the burden and cost of chronic diseases in lmics...the burden and cost of chronic diseases in lmics...
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![Page 1: The burden and cost of chronic diseases in LMICs...The burden and cost of chronic diseases in LMICs Dr Shanthi Mendis MBBS MD FRCP FACC Chronic Disease Prevention and Management World](https://reader034.vdocument.in/reader034/viewer/2022042420/5f386ff75b3a040d96596c3e/html5/thumbnails/1.jpg)
The burden and cost of chronic diseases in LMICs
Dr Shanthi MendisMBBS MD FRCP FACC
Chronic Disease Prevention and ManagementWorld Health Organization
Geneva, Switzerland
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Chronic NCDs in LMIC
Who is affected ?
What are the economic consequences?
Can interventions prevent at reasonable cost?
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10%
Low-income countriesGroup III - Injuries
Group II – Deaths from noncommunicable diseases Group I – Communicable diseases, maternal, perinatal and nutritional conditions
Global magnitude of deaths from noncommunicable diseases
0
10 million
20 million
30 million
40 million
50 million
60 million
70 million
18.0M
35.0M5.8M
31%
Total number of deaths (2004)
Source:
59%
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10%
Low-income countriesGroup III - InjuriesGroup II – Other deaths from non-communicable diseasesGroup II – Premature deaths from non-communicable diseases (below the age of 70), which are preventableGroup I – Communicable diseases, maternal, perinatal and nutritional conditions
0
10 million
20 million
30 million
40 million
50 million
60 million
70 million
18.0M
15.8M
5.8M19.2M
32%
31%
Total number of deaths (2004)
Source:27%
Global magnitude of deaths from noncommunicable diseasesProportion of premature mortality…
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Low-income countriesGroup III - InjuriesGroup II – Other deaths from non-communicable diseasesGroup II – Premature deaths from non-communicable diseases (below the age of 70), which are preventableGroup I – Communicable diseases, maternal, perinatal and nutritional conditions
0
10 million
15 million
20 million
25 million
High-income countries Upper middle-income Lower middle-income Low-income countries
1.9M
6.0M
6.1M
1.9M
Source:
Global magnitude of deaths from noncommunicable diseasesIn LMICs
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What is the magnitude in low- and middle-income countries?
Omitted from the MDGs:14.0 million premature deaths from non-communicable diseases
17.4 M
14.0 M
5.3 M
10 million
20 million
30 million
40 million
50 million
60 million
Total number of deaths in low- and middle-income countries (2004)
14.2 M
Low-income countriesGroup III - InjuriesGroup II – Other deaths from non-communicable diseasesGroup II – Premature deaths from non-communicable diseases (below the age of 70), which are preventableGroup I – Communicable diseases, maternal, perinatal and nutritional conditions
34%
28%
10%
28%
Source:
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Global Disease Burden in High/LMIC countries (DALYs thousands, 2004)
High Middle Low
CVD 17 853 76 204 57 258
Cancer 17 826 40 975 18 982
CRD 7 266 29 044 22 706
Diabetes 3 623 10 081 5 991
Total 122 092 572 859 827 669DALYs
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2005 2006-2015 (cumulative)
Geographical regions (WHO classification)
Total deaths
(millions)
NCD deaths
(millions)
NCD deaths
(millions)
Trend: Death from infectious
disease
Trend: Death from NCD
Africa 10.8 2.5 28 +6% +27%
Americas 6.2 4.8 53 -8% +17%
Eastern Mediterranean 4.3 2.2 25 -10% +25%
Europe 9.8 8.5 88 +7% +4%
South-East Asia 14.7 8.0 89 -16% +21%
Western Pacific 12.4 9.7 105 +1 +20%
Total 58.2 35.7 388 -3% +17%
Noncommunicable DiseasesDeath trends (2006-2015)
WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in LMIC.
(WH
O C
hronic Disease R
eport, 2005)
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Chronic NCDs
Who is affected ?Who is affected ?Who is affected ?
What are the economic consequences?
Can interventions prevent at reasonable cost?
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Why do we need to focus on costs?
• Advocacy for action• Cost data may justify public policy interventions• Health care should be distributed fairly according to
need and not ability to pay• Resources for health care are finite• Getting value for money is important in health care• Opportunity costs – spending in one area is lost to
other (more) important areas• Rationality – choices should maximize health gain at
lowest cost• Service planning
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Costs (partly overlapping evidence that illustrate the economic impact)
- Cost of illness - Microeconomic consequences - Macroeconomic consequences
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Cost of illness
Additional per person annual health care costs associated with risk factors
Obesity $395 (36% increase) Smoking $230 (21% increase Alcohol $150 (10% increase)
Sturm 2002
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Cost of illness
Chronic diseases and RF 02 -6.77 of GDPCVD in developed countries 1-3%Diabetes 1.8% GDP Venezuela, 5.9% GDP - BarbadosTobacco 1.5% of GDP - China Obesity 2.1% of GDP –China
Indirect costs account for more than half the costs
Barcelo et al 2003, Popkin 2001
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Summary of Total Costs During First Year After First-Ever-in-a-Lifetime Strokes That Occurred in Australia in 1997 (Dewey et al 1997)
3.922Out-of-pocket costs
528Carer time costs (opportunity cost approach)
634Rehospitalization for stroke complications
1163Nursing home care
27150Inpatient rehabilitation
28154Acute hospitalization
% of Total First-Year Cost
Cost, Australian Dollars(000,000)
Resource Category
15.7Outpatient rehabilitation
16Respite care
16Investigations (eg, pathology, radiology)
1.58Outpatient rehabilitation
1.810Ambulance transfers for acute care
317Community rehabilitation centers
3.218Hospitalization for recurrent stroke event
% of Total First-Year Cost
Cost, Australian Dollars(000,000)
Resource Category
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Microeconomic costs
Diabetes 15-25% of household income (India)Diabetes 25% of the minimum wage (Tanzania)Cancer hospital stay > annual per person income (China)
Shobhana et al 2001, Neuhann 2001.
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The cost of caring for a family member with diabetes can be more than 20 per cent of low-income household incomes
51%$427.046%3%5%8%39%Vietnam (2008)
21%$199.112%6%6%63%12%Zambia (2003)
7%$74.427%0%0%73%0%Nicaragua
(2007)
75%$273.661%9%1%24%5%Mozambique
(2003)
61%$339.412%7%8%34%38%Mali (2004)
% of per capita
Income
Total costTravelConsultationTestingSyringesInsulin
The cost per year of diabetes care at household level
The poorest people in LMIC countries affected the most
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Risk of catastrophic expenditure
Burkina Faso –When a family member has a chronic illness the probability of catastrophic exp 3.3-7.8 times (Tin Su 2006)
Share of households with catastrophic expenditure vary from 0.01% in France to 10.45 % in Vietnam (Xu et al 2003).
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Prevalence of daily smokers in the poorest and richest income quintiles in selectedlow- and middle-income countries
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Ratio of expenditures on tobacco versus education in Bangladesh, 1995–1996
Poorest households spend close to 10 times as much on tobacco as on education
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Source: Path Canada 2003
Monthly household expenditure of tobacco vs. nutritious food among street children in Mumbai (India)
Tobacco costs
186.1173.9
137.4119
109.8
61.948.5 43.6
020406080
100120140160180200
Gutkha
Cigaret
tes
Mutton
/ Chic
ken/
Beef
Paan with
toba
cco
Bidi Milk
Fruits
Eggs
Items Consumed
Avg
. Mon
thly
Exp
in IN
R
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30.1Tanzania
30311Russian Federation
311Pakistan
80.4Nigeria
2379India
55818China
493Brazil
Lost national income (billions)Lost national income (billions)Countries
2006-2015 (cumulative)2005Lost national income from premature deaths due to heart disease, stroke and diabetes
WHO: "Heart disease, stroke and diabetes alone are estimated to reduce GDP between 1 to 5% per year in developing countries experiencing rapid economic growth"
(WH
O C
hronic Disease R
eport, 2005)
Macro-economic Impact: Lost National Income
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14 million people die prematurely each yearin developing countries from non-communicable diseases
Loss of household incomefrom high cost of health care
Loss of household incomefrom unhealthy behaviours
Increased exposure to common modifiable risk factors:Unhealthy diets
Physical inactivityTobacco use
Harmful use of alcohol
Non-communicable diseases:Cardiovascular diseases
CancersDiabetes
Chronic respiratory diseases
GlobalizationUrbanization
Population ageing
Limited access to effective and equitable health-care services which respond to the needs of people with non-communicable diseases
Loss of household incomefrom poor physical status
Impact on socioeconomic development:Why are the poorest people in LMIC the most affected?
Populations in low- and middle-income countriesPoverty at household level
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Chronic NCDsInternal and external costs
Consumption and saving
Labour productivity and supply
Education and human capital accumulation
Health costs (morbidity and mortality)
Suhrcke M, Nugent RA, Stuckler, Rocco L 2006
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Parker (1999)0.38NSN0 of ADL for workersMexico (Elderly)
Schultz and Tansel(1997)0.09 – 0.28-Days unable to workCote d'Ivoire
Schultz and Tansel(1997)0.11 – 0.24-Days unable to workGhana
Espinosa and Hernandez(1999)
NS0.16Days sickNicaragua
Parker (1999)0.08NSDays sick or injured in last 180 days
Mexico (elderly)
Cortez (1999)0.200.10Days sickPeru (Urban only)
Murrugarra and Valdivia0.070.04Days sickPeru
Ribeiro and Nunez (1999)0.0170.10Unable to workColombia
Ribeiro and Nunez (1999)0.070.04Days unable to workColombia
SourceFor malesWage elasticities(%)(Females)
Chronic disease indicatorCountry
Change in wages associated with sickness due to chronic disease
When No of missed days increased by 1% wages decreased in men by 0.7%Savedoff et al 2000.
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-16.7Ukraine
-23.0Russia
-22.3Moldova
-18.8Kyrgyzstan
-30.4Kazakhstan
-6.9Georgia
-25.1Belarus
-16.3Armenia
Change(%)in the probability of labour-market participation
Country
Change in the probability of labour-market participation in response to limited ADL among countries in the
commonwealth of independent states
Eastern Europe and Central Asia probability that sick people will participate in the labour market 6.9%-30% lower
Suhrcke 2006
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Productivity losses of the worker’s company due to absenteeism caused by premature deaths or illness
Intra-household reallocation of labour (e.g., reduction in spouse’s labour supply in order to care for sick partner)
violence Diminished productivity and decreased wages Work absenteeism Early retirement Foregone income net of taxes Reduced labour supply (work absenteeism, early retirement, unemployment
Labour productivity and supply
Research, training, prevention, welfare Increased insurance premiums for those with healthy lifestyles Health insurance reimbursements Property damage (if other property affected) Covered sick loss Disability insurance Retirement pension and defined-benefit plans Taxes on earnings Group life insurance (death benefit)
Lost future income or other foregone long-term benefits from selling assets partly owned by other household members, or from dissaving (from common household resources) Property damage (e.g. fire due to smoking) Reduced household investment in productive assets
Medical expenditures: treatment for illness (user-paid insurance, out-of-pocket payments, co-payments) or Expenditure on addictive goods Lost future income or other forgone long-term benefits from selling assets or from dissaving Criminal justice response; unreimbursed property damage (e.g. due to fires caused by smoking) Uncovered sick loss Foregone income not replaced by disability insurance Defined pension contribution plans
Consumption and saving
EXTERNAL QUASI-EXTERNAL (costs to other household members)
INTERNAL
Costs - internal, quasi-external and external costs (and benefits) of chronic disease and unhealthy lifestyles (Manning 1991)
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Co-workers and others (e.g. environmental tobacco smoke in public places) Victims of alcohol-related traffic incidents Alcohol-related violence Diminished
Health of household members Pain and suffering of household members Domestic violence (alcohol) Health effect on the newborn child through maternal health behaviour and nutritional status, impact of death of the bread winner
Healthy life years lost Pain and suffering
Health costs / morbidity and mortality
Reduced educational and health attainment of those caring for the sick or substituting labour to compensate Crowding out of financial resources that could be invested in education and health of children Low birth weight of newborns with potential impact on cognitive development (e.g. through tobacco consumption in pregnancy) Reduced schooling through alcohol abuse in youth, impact of death of the bread winner
Reduced educational performance and attainment
Education and human-capital accumulation
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Chronic NCDs
Who is affected ?Who is affected ?Who is affected ?
What are the economic consequences?What are the economic consequences?What are the economic consequences?
Can interventions prevent at reasonable cost?
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10 year cardiovascular disease risk
05 10 15 20 25 30 35 40
% of World Population Present distribution
Optimal distribution
.
.
.
Population StrategyPopulation Strategy High Risk StrategyHigh Risk Strategy
Journal of Vascular Health and Risk Management 2005
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7-2331-4831-48Education and legislated salt reduction combined
9-1414-11434-78Legislated salt reduction
6-2710-9226-30Voluntary salt reduction
12-5419-9250-57Education and mass media
Medium income
Low incomeVery low income
Intervention
Cost per DALY saved for interventions to reduce BP and serum cholesterol by country income group
Murray et al 2003
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Cost to implement the package of interventions (US$ per person per year, 2005)
Asaria et al, Lancet 2007;370:2044-2053
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Average yearly cost (US$ per head) of scaling up a multidrug regimen for CVD prevention
Lim et al. Lancet 2007; 370: 2054–62
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Per capita expenditure on health (International dollars )
Less than 50 $ 50 – 99 100-499500-9991000-1999>2000
33 2572241918
Expenditure Number of countries
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NCDs• Cardiovascular disease• Chronic respiratory
disease• Diabetes• Prevention of renal
disease• Cancer• epilepsy etc
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Chronic NCDs
Who is affected ?
What are the economic consequences?
Can interventions prevent at reasonable cost?
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Summary• NCD are a major Public Health Problem in LMIC• Significant premature mortality• Cost of illness, micro and macroeconomic data illustrate the economic impact of NCD • Impact on the individual • Loss of household income • Pain/suffering due to loss of bread winner• Consumption and saving decisions• Labour market performance• Human capital accumulation• Detract economic growth • Cost effective population wide/ individual interventions available • Gaps in data in LMIC
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Thank You