Life-long burden

Chronic disease, health markets and poverty

The rise of chronic diseases, such as diabetes or heart disease, is strongly related to ageing populations, increased smoking, less physical exercise, and increased consumption of processed and fatty foods.

Chronic diseases are complex and expensive for patients, households, and health care providers to manage. A mix of behaviour change, self-care and medical treatment is required. Diabetes, for example, requires a continuous balance in terms of diet, physical effort and medication.

However, health services in low-income countries are mainly designed to deal with problems facing mothers and young children, and with curable infections. Most health workers do not have the skills or resources to treat chronic illnesses.

Recent surveys by the POVILL Consortium in China and Cambodia show that dealing with chronic disease places a high financial burden on households. Much of household expenditure is spent on substandard or unnecessary care. Households pay mostly out-of-pocket, and frequently sell assets or take loans, often with high interest rates. Based on cost-effectiveness analysis alone it is easy to conclude that curative care for chronic diseases is not a priority, as long-term treatment tends to be expensive and relatively ineffective.

Chronic diseases are complex and expensive for patients, households, and health care providers to manage

However, without intervention, the demand for the treatment of chronic diseases is escalating rapidly, especially in Asia and Latin America. Where government run-health services do not provide care for chronic diseases, private markets step in.

In Bangladesh, private pharmacies market lab tests and medicines for diabetes and other diseases. Accepting that chronic disease care is not cost-effective and consequently leaving it to unregulated health and credit markets, will continue to undermine the health of ageing populations, people’s livelihoods and poverty reduction efforts.

However, some demand-side interventions, such as those to inform and empower patients and communities, seem to yield promising results. Indeed, the challenge of lifelong coping with a chronic disease also creates new opportunities, for example through peer support and expert patients who become key decision-makers and advisers in their own and others’ treatment. Many HIV and AIDS support networks around the world, including The AIDS Support Organisation (TASO) in Uganda, have led the way. MoPoTsyo, an NGO in Cambodia, provides advice and information on diabetes and other non-communicable diseases. To date it has trained 18 educators who support 800 patients.

Whilst these empowerment initiatives offer promising results, they need links with reliable, affordable medical services to be fully effective and sustainable. Much can be done to stimulate such provision, through appropriate incentives and regulation, including public financing. There is a need to explore which bundle of demand-side, supplyside and social protection initiatives have the greatest promise in which contexts.

Until solutions are found, the burden of chronic disease will continue to fall largely on households, local communities and societies.

Wim Van Damme and Kristof Decoster

Institute of Tropical Medicine
Nationalestraat 155, B-2000
Antwerp, Belgium
wvdamme@itg.be
kdecoster@itg.be