health care system and the Govern-
ment? s plan to achieve universal health coverage by
2022.
As the burden of diabetes on total health care spend-
ing is likely to increase and, potentially, will have im-
portant consequences on the sustainability of health care
financing, this study presents a critical review of the lit-
erature on cost of illness of diabetes and its complica-
tions in India and also makes recommendations on areas
requiring further attention and research.
Methods
A comprehensive literature review of the direct and indirect
costs of diabetes in India was conducted in October 2014
following the Preferred Reporting Items for Systematic Re-
views and Meta-Analyses (PRISMA) [21] guidelines.
Search strategy
Searches were performed for all papers published up to
18 October 2014 in relevant databases (PubMed, Web of
Science and Scopus). Reference lists in the articles in-
cluded in the review were searched to identify further
eligible articles.
Search terms
Search terms and their combinations are presented in
Table 1. Databases were searched using the primary term
? India? in combination with one term associated with dia-
betes and complications from diabetes (column 2, Table 1)
and one term associated with costs (column 3, Table 1).
Inclusion criteria
Papers were included if they provided original research
findings on the cost (direct and indirect) of diabetes and
its complications in India, were written in English and
met the inclusion criteria following the PICOS approach,
adapted to meet the needs of the review [22]. We did not
include cost-benefit, cost-effectiveness, cost-minimisation
and cost-utility analyses. The population considered con-
sisted of people diagnosed with type 1 or 2; the contexts
of interest were hospitals, clinics, and home settings in
India, outcomes comprised direct and indirect costs for
health systems, households and individuals; and, the rele-
vant study designs were randomised controlled trials
(RCTs), cohort and observational studies and surveys.
Critical review of the data and quality of the studies
The review included articles reporting on the economic
burden of diabetes using both quantitative and qualitative
methods to elicit information on costs. In conducting our
Table 1 Search terms
Combined with
(individually)
Combined with
(individually)
India diabetes expenditure
diabetic expenses
? diabetic complications? cost
neuropathy ? economic burden?
nephropathy
? renal replacement?
? chronic kidney?
? diabetic foot?
? diabetic ulcer?
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analysis, we have developed two extraction tables in two
different Excel spreadsheets [23] in which the data was
summarised. In the first one, we used predefined categories
such as the year published, the research objectives, the
methods and the sample characteristics for each article. Rele-
vant findings were classified using a framework developed to
guide the analysis of retrieved cost data (Table 2). Historical
conversion rates from www.xe.com/currencytables/ were ap-
plied to report on cost estimates in both INR and USD
throughout the article.
In the second spreadsheet we listed a number of tech-
nical criteria for a sound cost of illness study (COI). The
quality indicators wer e selected based on criteria pro-
posed by previous reviews and good practice guidelines
[24-27] and adjusted in accordance with specific features
of diabetes. Following data extraction, a score of either
0, 0.5 or 1 was assigned for each quality indicator. This
led to a maximum obtainable score of 17.
An indicator was assigned the score of 1 if the quality
and the appropriateness of the parameter were high, a
score of 0.5 was assigned in the case quality parameter
was only partially met and a score of 0 was assigned if
there was no information on the particular parameter
(unless a logical reason justifying the lack of this infor-
mation was provided).
All the details of the parameters employed are pre-
sented in Table 3.
Findings
A total of nineteen studies met the inclusion criteria.
The flow of information through the different phases of
the re view is depicted in Figure 1.
A summary of the main features of the studies in-
cluded is presented in Table 4. Eighteen studies were ob-
servational studies of which twelve were cross-sectional,
four were cohort longitudinal and two were case control
studies. Only one study was a RCT.
Sixty-three percent of the studies dealt with the gen-
eral costs of diabetes while 21% focused only on diabetes
complications, including diabetic foot wound (DFW)
and chronic kidney disease, and 16% of the studies ana-
lysed the cost of a specific drug for the treatment of dia-
betes (Figure 2).
The study samples varied from 50 to 5,516 individuals,
and from local, regional, cross-regional to national studies.
A summary of the studies reviewed is presented in
Table 5.
With regards to the type of diabetes analysed, most
studies (n =11) considered the cost of diabetes mellitu s
type 2, six studies considered the costs of both, only one
study focused on the cost of diabetes mellitus type 1 and
one study did not clearly define the type of diabetes con-
sidered (Figure 3).
Different types and perspectives of costs
Overall, the majority of the studies included only direct
costs in their evaluation (n =14), 4 studies included dir-
ect and indirect costs and only one study included dir-
ect, indirect and intangible costs (Figure 4).
Most studies (17 studies) report on the costs to the in-
dividual, while only two studies report on costs for the
health system.
Health system perspective
Both studies using a health system perspective reported
costs for consultations and medicines [31,38] and drug
costs [31,38]. Studies reported that the costs to hospitals
and other health providers constitu ted only a small part
of total diabetes costs. In the study on ambulatory dia-
betes care in northern India, the authors found that the
mean cost borne by the hospital over a six-month period
was 2.83% of the total direct costs. No study reflected on
indirect costs from a societal perspective, although one
study provided annual societal indirect costs at INR
15,376.30 (USD 393.25) [38].
Direct costs
Direct costs were investigated in all the reviewed studies.
Detailed costing data for these studies are provided in
Table 6. The most common cost item reported on was
drug costs (12 studies), followed by hospital related costs
(11 studies), consultation costs (11 studies), laboratory
costs (10 studies) and transport costs. Less common cost
items were surgery cost s (3 studies), monitoring costs
(2 studie s) and food costs (2 studies). In six studies
providing estimates for cost components as well as
total costs , drug cost s accounted for more than half of
the total dire ct costs [31,34,36 ,40,41,43,47]. A study
from Delhi reported that the average annual direct cost
of type 2 diabetes was INR 6,212.4 (USD 143.14) in
Table 2 Classification of costs and economic impact on individuals and society
Economic impact on individual and household Economic impact on health sector and economic sector
Direct costs Hospital, transport, drug costs, foods Direct costs (health sector) Inpatient care, outpatient care (GPs, district
hospitals, pharmacy), long-term care
Indirect costs Loss of income associated with
morbidity, mortality and disability
Indirect costs (economic sector) Costs due to absenteeism, permanent disability
and mortality
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Table 3 Quality indicators for cost of illness studies
General
Objective of the study Cost of drugs: studies that aim to calculate the cost of a specific drug
General Costs: studies that aim to calculate direct or indirect costs for the
diabetes in general, for ambulatory care or for a specific subgroup.
Cost of Complication: studies that aim to calculate the cost of a specific
complication of diabetes.
How is the disease defined? Diabetes type 1/Diabetes type 2/ Gestational diabetes
Is the definition clear and precise? 1 = the definition of the type of diabetes considered is clear and all the
morbidities and co-morbidities considered are listed. 0 = the definition is vague
and do not include any details of all the morbidities and co-morbidities
considered
Which complications the authors have included? 1 = more than 4 complications are considered and specified.
0,5 = up to 3 complications are considered for each patient but they are not
specified.
0 = no complications are considered or if they are considered there is no clear
documentation in their inclusion.
Is a clear epidemiological definition provided? The type of diabetes studied is specified
SAMPLE
Which is the population sample considered? Description of the population considered by the study.
Is the population selected appropriate? The sample size is sufficiently large and the epidemiological characteristics of the
population are in line with the objectives of the study. For example, a large
national assessment of diabetes requires a large sample with a balanced
population composition in terms of social class, the gender and other factors such
as the education level. For a study focused on the costs of drug an appropriate
sample could be small but should be focused on a particular health history of
patients.
Are sources for population data reliable? 1 = self-assessment and questionnaire are confirmed by hospital records or
hospitals and practitioners? bills.
0,5 = The only sources of data are questionnaire and self-assessment.
0 = The sources of data are not defined or are subject to a number of biases.
The period of evaluation is appropriate? A period of evaluation is considered appropriate if is equal or more than
6 months for prevalence- based studies and consider more than 1 year for
incidence based studies.
COSTS
Direct costs: All resource costs employed to treat patients with diabetes (care and/or
assistance). It includes medical and non-medical costs.
Indirect costs: All the costs associated with the loss of productivity resulting from morbidity and
mortality caused by diabetes.
Intangible costs: All the costs associated with all the negative effects caused by the disease leading
to deterioration in the quality of life of patients (e.g. isolation, anxiety, pain).
Healthcare costs
People with the health condition Premiums and levies paid to collectively financed healthcare systems;
out-of-pocket costs of healthcare services and products; transport costs related to
treatment; home and car modifications; special diets; domestic care; lost income
for unpaid leave to attend treatment.
Others, including family members Premiums and levies paid to collectively financed healthcare systems;
out-of-pocket costs of healthcare and domestic services and products and home
and car modifications for sick family members.
Healthcare system (public and private) Hospitals; primary care services; nursing homes; pharmaceuticals; domiciliary care;
rehabilitation; home nursing; medical specialists; general practitioners; community
healthcare services; ambulance services; paramedical services; specialist
equipment; diagnostic tests; training; research; infrastructure; equipment;
preventive programmes; administration
Business/industry/employers (includes government
employers)
Premiums and levies paid to collectively financed healthcare systems; preventive
programmes
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Table 3 Quality indicators for cost of illness studies (Continued)
Government (excluding health care system) Specialist equipment/infrastructure modifications; community support services;
residential support services; preventive programmes (e.g. education and training)
Other resource use
People with the health condition Legal representation; childcare
Others, including family members Damage to property (e.g. for substance abuse, smoking), crime-related costs
(e.g. for substance abuse)
Healthcare system (public and private) None
Business/industry/employers (includes government
employers)
Worker replacement costs (recruitment, training, retraining); cost of implementing
and adhering to regulation and legislation
Government (excluding health care system) Regulation, inspection and monitoring; child welfare services; disability support
services; courts services; police services; prison services; emergency/fire services;
cost of administering additional taxes, levies and benefits.
Production losses
People with the health condition Lost income due to unpaid sick leave (absenteeism), treatment related time off
work, temporary unemployment, reduced on-the job productivity (? presenteeism? ),
premature retirement through morbidity or early mortality, unwanted job
changes, loss of opportunities for promotion and education; loss of unpaid
production while ill.
Others, including family members Loss of income and unpaid production while caring for sick family members and
friends.
Healthcare system (public and private) None
Business/industry/employers (includes government
employers)
Lost paid and unpaid output due to sickness (absenteeism for paid output),
treatment-related time off work, temporary unemployment, reduced capacity,
reduced on-the job productivity (? presenteeism? ), work injury, premature
retirement through morbidity or early death
Government (excluding health care system) None
Intangible costs
People with the health condition Quality of life (health, functioning, psychosocial impacts, including loss of leisure
time), premature loss of life
Others, including family members Psychosocial costs related to family members? suffering; Quality of life lost
providing care to family members
Healthcare system (public and private) None
Business/industry/employers (includes government
employers)
Employee morale
Government (excluding health care system) Deadweight loss of additional taxation
Appropriateness
Does the study include the relevant costs? 1 = the costs included are relevant for the objective of the stud. (minimum of 80%
of the costs included in the section costs of this table)
0,5 = the inclusion of the costs is partial
0 = there are missing a large number of costs that should be included or there is
no specification of the costs included
Are the inclusion of the costs appropriate for the objective of
the study?
1 = considering the aim, all the necessary type of costs are included. (for ex for
the evaluation of direct costs of a drug treatment all the costs borne by the
patients directly and by the health care are included)
0,5 = Only partial relevant costs are included. There are missing of some important
costs related to the aim of the study.
0 = Although the study aim is to consider a general costs of diabetes or a costs of
drug or complications there are included only a category of costs (for ex direct
costs).
Has the Diabetes severity Index been used? 1 = Yes
0=No
Is adequate documentation and justification given for cost
components, data and sources, assumptions and methods?
1 = detailed justifications are given for all the approach and methods adopted.
The exclusion and inclusion of categories of cost and data are well motivated. All
the sources are documented.
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Table 3 Quality indicators for cost of illness studies (Continued)
0,5 = partial justification is given for the methods and approach adopted. There is
limited or absence of justifications for the inclusion or exclusion of costs. The
documentation is scarce and not precise.
0 = absence or minimal presence of documentation and justification
Are important limitations discussed regarding the cost
components, data, assumptions and methods?
1 = all the most important limitations are discussed. In same cases some minor
limitation is discussed.
0,5 = one or only not important limitations are discussed.
0 = there is no discussion around the limitations of the study.
METHODS
Which is the epidemiological approach employed? A) Prevalence-based: estimates the total cost of a disease in a given population
for a given period. (Static)
B) Incidence-based: estimates the potential averted costs if new (incident) cases
are prevented. (Dynamic)
Is the data representative of the study population? 1 = prevalence-based
0, 5 = Incidence based
0 = no definition of the approach considered
Which approach in quantification of the costs were used? A) Top-down approach refers to aggregate data available at national level, and
involves a process of relating the overall health care spending to the individual
diseases. From a methodological point of view to estimate the costs with the
top-down method is crucial an excellent databases.
B) The bottom-up approach refers to the direct consumption of resources,
including epidemiological data, the cost of individual factors and the costs by the
product, the average consumption of resources and its price/cost.
Was the approach appropriate? 1 = bottom-up approach.
0,5 = top down.
0 = no approach defined/ or impossibility to infer the approach employed
Which is the method used to evaluate the value of health? A) Human Capital approach (generally recommended)
B) Friction Costs approach.
C) Willingness to pay.
How is used the discount? Discounting is an economic method that captures an individual? s preference for
income today rather than income in the future. This time preference is often
explained by the opportunity-cost of interest. Income earned today can earn
interest through investment.
Is the approach appropriate? Discounting is relevant for direct and indirect costs and health outcomes that accrue
past the first year.
How are estimated the costs and health outcomes ? A) Total disease costs: estimating of the total health-care expenditure of people
diagnosed with diabetes.
a) Sum_All Medical costs: Identify all patients with a diagnosis and sum costs
b)Sum_Diagnosis Specific: Identify all patients with a primary diagnosis and sum
costs for treatments for that diagnosis
B) Incremental costs: estimating the increase in costs that is attributable solely to
the presence of the diabetes:
a) Matched Control: Identify all patients with a diagnosis and sum cost. Subtract
out the average cost of the sample to find incremental costs for treatment;
alternatively, subtract out the average cost of a matched cohort instead
b) Regression_Method: Identify all patients with a diagnosis, complete a
regression analysis and indicate the individual β for each diagnosis
Identify all patients with a diagnosis, find a matched cohort (similar to a clinical
trial) and complete a regression analysis to quantify the individual β for each
diagnosis ? gold standard
Is the estimation method of the cost of diabetes
appropriate?
1 = Incremental costs method.
0,5 = Total disease costs
0 = no methods designed or impossibility to retrieved a clear method from the study.
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Table 3 Quality indicators for cost of illness studies (Continued)
Are the deviation standard and the means calculated? 1 = both, standard deviation and Means are calculated. 0,5: only one of them
is calculated. 0: none of them is calculated
Is a sensitivity analysis performed? 1 = the sensitivity analysis is performed and the results are clearly shown.
0,5 = some linear regression method are employed to correlate the variables
0 = no sensitivity analysis or linear regression are performed.
If yes, is it performed on: 1) Important (uncertain) parameter estimates
2) Key assumptions
3) Point estimates
Which statistical methods are used 1 = the statistical analysis is performed with consistent statistical formulas. The
formulas used should non-parametrical statistical hypothesis test.
0,5 = the statistical analysis is performed but only with few statistical tools.
0 = no statistical methods are used.
Figure 1 Flow chart of the study selection process.
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2005, of w hich more than half w ere drug costs (INR
3,324; USD 76.5 9) [34]. Similarly, a study from north -
ern India on diabetes type 1 and 2 reported a total dir-
ectcostofINR4,966(USD114.4)oversixmonthsin
2005
a
; 62% of the total direct cost were drug costs
(INR 3,076; USD 70.88) [31] Table 6.
Indirect costs
Indirect costs of diabetes and its complications were re-
ported in four studies. A study from northern India reported
a total INR 2,087 (USD 48.09) indirect costs over a six-
month period in 2005
a
. Patient income loss accounted for
61% of the total indirect cost (INR 1,263, USD 29.10) while
the remainder 39% (INR 823, USD 18.96) was due to in-
come loss of the carer [31].
Socioeconomic burden of diabetes
Several studies investigated differences in costs as related to
one or several demog raphic and socioeconomic parameters
by looking at levels of income, education and occupational
status, and by comparing costs in rural and urban popula-
tions [30,31,34,36,43,48]. Several studies found that lower
income groups generally spent a larger proportion of their
income on diabetes care, that urban populations spent
more in absolute terms, and that cost of complications
weighed hea vily on overall costs.
Within the diabetes population, low income individ-
uals bear the highest burden of diabetes [40]. A study on
type 2 diabetes in se ven states in India during the period
Table 4 Study characteristics of included articles
Ref Author Year Study design Diabetes type Type of complication Sample size Data collection period Region
[28] Abdi et al. 2012 RCT 1 and 2 350 *** Southern India
[29] Adiga et al. 2010 CS 2 238 2008 Karnataka
[30] Bjork et al. 2003 CS 1 and 2 5516 Jan-Sep 1999 National
[31] Grover et al. 2005 COH 1 and 2 50 *** Northern India
[32] Joshi et al. 2013 CS 2 166 Feb-Apr 2010 Punjab
[33] Kuchake et al. 2010 CS 2 163 Jul 2009- Feb 2010 Maharashtra
[34] Kumar et al. 2008 COH 2 819 2005 Delhi
[35] Kumpatla et al. 2013 CC 2 368 Jun 2008-dec 2009 Chennai
[36] Ramachandran et al. 2007 CS 2 556 1998 - 2005 7 states
[37] Rao et al. 2011 CS ** 1858 Jan - Jun 2004 National
[38] Rayappa et al. 1999 CS 1 and 2 611 1997 - 1998 Bangalore
[39] Shivaprakash et al. 2012 COH 1 and 2 200 2005 and 2010 Mangalore
[40] Shobhana et al. 2000 CC 2 270 Jan - Jun 1998 Chennai
[41] Shobhana et al. 2002 CS 1 209 Jan - Oct 2000 Chennai
[42] Shobhana et al. 2000 CS 2 596 1999 Chennai
[43] Tharkar et al. 2010 CS 2* 718 Aug -Dec 2009 Chennai
[44] Akari et al. 2013 COH 1 and 2 150 Feb-July 2012 Hanamkonda
[45] Satyavany et al. 2014 CS 2 209 Aug 2008- Jan 2010 **
[46] Tharkar et al. 2009 CS 2 443 Oct- Dec 2007 **
CC = Case Control Study CS = Cross Sectional Study, COH = cohort study, RCT = randomised controlled trial.
*The study does not clearly state whether it refers to diabetes type 1, type 2 or both. We assume type 2 diabetes as the articles references refer to type 2
diabetes studies.
**The information is not provided in the study.
***Year of data collection could not be identified. Year of publication utilised as proxy.
Figure 2 Study objective.
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Table 5 Main cost data of reviewed studies
Ref Author Year of
data
INR per USD Health system costs INR (USD current
value/USD 2014 value)/person
Individual/household costs INR (USD current value/USD 2014
value)/person
Direct Indirect Direct Indirect
[28] Abdi et al. 2012* 53.06 Drug consumption (DDD
1
/100 bed days)
13.42 (0.25) (0.26)
[29] Adiga et al. 2008 39.41 Annual costs of consultations and drugs
19,076.07(484.04/535.14)
[44] Akari et al. 2012 53.06 Average cost for patient with diabetes
complication (including costs of drugs,
consultations, hospitalisation, (314.15/325.69),
without (29.91/30.17)
[30] Bjork et al. 1999 42.49 Total costs, annual (drugs, monitoring,
check-ups, hospitalisation) 7,159
(168.49/240.73)
[31] Grover et al. 2005* 43.40 Total costs over 6 months (incl. consultations,
investigations, nursing, infrastructure)
205.55(4.74/5.78)
Total costs over 6 months (incl. drugs,
food, travel) 4,966.42 (114.43/139.47)
Total costs (income loss,
patient and caregiver)
2,086.74(48.08/58.60)
[32] Joshi et al. 2010 46.61 Cost per consultation 166 (3.56/3.89)
[33] Kuchake et al. 2010 46.61 Cost per consultation 116.85 (2.51/2.74)
[34] Kumar et al. 2005 43.40 Total costs per year (incl. consultations,
tests, drugs, monitoring) 6,212.4
(143.14/174.76)
2
[35] Kumpatla
et al.
2009 48.76 Total cost without complication 4,493
(92.15/102.24), with complication(s)
15,280 (313.37/347.69)
3
[36] Ramachandran
et al.
2005 43.4 Total costs (incl. drugs, tests, consultations,
hospitalisation, surgery, median) 8,130
(187.33/228.32)
5
[37] Rao et al. 2004 45.60 Costs per hospitalisation 5925(136.5/172)
[38] Rayappa et al. 1999 39.10 Annual societal costs (incl. routine,
monitoring, tests, hospital) 1,305.20
(33.38/47.69)
Annual societal
costs 15,376.30
(393.25/561.86)
Annual costs (incl. routine, monitoring,
tests, hospital) 15460.40 (395.41/564.95)
Annual costs 3,572.5
(91.37/130.55)
[45] Satyavany
et al.
2010 46.61 Total annual costs for a patient with Kidney
problems associated with diabetes: 392,920
(8450/9224.06)[transplantation]; 61,170
(1,315/1435.46) [dialysis]; 12,664(272296.62)
[CKD stages]; 3,214 (69/75.32)[without
complications]
[39] Shivaprakash
et al.
2005 43.40 Cost per consultation 363(8.36/10.19)
[40] Shobhana
et al.
1999 39.1
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Table 5 Main cost data of reviewed studies (Continued)
Costs during 6 months (incl. consultation,
surgery, hospitalisation, tests, drugs,
transport)12,055(308.31/440.50
6
[41] Shobhana
et al.
2000 Values for both currencies as
provided in the article
Total annual costs (including drugs, tests,
consultation, hospital, transport) Inpatient
15,596(331.8/468.65), Outpatient
8,578(200.7/277.3)
[42] Shobhana
et al.
1999 42.49 Total annual costs (incl. drugs, tests,
consultation, hospital, surgery, transport)
private hospital 4,510 (106.1/151.59),
public hospital 246 (5.8/8.29)
[43] Tharkar et al. 2009 48.76 Total annual costs (incl. consultation, drugs,
investigation, transport, food, miscellaneous,
accommodation for alternate caregiver,
management) 25,391 (520.73/577.76)
[46] Tharkar et al. 2007 44.11 Total costs hospital admission during 2 years
(Incl. drugs, investigations, miscellaneous,
admin), without comorbidities 28,000
(634.78/728.73), with comorbidities 38,000
(861.48/988.99)
Notes: USD current refers to the value reported in the study, USD 2014 it the value adjusted to 2014 price levels using http://www.bls.gov/data/inflation_calculator.htm.
CKD: Chronic kidney disease; INR: Indian rupee.
*Year of data collection could not be identified. Year of publication utilised as proxy.
1
DDD: defined daily dose.
2
Total costs per year are averaged between male and female.
3
Values for patients with complications are average of 5 groups: renal, cardiovascular, foot, retinal, two complications.
4
Values are average of treatment arms: human insulin and blood, glucose monitoring, bovine insulin and blood glucose monitoring, bovine insulin and urine glucose monitoring.
5
Values are average of urban and rural population.
6
Values are average of outpatients and hospital patients with foot problems.
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1998 to 2005 found spending to be higher among the
urban than the rural population both in absolute terms
and as a proportion of income. This was due to higher
expenditure on medical consultations , laboratory tests
and drugs, which the authors attributed to the use of
more expensive treatments in urban areas (which have
remained unavailable in rural areas). Also , in lower-
income groups spending was higher in the urban than
the rural population, possibly because awareness of dia-
betes care was better among the urban poor [36]. A
Chennai-based study in 1999 compared costs for type 2
diabetes in public and private ins titutions and found
that individuals seeking care in private hospitals w ere
economically better off, and that fam ili es who could af-
ford it preferred private pr ovis ion over st ate- funde d
care a s the public hospitals were crowded and the staff
overworked [42]. A study from Banga lore with cost
data from 1997 and 1998 fou nd that uneducated, un-
employed people in semi-urban or rural area s were
more likely to be diagnosed later as they could not af-
ford to consult a doctor, and therefore developed com-
plications [38]. Treatment costs were found to be
significantly higher in those who were more educated
in a study from northern India [ 43]. Patients with less
than five year of education spent INR 398.66 (USD 9.19),
while those with more than five years education spent
INR 2,810.20 (USD 64.77).
Complications
Sixty-nine percent of the studies include d complications
in their evaluation of the cost of diabetes. Only 32% of
the studies [29,33,40,45,46] have specified the type of
complications included while 37% of the studies only
identified the presence of a number of complications
(1 to 3) without spe cifying the type (Figure 5).
Studies considering diabetes complications indicated
that they weighed heavily on the overall costs. For ex-
ample, the number of complications per patient was found
to be positively correlated with the patient? shealthcareex-
penditure [30,36]. However, no significant urban/rural dif-
ferences were found in the prevalence of complications of
diabetes [36]. Studies argued that any measure to reduce
hospitalisation costs would sharply reduce the economic
burden for households and society, and increase patients?
quality of life [30]. Further, that substantial cost savings
could be achieved by focusing on provision of care in out-
patient settings [40].
Two studies compared costs of diabetes care for pa-
tients with and without complications [35,46]. A study
from Chennai reporting on costs from 2008 and 2009
found that total costs for patients without complications
were INR 4,493 (USD 92.15) compared to INR 14,691.75
(USD 301.32) for patients with complications
b
[35]. Among
the different types of complications investigated, foot com-
plications incurred the highest costs; patients with foot
complications spent four times more than patients with no
complications. Patients with renal disease, cardiovascular
and retinal complications spent three times more than
those without complications. Co nsultation and hospital isa-
tion costs were especially high for patients with
Figure 4 Costs included.
Figure 3 Type of diabetes considered.
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Table 6 Costing items and estimates per person in studies reporting on direct cost of diabetes for individuals and households INR (USD current value)
Ref Drug Test/investigation Monitoring Transport Hospitalisation Consultation Surgery Food
[33] Cost per consultation
116.85 (2.51)
[34] Costs per year 3,324.45 (76.60) Costs per year 1803.35 (41.55) Costs per year 322.75
(7.44)
Costs per ye ar 87 5.85
(20.18)
2
[35] Costs without complications
800 (8.20), with complications
1,960 (40.20)
3
Costs without
complications
300(6.15), with
complications
830 (17.02)
3
Hospital charges
without complications
1,083 (22.21), with
complications 5,256.4
(107.80)
3
Costs without complications
350 (7.18), with complications
1,085 (22.25)
3
[36] Median c osts at 3,250 (74.88)
6
Median costs at 1,000 (23.04)
6
Median costs at 8,000
(184.33)
6
Median costs at 800 (18.43)
6
Median costs
13,750 (316.82)
6
[37] Costs per hospitalisation
5,925 (136.5)
[29] Annual costs, 18,623.94 (472.57) Annual costs, 452.13 (11.47)
[38] Annual monitoring
and lab costs 822.6
(21.04)
Annual costs 8,678.6
(221.96)
[39] Cost per consultation
363(8.36)
[40] Costs during 6 months 3,000
(76.7)
7
Costs dur ing 6 m ont hs 1,4 35
(36.70)
7
Costs during
6 months 225
(5.75)
7
Costs dur ing 6 m ont hs
3,650 (93.4)
7
Costs during 6 months
1,900 (48.59)
7
[41] Annual costs Inpatient 6,840
(145.5), Outpatient 6,150 (130.8)
Annual costs Inpatient 630
(13.4), Outpatient 400 (8.4)
Annual costs 5,000 (106.3) Annual GP and specialist
costs Inpatient 550 (11.5),
Outpatient 420 (8.8)
[42] Annual costs, private hospital
3,000 (70.6), public 735 (17.3)
Annual costs, private hospital
360 (8.5), public hospital
240 (5.6)
Annual costs, private
hospital 240 (5.6),
public hospital
192 (4.5)
Annual costs private
hospital 5,000 (117.7),
public hospit al 0.0
Annual GP and specialist
costs, private hospital 600
(14.12), public hospital 670
(15.7)
Annual costs
private hospital
9,000 (211.8)
[43] Annual costs Hospital 1,500
(30.76)
Annual costs, hospital 2,250
(46.14), ambulatory 1,050
(21.53)
Annual costs, hospital
600 (12.30), ambulatory
202 (4.14)
Annual costs, hospital 550
(10.37), ambulatory 320 (6.56)
Annual costs,
hospital
600 (12.30),
ambulatory
190 (3.89)
[46] Average cost per hospitalisation,
without comorb. 184 (4.17),
without comorb. 2,098 (47.56),
outpatient without comorb. 456
(10.34), with comorb. 488 (11.06)
Average cost per hospitalisation,
without comorb 903 (20.47), with
comorb 968 (21.94), outpatient
without comorb. 373 (8.46), with
comorb. 405 (9 .18)
Cost per hospital
admission, without
comorb. 18650 (422.80),
with comorb. 2,1000
(476.08)
[45] Transplantation 40,400(869);
dialysis 7250 (156); CKD 1,500
(156); No complications 800 (17)
Transplantation 64,925 (1.396);
dialysis 2800 (60); CKD 3,625 (78);
No complications 1,214 (26)
Transplantation 3,250
(70); dialysis 3480 (75);
CKD 625(13);
No complications 300(6)
Transplantation 21,5000
(4,624); dialysis 22,000
(473); CKD 4,010(86);No
complications 1,082(23)
Transplantation 67,000
(1,441); dialysis 32,200
(692); CKD 1,000 (121);
No complications 350 (8)
Total c ost for
Transplantation
392,920 (8,450)
[44] Average per patient 1,598 (29.45) Average cost per patient
7,800 (143.75)
Average cost per patient
2,191 (40.37)
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Table 6 Costing items and estimates per person in studies reporting on direct cost of diabetes for individuals and households INR (USD current value) (Continued)
Average per patients: Without
complications 380 (7) with
complications 3,769 (69)
[31] Costs during 6 months 3,076.28
(67.46)
Costs dur ing 6 m ont hs 27 7.8 0
(6.09)
Costs during 6 months
458.96 (10.04)
Costs during
6 months 72.66
(1.59)
[30] Annual costs 2,435 (57.31)
Totall
1
12 10 2 6 11 11 3 2
1
Total number of studies addressing the costing item.
2
Values are aver ages between male and female.
3
Values for patients with complications are average of 5 groups: renal, cardiovascular, foot, retinal, two complications.
4
Values are average of treatment arms: human insulin and b lood, glucose monitoring, bovine insulin and blood glucose monitoring, bovine insulin and urine glucose monitoring.
5
Values are average o f treatment groups: teleophthalmology (screening), hospital ( dilated ret inal examination), hospital (laser photocoagulation). We assume costs are yearly estimates.
6
Values are average o f urban and rural population.
7
Values are average of outpatients and hospital patients with foot problems.
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complications (on a verage INR 1,085 (USD 22.25) for con-
sultation costs and INR 5,256.4 (USD 107.80) for hospital
costs compared to patients without complications INR 350
(USD 7.18) for consultation costs and INR 1,083 (USD
22.21).
Quality analysis
The analysis focused on the key elements necessary to
perform a good cost of illness analysis. Most of the studies
(n =11) scored less than 10 on 17 points scale. Interestingly,
the remaining 8 studies reached a score slightly higher, with
amaximumscoreof13.5.Themedianscorewas9.5.
Overall studies lacked an accurate and precise defin-
ition of the disease, with only 4 articles referring to
WHO definition of diabetes, and only 3 studies gave a
clear definition of the type of diabetes considered.
Most studies developed their research over an ad-
equate period, usually of 6 months, while two studies
did not specify the timeframe.
Although we considered discounting in the qualitative
table, we have not accounted for it as a quality element
for two main reasons. First, the prevalence-based studies
considered a time short-term horizon and the need to
apply a discount rate is the subject of an on-going de-
bate [27]. Second, for incidence-based studies, the ap-
propriate approach for calculating the discount is still an
unsettled matter in the literature [49].
The majority of the studies (84%) considered an appro-
priate number of patients or household for the purpose of
their study objective. The benchmark employed is based
on the work of Krathwohl, which provides a number of
questions to individuate if the sample is appropriate in
comparison with the purpose of the study [50].
The remaining 16% of the studies consider samples
that either are too small or do not state the size of the
sample considered. Further, it is important to note that
the majority of the studies only considered the middle
and high-income portion of the Indian population due
to the difficulties involved in collecting data on the low-
income classes.
All studies used a questionnaire, or a survey, to collect
the data based on self-assessment of illness and costs. In
addition, 12 out of 19 studies validated the reliability of
the self-assessment against hospital bills and clinical re-
cords retrieved directly from the hospitals or practitioners.
The se cond part of the quality analysis considered the
appropriateness of the various types of costs that each
study included. The appr opriateness of cost inclusion
was benchmarked against the study objectives and the
minimum requirements for a sound cost of illness study
according to intern ational best practice [27,51]. Only
52% of the studies included the appropriate costs, both
in terms of their objective and in terms of minimal re-
quirements for a sound cost of illness analysis. In one
case, it was not possible to assess the relevance and the
appropriateness of the costs included due to a lack of in-
formation on data sources and categories of cost.
In terms of methods, most studies lacked sufficient details
on the methods used. In particular, 42% of the studies did
not specify how costs were estimated. Only 32% of the stud-
ies adopted the incremental costs method, which is the most
appropriat e for diabetes, and only 4 studies mentioned the
use of either matched control (n =2) or regression method
[24] (F igure 6).
Results indicate that the prevalence-based approach,
with a bottom-up quantification of the costs, was the most
common method used to conduct cost of diabetes studies
in India. Notably, 16 studies employed a prevalence-based
approach and measured diabetes attributable costs that
occurred concurrently with prevalent cases over a speci-
fied time period, usually 6 months (Figure 6).
A bottom-up approach was used in 15 studies by assign-
ing costs to individuals with diabetes based on clinical
practice data.
Regarding the evaluation of uncertainty, the majority
of the studies did not perform any type of analysis. In
fact, only one study performed a sensitivity analysis and
3 studies conducted linear or multivariate regressions.
Figure 5 Complications included.
Figure 6 Cost estimation methods.
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In addition to inconsistencies regarding the type and
extent of information provided on methods, a discussion
of limitations was largely absent (Figure 7). 50% of the
studies did not mention any limitation, while 11% men-
tioned only one minor limitation, such as related to the
size of the sample (n =2). Only 39% of the studies pro-
vided a comprehensive discussion of the limitations of
the cost components, data, assumptions and research
methods.
Regarding the statistical methods employed, 14 studies
performed the necessary statistical analysis for a good qual-
ity study. The majority employed the student t-test to deter -
mine the statistical significance and the Wilcoxon matched
pair signed-rank test to verify the validity of the data. A
number of studies employed the Chi-square test and per-
centage value to validate their data. A large number of stud-
ies used the statistical package SPSS to analyse the data.
Two studies state the presence of statistical analysis.
However, they did not identify whic h statistical formulas
had been used. One study even declared that it had not
performed any kind of any statistical analysis at all.
11 studies presented the standard deviation along with
the mean estimate while 4 studies included only the
mean.
Discussion and recommendations
With the population of people living with diabetes pre-
dicted to rise above 109 million by 2035 [17], there is an
urgent need to act at all levels of authority in India, and
with additional coordination at the national level. Fur-
ther, there are several specific areas in which policy
makers could concentrate efforts to reduce the impact
of the economic burden of disease.
Firstly, the economic burden falls heavily on patients and
their families and requires better health care coverage.
There is a need to mitigate the serious adverse effects of
high out-of-pocket expenditure, including impoverishment
of catastrophic spending and cost of complications. To this
end, efforts, such as the expert group set up by the Plan-
ning Commission of India to achieve universal health
coverage by 2022 [52] need to be considered in order to in-
crease coverage and pool healthcare costs across the popu-
lation. Policies aiming to strengthen health systems are
also essential in this process.
Secondly, high costs and suboptimal access to drugs
contribute significantly to the burden of the disease and
should be addressed through market shaping strategies.
While hospitalisation and complications are major com-
ponents of the costs of diabetes, drug costs constitute an
important part of the expenses, often representing more
than 50% of total direct costs for households. A study
based on a large dataset, found that drug costs accounted
for 58% of out? of-pocket expenditure on diabetes [53].
Another study on drug costs as share of expenses paid out
of pocket by quintile group revealed progressive private
spending on health, with the poorest spending 75.42 per-
cent on drugs, compared to 65.9 percent spent on drugs
by the richest in 2009? 10 [12]. By further comparison,
studies of diabetes in Western countries shows that drug
costs constitute a much lower share of total direct health
expenditure on diabetes, ranging from 6.2 percent to 10.5
percent [54,55] in Europe and 12 percent in the United
States [56]. In addition to better drug coverage for individ-
uals, Indian authorities, together with the international
community, should aim to employ market-shaping mech-
anisms to increase the access of medicines in India. Poor
procurement procedures and weak supply chain systems
are major barriers to access to medicines in Indi a, con-
tributing to low competition, low quality, high price
and variable availability of drug s [ 12]. P ooled drug
procurement of essential medicines between several
Indian states ha s proven efficient for essential medi-
cines [ 57], and should therefore be considered for
medications for diabetes and related drugs.
Thirdly, lower expenditure among the rural and
low income population may be due to issues of ac-
cess and affordability rather than lower need [6], and
late dete ction of the disease in these settings often
leads to catastrophic spending for individual s and
households [38]. Early detection and treatment pro-
vided in outpatient settings has been identified as an
important means for cost reduction [30,40] and
should thus be strengthened. Socioeconomic differ-
ences and the urban? rural divide suggest divergence
in disease outcomes. In other words , the relatively
wealthier population living in urban areas spend
more on diabetes care and have better outcomes ,
while relatively poorer p eople living in rural areas
tend to have more difficulties accessing diabetes care,
and therefore spend less o n diabetes care and tend to
have worse health outcomes [58]. Mobile health
Figure 7 Limitations discussed.
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units, which can increa se access in remote areas ,
may h elp mitigate these socioeconomic differences.
With regards to the methodological quality of the
studies considered, only a few of the studies adhered to
recognised standards of methodological quality, which
utilised a transparent methodology, and thus provided
credible results.
The aim of COI is to identify, measure and value the
resources consumed by a disease in order to determine
not only the total cost, but also all the elements and
methods used to design the analysis itself [24]. However,
the majority of the studies failed to achieve this aim due
to a lack of solid methodology.
First of all, the lack of both a clear definition and
foundation in the literature, or justifications for apply-
ing new approache s , for the methods employed affe ct
the reproducibility of the studies. Notably, the total costs
were often calculated without providing a detailed list of
unit costs and resource consumption was also rarely de-
scribed. In addition, the majority of the studies lacked of a
clear epidemiological definition of diabetes which also lead
to comparability problems [59].
Secondly, the lack of a clear justification of the cost
component s and the data sources, together with the lack
of a discussion on the intrinsic limitations of the study,
produced doubts about the quality of the research. The
absence of these elements could either be indicative of
lack of accuracy of the study or even aimed at hiding
possible gaps and/or errors in the collection of data and
the calculations of costs [51].
To enhance the transparency of the cost of illness
studies, it appears fundamental to provide sufficient
documentation on data sources, assumptions and esti-
mation methods [51].
In terms of costs included, there are a numbe r of fac-
tors that could have led to possible biases in the estima-
tion of the economic burden of diabetes in India.
One of such factor is the absence, in the majority of
studies, of the cost of complication or a description of
complication profile of the included patients. In particu-
lar, studies failed to include health care utilisation costs
associated with chronic complications of diabetes, which
are usually the most expensive [59]. Indeed, according to
WHO [59] data and to a number of studies outside India
[60], the treatment of patient with diabetes for other
complications and comorbidities is a major source of the
increasing in the health care expenditure on diabetes.
The exclusion of the estimation of the intangible costs
and the loss of productivity leads to an underestimation
of diabetes. Loss in productivity for the patient or carers
was shown to represent up to half of the total costs of
diabetes [30]. Despite difficulties in their extraction and
quantification, both costs are important for a compre-
hensive calculation of the actual cost of the disea se,
which affects not only diabetes patients , but also their
families and the society [25,51]. The inclusion of intan-
gible costs is especially important in studies aiming to
give a general analysis of the burden of this disease in
the country or in a specific region.
In terms of perspective of analysis , the third party
payer is the most common perspective adopted in the
studies reviewed. The exclusion of the perspective of the
healthcare sector and the households as well as the gov-
ernments and local authorities excludes a number of key
costs, such administrative costs and personnel costs.
The implementation of a comprehensive and accurate
estimation of the cost of diabetes enables the use this
cost as both a baseline and a reference, which can help
to identify the programmes and strategies most effective
in reducing costs associated with diabetes [50].
From a methodological perspective, most studies used
a prevalence-based epidemiological approach and a bot-
tom up quantification of the costs method, both of
which are considered the most accurate and consistent
for the calculation of the burden of diabetes [25,51].
Nevertheless, they also lack of other major elements for
a complete COI.
The absence of an estimation of uncertainty in a large
number of the studies is an important limitation. Due to
the large number of uncertainties involved in a COI, it is
necessary to consider alternative values for all important
parameters and assumptions [50,51]. Therefore, it is ne-
cessary to conduct a proper sensitivity analysis [26,29,61].
Cost of illness studies are an important instrument for
informing and raising awareness among policy-makers
by providing economic information to support their de-
cisions. Further, results of this type of economic evalu-
ation are often used to justify the allocation of more
resources to prevent and treat a certain illness [26,39].
More efforts in designing study methodologies are ne-
cessary to improve the quality of studies on the cost of
diabetes in India.
Therefore, it would appear advantageous to develop
and implement standardised guidelines regarding the
conduct of comprehensive and accurate cost of illness
studies in India. Certainly, a well designed methodology
and an accurate computation and inclusion of all the
costs would enhance the COI validity as a policy tool.
Limitations
This review provides a fragmented picture of the eco-
nomic burden of diabetes in India. Given the heterogen-
eity of study designs and diversity of methods used in
the literature reviewed, we were unable to gener ate
meaningful aggregate data for meta-analysis purposes.
This heterogeneity also complicated the synthesis of the
papers , and comparisons should be treated with caution
due to the variability in study design and thematic focus.
Yesudian et al. Globalization and Health 2014, 10:80 Page 16 of 18
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Future studies should aim to explore optimal methodo-
logical study designs that may facilitate the production
of meaningful national estimates for meta-analysis.
Conclusion
This study has aimed to inform the discussion on the
economic burden of diabetes by reviewing the literature
on diabetes costs for individuals and society. We found
that most studies on the cost s of diabetes and its com-
plications in India have focused on the costs borne by
patients, both direct and indirect, and less evidence exist
on the economic burden for the health care system and
society. Three areas of concern were identified for policy
interventions. First, the heavy economic burden of diabetes
borne by individuals should be reduced via the improve-
ment of universal healthcare coverage. Second, market
shaping mechanisms should be considered to improve the
access to affordable medicines, which constitutes an im-
portant part of private costs. Finally, early disease detection
and treatments in outpatient settings provide cost saving
ways of tackling the disease.
As the epidemiological burden of diabetes increases,
the economic burden on households is expected to rise
and the economically disadvantaged will be the most af-
fected. Future initiatives to tackle diabetes type 1 and 2
should be grounded in evidence-based and integrated
strategies of prevention and disease management, and
implemented at all levels of authority. Cost of illness
analysis should be a basis on which strategies for miti-
gating the effects of this pervasive illness gain a higher
priority on the health policy agenda.
Endnotes
a
The authors do not provide the year of data collection
and the year of article publication is used as a proxy.
b
Values are averaged across the different types of
complications: rena l, cardiovascular, foot, retinal.
Abbreviations
CRF: Chronic renal failure; CKD: Chronic kidney disease; DALYs: Disability
adjusted life years; GDP: Gross domestic product; KT: Kidney transplant;
DFW: Diabetic foot wound; INR: Indian rupee; NCDs: Non-communicable
diseases; PRISMA: Preferred reporting items for systematic reviews and
meta-analyses; RCT: Randomised controlled trials; W HO: World health
organization.
Competing interests
AF received travel reimbursement and speaker fees from Novo Nordisk for
delivering two presentations on diabetes in EU5 at national diabetes
conferences in Portugal and Spain.
Authors? contributions
All authors contributed to the literature review and in the appraisal of the
retrieved information. CAKJ wrote the first draft, MG and EV analysed the
data and redrafted subsequ ent versions of the article with the input of AF
up to its final version. All authors contributed to the critical revision of the
article for important intellectual content and approved the final manuscript.
Acknowledgements
This study was funded by an unrestricted educational grant from Novo
Nordisk Switzerland. The authors would like to thank Ms Marsha Fu and
Danica Kwong for their editorial assistance.
Author details
1
School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai,
India.
2
LSE Health, London School of Economics and Political Science,
Houghton Street, London WC2A 2AE, UK.
3
Social Policy Department, London
School of Economics and Political Science, Houghton Street, London WC2A
2AE, UK.
Received: 29 January 2014 Accepted: 4 November 2014
References
1. Roglic G, Unwin N, Bennett PH, Mathers C, Tuomilehto J, Nag S, Connolly V,
King H: The burden of mortality attributable to diabetes realistic
estimates for the year 2000. Diabetes Care 2005, 28(9):2130? 2135.
2. Roglic G, Unwin N: Mortality attributable to diabetes: estimates for the
year 2010. Diabetes Res Clin Pract 2010, 87(1):15? 19.
3. International Diabetes Federation: IDF Diabetes Atlas 2014 update. http://www.
idf.org/diabetesatlas [Last accessed 16.11.2014]
4. World Health Organization. India NCD Country Profile 2014. 2014; Available
from: http://www.who.int/nmh/countries/ind_en.pdf [Last accessed 14.10.2014]
5. World Health Organization, Noncommunicable Diseases Country Profiles,
World Health Organization. 2014 http://apps.who.int/iris/bitstream/10665/
128038/1/9789241507509_eng.pdf [Last accessed 14.10.2014]
6. Anjana RM, Ali MK, Pradeepa R, Deepa M, Datta M, Unnikrishnan R, Rema M,
Mohan V: The need for obtaining accurate nationwide estimates of
diabetes prevalence in India-rationale for a national study on diabetes.
Indian J Med Res 2011, 133(4):369.
7. Shetty P: Public health: India? s diabetes time bomb. Nature 2012,
485(7398):S14? S16.
8. Yoon K-H, Lee JH, Kim JW: Epidemic obesity and type 2 diabetes in Asia.
Lancet 2006, 368(9548):1681? 1688.
9. Sadikot S, Nigam A, Das S, Bajaj S, Zargar AH, Prasannakumar KM, Sosale A,
Munichoodappa C, Seshiah V, Singh SK, Jamal A, Sai K, Sadasivrao Y, Murthy SS,
Hazra DK, Jain S, Mukherjee S, Bandyopadhay S, Sinha NK, Mishra R, Dora M, Jena
B, Patra P, Goenka K,DiabetesIndia:The burden of diabetes and impaired
glucose tolerance in India using the WHO 1999 criteria: prevalen ce of
diabetes in India study (PODIS). Diabetes Res Clin Pract 2004, 66(3):301? 307.
10. Mohan V, Mathur P, Deepa R, Deepa M, Shukla DK, Menon GR, Anand K,
Desai NG, Joshi PP, Mahanta J, Thankappan KR, Shah B: Urban rural
differences in prevalence of self-reported diabetes in India? The WHO?
ICMR Indian NCD risk factor surveillance. Diabetes Res Clin Pract 2008,
80(1):159? 168.
11. Gupta R, Misr a A: Review: type 2 diabetes in India: regional disparities.
Br J Diabetes Vasc Dis 2007, 7(1):12? 16.
12. Selvaraj S, Abrol D, Gopakumar KM: Access to Medicines in India. New Delhi,
India: Academic Foundation; 2014.
13. World Health Organization. Global Health Expenditure Database. General
government expenditure on health (GGHE) as % of THE
. 2012 [16.10.2014];
Available from: http://apps.who.int/nha/database/Select/Indicators/en.
14. World Health Organization. Global Health Expenditure Database. Total health
expenditure (THE) % Gross Domestic Product (GDP). 2012 [16.10.2014];
Available from: http://apps.who.int/nha/database/Select/Indicators/en.
15. World Health Organization. SIXTY-FIFTH WORLD HEALTH ASSEMBLY. GENEVA,
21? 26 MAY 2012 RESOLUTIONS AND DECISIONS ANNEXES. 2012 [16.10.2014];
Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA65-REC1/
A65_REC1-en.pdf.
16. La Forgia G, Nagpal S: Government-Sponsored Health Insurance in India: Are
You Covered?. Washington DC: World Bank Publications; 2012.
17. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE:
Global estimates of diabetes prevalence for 2013 and projections for
2035 for the IDF Diabetes Atlas. Diabetes Res Clin Pract 2013, 49.
18. Ramachandran A: Socio-economic burden of diabetes in India. J Assoc
Physicians India 2007, 55(L):9.
19. World Health Organization. Global Health Expenditure Database. Total
expenditure on health/capita at exchange rate. 2012 [16.10.2014]; Available
from: http://apps.who.int/nha/database/ViewData/Indicators/en.
Yesudian et al. Globalization and Health 2014, 10:80 Page 17 of 18
http://www.globalizationandhealth.com/content/10/1/80
20. World Health Organization. Diabetes mellitus. Fact sheet N?138 2014
[16.10.2014]; Available from: http://www.who.int/mediacentre/factsheets/
fs138/en/.
21. Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. J Clin
Epidemiol 2009, 62(10):1006? 1012.
22. CRD: Undertaking Systematic Reviews of Research on Effectiveness. CRD? s Guidance
for those Carrying Out or Commission ing Reviews . York: University of York; 2001.
23. Dixon-Woods M, Bonas S, Booth A, Jones DR, Miller T, Shaw RL, Smith J,
Sutton A, Young B: How can systematic reviews incorporate qualitative
research? A critical perspective. Qual Res 2006, 6(1):27? 44.
24. Akobundu EJu J, Blatt L, Mullins CD: Cost-of-Illness Studies. 2012.
25. Hodgson TA, Meiners MR: Cost-of-illness methodology: a guide to current
practices and procedures. Milbank Mem Fund Q Health Soc 1982, 60(3):429? 462.
26. Rice DP: Cost of illness studies: what is good about them? Inj Prev 2000,
6(3):177? 179.
27. Segel: Cost-of-Illness Studies ? a Primer. Research Triangle Park. Washington
DC: RTI International; 2006.
28. Abdi SAH, Churi S, Ravi Kumar YS: Study of drug utilization pattern of
antihyperglycemic agents in a South Indian tertiary care teaching
hospital. Indian J Pharmacol 2012, 44(2):210? 214.
29. Adiga S: Health care cost incurred by patients of diabetes mellitus in a
tertiary care hospital setting in coastal Karnataka district. J Glob Pharm
Technol 2010, 2(6):8? 12.
30. Bjork S, Kapur A, King H, Nair J, Ramachandran A: Global policy: aspects of
diabetes in India. Health Policy 2003, 66(1):61? 72.
31. Grover S, Avasthi A, Bhansali A, Chakrabarti S, Kulhara P: Cost of ambulatory
care of diabetes mellitus: a study from north India. Postgrad Med J 2005,
81(956):391? 395.
32. Joshi A, Mohan K, Grin G, Perin DM: Burden of healthcare utilization and
out-of-pocket costs among individuals with NCDs in an Indian setting.
J Community Health 2013, 38(2):320
? 327.
33. Kuchake V, Kumbhar P, Dighore P, Patil P: Comparison of lipid profile
pattern in obese and non obese type 2 diabetic patients and to study
the prescription pattern of antidiabetic drugs. Int J Pharm Sci Rev Res
2010, 4(3):53? 58.
34. Kumar A, Nagpal J, Bhartia A: Direct cost of ambulatory care of type 2
diabetes in the middle and high income group populace of Delhi: The
DEDICOM survey. J Assoc Physicians India 2008, 56(SEPTEMBER):667? 674.
35. Kumpatla S, Kothandan H, Tharkar S: The costs of treating long term
diabetic complications in a developing country: a study from India.
JAPI 2013, 61:17.
36. Ramachandran A, Ramachandran S, Snehalatha C, Augustine C, Murugesan N,
Viswanathan V, Kapur A, Williams R: Increasing expenditure on health care
incurred by diabetic subjects in a developing country: a study from India.
Diabetes Care 2007, 30(2):252? 256.
37. Rao KD, Bhatnagar A, Murphy A: Socio-economic inequalities in the
financing of cardiovascular & diabetes inpatient treatment in India.
Indian J Med Res 2011, 133(1):57? 63.
38. Rayappa: The economic cost of diabetes care the bangalore urban
district diabetes study. Int J Diab Dev Ctries 1999, 19.
39. Shivaprakash G, Akash, Nishith RS, Basu A, Pallavi S, Adhikari P,
Gopalakrishna HN, Rathnakar UP: Dispensing patterns and cost of glucose-
lowering therapies in diabetes mellitus patients at a tertiary care hospital
in Southern India. Drug Invent Today 2012, 4(12):671? 673.
40. Shobhana R, Rao PR, Lavanya A, Vijay V, Ramachandran A: Cost burden to
diabetic patients with foot complications? a study from southern India.
J Assoc Physicians India 2000, 48(12):1147.
41. Shobhana R, Rama Rao P, Lavanya A, Williams R, Padma C, Vijay V,
Ramachandran A: Costs incurred by families having Type 1 diabetes in a
developing country - a study from Southern India. Diabetes Res Clin Pract
2002, 55(1):45? 48.
42. Shobhana R, Rama Rao P, Lavanya A, Williams R, Vijay V, Ramachandran A:
Expenditure on health care incurred by diabetic subjects in a
developing country? a study from southern India. Diabetes Res Clin Pract
2000, 48(1):37? 42.
43. Tharkar S, Devarajan A, Kumpatla S, Viswanathan V: The socioeconomics of
diabetes from a developing country: a population based cost of illness
study. Diabetes Res Clin Pract 2010, 89(3):334?
340.
44. Akari S, Mateti UV, Kunduru BR: Health-care cost of diabetes in South
India: a cost of illness study. J Res Pharm Pract 2013, 2(3):114? 117.
45. Satyavani K, Kothandan H, Jayaraman M, Viswanathan V: Direct costs
associated with chronic kidney disease among type 2 diabetic patients
in India. Indian J Nephrol 2014, 24(3):141? 147.
46. Tharkar S, Satyavani K, Viswanathan V: Cost of medical care among type 2
diabetic patients with a co-morbid condition-Hypertension in India.
Diabetes Res Clin Pract 2009, 83(2):263? 267.
47. Miglani S, Goswami R, Tandon N, Dudha A, Kochupillai N: Glycaemic
control and microvascular complication among patients with youth
onset diabetes in India using differing types of insulin and methods of
glucose monitoring. Diabetes Res Clin Pract 2004, 65(2):183? 185.
48. Ramachandran R, Jha V: Kidney transplantation is associated with
catastrophic out of pocket expenditure in India. PLoS One 2013,
8(7):e67812.
49. Drummond M: Cost-of-illness studies: a major headache?
Pharmacoeconomics 1992, 2(1):1? 4.
50. Mauskopf JA, Sullivan SD, Annemans L, Caro J, Mullins CD, Nuijten M,
Orlewska E, Watkins J, Trueman P: Principles of good practice for budget
impact analysis: report of the ISPOR Task Force on good research
practices? budget impact analysis. Value Health 2007, 10(5):336? 347.
51. Larg A, Moss JR: Cost-of-illness studies: a guide to critical evaluation.
Pharmacoeconomics 2011, 29(8):653? 671.
52. Singh Z: Universal health coverage for India by 2022: a Utopia or reality?
Indian J Commun Med 2013, 38(2):70.
53. Mahal A, Karan A, Engelgau M: The economic implications of non-communicable
disease for India. Washington: World Bank; 2010.
54. Kanavos, P, van den Aardweg S, and Schurer W, Diabetes expenditure,
burden of disease and management in 5 EU countries. LSE Health Soc
Care, 2012 http://eprints.lse.ac.uk/54896/1/__libfile_REPOSITORY_Content_LSE%
20Health%20and%2 0Social%2 0Care_Jan%2 02012_ LSEDiabe tesReport2 6Jan2012 .
pdf [Last accessed 17.11.2014 ]
55. J ?nsson B: Revealing the cost of Type II diabetes in Europe.
Diabetologia 2002, 45(7):S5? S12.
56. Association AD: Economic costs of diabetes in the US in 2012. Diabetes Care
2013, 36(4):1033? 1046.
57. Chaudhury RR, Parameswar R, Gupta U, Sharma S, Tekur U, Bapna JS:
Quality medicines for the poor: experience of the Delhi programme on
rational use of drugs. Health Policy Plan 2005, 20(2):124? 136.
58. Singh, J., Economic Burden of Diabetes. In: Muruganathan A, Geetha T, editors.
Vol. 23. Medicine Update. Association of Physicians of India, India; 2013. p. 205? 8.
59. World Health Organization, Diabetes: the cost of diabetes: WHO Fact sheet
N?236. 2014. available at: http://www.who.int/mediacentre/factsheets/
fs236/en/ [ Last accessed on 02.10.2014]
60. Ettaro L, Songer TJ, Zhang P, Engelgau MM: Cost-of-illness studies in
diabetes mellitus. Pharmacoeconomics 2004, 22(3):149? 164.
61. Ament A, Evers S: Cost of illness studies in health care: a comparison of
two cases. Health Policy 1993, 26(1):29? 42.
doi:10.1186/s12992-014-0080-x
Cite this article as: Yesudian et al.: The economic burden of diabetes in
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