LIFESTYLE DISEASES: Access to Chronic Disease Care in Low- and Middle-Income Countries

Chronic, non-communicable diseases or chronic diseases,* such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes, have a considerable impact on human life and the economy. They shrink the quality of life in patients, cause premature death, and lead to other adverse consequences. These diseases have become the leading cause of mortality worldwide and were estimated to account for 60 per cent of global deaths -- 35 million -- in 2005. They are now rapidly emerging as major health burdens in low- and middle-income countries, where 80 per cent of global chronic disease deaths occur.1 Unfortunately, in resource-limited countries, policy makers, donors, and academics have paid less attention to these diseases than to acute, communicable diseases.2 Yet the increase in chronic diseases in low- and middle-income countries is more alarming than the previous epidemiological transition in industrialized, high-income countries. This sharp increase in the frequency of chronic diseases in developing countries has arisen within a relatively short period of time, and these countries are now faced with the burden of chronic diseases, in addition to the already existing burden of acute communicable diseases. The effect of chronic diseases on poor and disadvantaged populations in developing countries is of growing -concern as it could, in turn, widen the health gap between and within countries.3-6
Although the management of chronic diseases is well established, many patients, particularly those in low- and middle-income countries, do not have access to established treatment measures. In fact, "access to care" is a complex concept: its definition and measurement have been debatable. Geography, architecture, transport, and financial considerations, among others, were believed to be major factors influencing an individual's ability to access care. Recently, insurance coverage has become another important factor. However, merely residing close to healthcare facilities and health insurance coverage does not ensure access to chronic disease care. What complicates the situation with regard to chronic diseases is that its treatment is mostly lifelong.
Studies on access to diabetes care conducted in the Philippines and Viet Nam revealed that many patients diagnosed with diabetes encountered a variety of barriers to continued care. Even if there had been a general practitioner in the vicinity, the inability to undergo laboratory tests or purchase prescription medicines prevented the patient from accessing routine care. The high cost of medicine, poor procurement practice, and other interrelated causes had a direct impact on sustaining necessary patients' adherence to care. Social security systems, including public health insurance, did not have a stable mechanism to support patients for the ongoing care of diabetes. Inadequate knowledge of the disease was due to factors in both the patient and the provider's circumstances. 7,8
In providing access to chronic disease care, the following dimensions should be considered:
Physical accessibility -- whether patients can -easily reach healthcare providers like hospitals, clinics, -laboratories, and pharmacies
Availability of resources -- whether human and material resources at healthcare providers are actually present and in a functioning or usable condition
Affordability -- whether the out-of-pocket expenditures of patients are within their ability to pay
Acceptability -- whether patients clearly understand why, when, and how to seek care and whether they are -willing to do so
Barriers to each element are determined by stakeholders at different levels, such as government health policies, healthcare systems, healthcare providers, as well as patients. In every country, various barriers can be found, as shown by the studies undertaken in the Philippines and Viet Nam.
It is necessary to address the potential impact of the greater frequency of chronic diseases affecting populations in low- and middle-income countries. These diseases overburden the health system as well as the affected patients and their family members, and impede the overall development of a country. Every government should investigate the barriers preventing access to chronic disease care in their country as a crucial initial step in combating the emerging threat of these diseases. Strategies should be designed and employed to ensure the continuity of medical supply at an affordable price to all.


Notes

1 WHO, Preventing chronic diseases: a vital investment (Geneva: 2005).
2 R. Beaglehole & D. Yach, "Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults", Lancet 362(9387) (2003): p. 903-8.
3 J. Landers, "Historical epidemiology and the structural analysis of mortality", Health Transition Rev, 2(Suppl) (1992).: p. 47-75.
4 C.G. Mascie-Taylor, E. Karim, "The burden of chronic disease", Science, 302(5652) (2003): p. 1921-2.
5 A. Boutayeb, "The double burden of communicable and non-communicable diseases in developing countries", Transactions of the Royal Society of Tropical Medicine and Hygiene, 100(3) (2006): p. 191-9.
6 J.J. Miranda, et al., "Non-communicable diseases in low- and middle-income countries: context, determinants and health policy", Trop Med Int Health, 13(10) (2008): p. 1225-34.
7 M. Higuchi, Costs, availability and affordability of diabetes care in the Philippines. Foundation for Advanced Studies on International Development, 2009. http://www.haiweb.org/medicineprices/news/index.html
8 D. Beran, et al., Report on the Rapid Assessment Protocol for Insulin Access in Vietnam. (London: International Insulin Foundation, 2008). http://www.access2insulin.org/