The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

Diabetes care among urban women in Soweto, South Africa: a qualitative study

Background

Escalation of non-communicable diseases such as Type 2 diabetes among low-income populations in low- and middle-income countries presents challenges for health systems. Yet, very little is known about low-income people’s diabetes care experiences in such contexts. One of the greatest challenges of diabetes care in such contexts is providing care for those who face poverty, poor healthcare access, and concurrent physical and mental conditions. This article investigates women’s experiences with diabetes care in Soweto, a township of Johannesburg, South Africa.

Methods

This study involved caregivers for children enrolled in the Birth to Twenty (Bt20) cohort study initiated in 1990. Enrolled in the study for more than two decades, women previously diagnosed with type 2 diabetes were invited to participate. We conducted 27 in depth interviews around issues of stress, diabetes, mental health, and diabetes care. We transcribed interviews and used content analysis to analyze emergent themes into three categories: counseling, treatment, and social support.

Results

First, counseling focused on nutrition but very little on exercise, and women had limited understanding of what was diabetes or what they should do to control it. Second, women were inconsistent with reporting their diabetes treatment routines, both with adhering to medicines and seeking treatments. They identified structural barriers as overcrowded clinics and poor access to medicines as impeding adherence to treatment. Finally, women identified support from their families and friends and recognized stress associated with these relationships around food (e.g., we’re not eating that!) and diabetes stigma.

Conclusions

Effective diabetes education and management in the clinical setting will require systematic changes to healthcare. Inconsistencies across public and private health systems with regards to diabetes counseling, drug availability, quality of care, and patient wait times indicate patients will forego a clinical visit in lieu of diabetes self-care. For example, structural barriers in the public health system undermine medication adherence. With a stronger national emphasis in healthcare on diabetes counseling and management such systemic issues should be reshaped to ensure patients have access to essential medication and services.

Shared Decision-Making in Diabetes Care

Shared decision-making (SDM) is a collaborative process by which patients and clinicians work together in a deliberative dialogue. The purpose of this dialogue is to identify reasonable management options that best fit and addresses the unique situation of the patient. SDM supports the patient-centered translation of research into practice. SDM also helps implement a core principle of evidence-based medicine: evidence is necessary but never sufficient to make a clinical decision, as consideration of patient values and context is also required. SDM conversations build on a partnership between the patient and the clinician, draw on the body of evidence with regard to the different treatment options, and consider options in light of the values, preferences, and context of the patient. SDM is appropriate for diabetes care because diabetes care often requires consideration of management options that differ in ways that matter to patients, such as the way in which they place significant demands on patient's life and living. In the last decade, SDM has proven feasible and useful for sharing evidence with patients and for involving patients in making decisions with their clinicians. Health care and clinical policies advocate SDM, but these policies have yet to impact diabetes care. In this paper, we describe what SDM is, its known impact on diabetes care, and needed work to implement this patient-centered approach in the care of the millions of patients with diabetes.

Provider costs for prevention and treatment of cardiovascular and related conditions in low- and middle-income countries: a systematic review

BACKGROUND

The burden of cardiovascular disease (CVD) and CVD risk conditions is rapidly increasing in low- and middle-income countries, where health systems are generally ill-equipped to manage chronic disease. Policy makers need an understanding of the magnitude and drivers of the costs of cardiovascular disease related conditions to make decisions on how to allocate limited health resources.

METHODS

We undertook a systematic review of the published literature on provider-incurred costs of treatment for cardiovascular diseases and risk conditions in low- and middle-income countries. Total costs of treatment were inflated to 2012 US dollars for comparability across geographic settings and time periods.

RESULTS

This systematic review identified 60 articles and 143 unit costs for the following conditions: ischemic heart disease, non-ischemic heart diseases, stroke, heart failure, hypertension, diabetes, and chronic kidney disease. Cost data were most readily available in middle-income countries, especially China, India, Brazil, and South Africa. The most common conditions with cost studies were acute ischemic heart disease, type 2 diabetes mellitus, stroke, and hypertension.

CONCLUSIONS

Emerging economies are currently providing a base of cost evidence for NCD treatment that may prove useful to policy-makers in low-income countries. Initial steps to publicly finance disease interventions should take account of costs. The gaps and limitations in the current literature include a lack of standardized reporting as well as sparse evidence from low-income countries.

Effects of Soy Flour Fortified Bread Consumption on Cardiovascular Risk Factors According to APOE Genotypes in Overweight and Obese Adult Women: A Cross-over Randomized Controlled Clinical Trial

Recent studies suggest that inclusion of soy product in the diet may have favorable effects on relief of cardiovascular diseases (CVDs) and risk factors. These effects might be associated with the presence of specific polymorphism in gene. The aim of this study was to examine the effects of consumption of soy flour fortified bread on cardiovascular risk factors in overweight and obese women according to APOE genotype. In a randomized cross-over clinical trial 30 overweight and obese women received a mild weight loss diet and assigned to a regular diet and a soy bread diet, each for 6 weeks and a washout period for 20 days. Subjects in the soy bread diet were asked to replace 120 grams of their daily usual bread intake with equal amount of soy bread. No significant effects of soy bread on serum lipid, systolic blood pressure and anthropometric indices were observed compared to the regular diet (p > 0.05). For diastolic blood pressure (DBP), comparison of mean differences between two groups showed a marginally significant effect of soy bread (p = 0.06). Compared to regular diet, soy bread had a significant effect on DBP in E2 genotype group (ε2/ε2) (p = 0.03). Having ε2 allele may influences responses of CVD risk factor to soy bread consumption. However more nutrigenetic studies are required.

A systematic review of social capital and chronic non-communicable diseases

Nowadays, chronic non-communicable diseases have become a significant social problem of healthcare which threatens human health along with their rapid progress of morbidity and mortality. How to develop potential, intangible resources to compensate for insufficient physical resources is urgent. By analyzing literature reporting the association between social capital and chronic non-communicable diseases systematically, evidence was found for a positive association between social capital and chronic non-communicable disease prevention and control. The social capital theory may provide a new idea to solve the problem.

[Chronic noncommunicable diseases in Senegalese soldiers: cross-sectional study in 2013]

Introduction

Méthodes

Résultats

Conclusion

Health information priorities for more effective implementation and monitoring of non-communicable disease programs in low- and middle-income countries: lessons from the Pacific

BACKGROUND

Non-communicable diseases (NCDs) place enormous burdens on individuals and health systems. While there has been significant global progress to guide the development of national NCD monitoring programs, many countries still struggle to adequately establish critical information systems to prioritise NCD control approaches.

DISCUSSION

In this paper, we use the recent experience of the Pacific as a case study to highlight four key lessons about prioritising strategies for health information system development for monitoring NCDs: first, NCD interventions must be chosen strategically, taking into account local disease burden and capacities; second, NCD monitoring efforts must align with those interventions so as to be capable of evaluating progress; third, in order to ensure efficiency and sustainability, NCD monitoring strategies must be integrated into existing health information systems; finally, countries should monitor the implementation of key policies to control food and tobacco industries. Prioritising NCD interventions to suit local needs is critical and should be accompanied by careful consideration of the most appropriate and feasible monitoring strategies to track and evaluate progress.

Demographic and Prescribing Patterns of Chinese Herbal Products for Individualized Therapy for Ischemic Heart Disease in Taiwan: Population-Based Study

Objective

Combinations of Chinese herbal products (CHPs) are widely used for ischemic heart disease (IHD) in Taiwan. We analyzed the usage and frequency of CHPs prescribed for patients with IHD.

Methods

A nationwide population-based cross-sectional study was conducted, 53531 patients from a random sample of one million in the National Health Insurance Research Database (NHIRD) from 2000 to 2010 were enrolled. Descriptive statistics, the multiple logistic regression method and Poisson regression analysis were employed to estimate the adjusted odds ratios (aORs) and adjusted risk ratios (aRRs) for utilization of CHPs.

Results

The mean age of traditional Chinese medicine (TCM) nonusers was significantly higher than that of TCM users. Zhi-Gan-Cao-Tang (24.85%) was the most commonly prescribed formula CHPs, followed by Xue-Fu-Zhu-Yu-Tang (16.53%) and Sheng-Mai-San (16.00%). The most commonly prescribed single CHPs were Dan Shen (29.30%), Yu Jin (7.44%), and Ge Gen (6.03%). After multivariate adjustment, patients with IHD younger than 29 years had 2.62 times higher odds to use TCM than those 60 years or older. Residents living in Central Taiwan, having hyperlipidemia or cardiac dysrhythmias also have higher odds to use TCM. On the contrary, those who were males, who had diabetes mellitus (DM), hypertension, stroke, myocardial infarction (MI) were less likely to use TCM.

Conclusions

Zhi-Gan-Cao-Tang and Dan Shen are the most commonly prescribed CHPs for IHD in Taiwan. Our results should be taken into account by physicians when devising individualized therapy for IHD. Further large-scale, randomized clinical trials are warranted in order to determine the effectiveness and safety of these herbal medicines.

Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries

BACKGROUND

One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region - the Asean CosTs In ONcology (ACTION) study - to assess the economic impact of cancer.

METHODS

The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30% of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model.

RESULTS

The mean age of participants was 52 years; 64% were women. A year after diagnosis, 29% had died, 48% experienced financial catastrophe, and just 23% were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95% confidence interval, 4.76-7.23) and death (5.52; 4.34-7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05-1.52) and die (1.51; 1.21-1.88) than participants with insurance.

CONCLUSIONS

A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75% of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness.

Use of major surgery in south India: A retrospective audit of hospital claim data from a large, community health insurance program

BACKGROUND

Information on the use of major surgery in India is scarce. In this study we aimed to bridge this gap by auditing hospital claims from Rajiv Aarogyasri Community Health Insurance Scheme, which provides access to free hospital care through state-funded insurance to 68 million beneficiaries, an estimated 81% of population in the states of Telangana and Andhra Pradesh.

METHODS

Publicly available deidentified hospital claim data for all surgery procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh.

RESULTS

A total of 677,332 operative admissions (80% at private hospitals) were recorded at an annual rate of 259 per 100,000 beneficiaries, with male subjects accounting for 56% of admissions. Injury was the most common cause for operative admission (27%) with operative correction of long bone fractures being the most common procedure (20%) identified in the audit. Diseases of the digestive (16%), genitourinary (12%), and musculoskeletal (10%) systems were other leading causes for operative admissions. Most hospital bed-days were used by admissions for injuries (31%) and diseases of the digestive (17%) and musculoskeletal system (11%) costing 19%, 13%, and 11% of reimbursement. Operations on the circulatory system (8%) accounted for 21% of reimbursements. Annual per capita cost of operative claims was US$1.48.

CONCLUSION

The use of surgery by an insured population in India continued to be low despite access to financing comparable with greater spending countries, highlighting need for strategies, beyond traditional health financing, that prioritize improvement in access, delivery, and use of operative care.

Incidence of type 2 diabetes in pre-diabetic Japanese individuals categorized by HbA1c levels: a historical cohort study

Objective

Reported incidence of type 2 diabetes estimated at the pre-diabetic stage differs widely (2.3–18.1% per year). Because clinicians need to know the risk of incident diabetes after a diagnosis of pre-diabetes, our objective was to estimate precise incidence of diabetes using baseline HbA_1c levels.

Methods

A historical cohort study using electronic medical record data obtained between January 2008 and December 2013. A total of 52,781 individuals with HbA_1c < 6.5% were assigned to one of six groups categorized by baseline HbA_1c level: ≤ 5.5% (n=34,616), 5.6–5.7% (n=9,388), 5.8–5.9% (n=4,664), 6.0–6.1% (n= 2,338), 6.2–6.3% (n=1,257), and 6.4% (n=518). Participants were tracked until a subsequent diagnosis of diabetes or end of follow-up during a period of 5 years.

Results

During the follow-up period (mean 3.7 years), 4,369 participants developed diabetes. The incidence of diabetes in the first year was 0.7, 1.5, 2.9, 9.2, 30.4, and 44.0% in the six HbA_1c groups, respectively. At five years the incidence was 3.6, 8.9, 13.8, 27.5, 51.6, and 67.8%, respectively (p < 0.0001 comparing the HbA_1c ≤5.5% group to the other groups). After adjustment for confounding factors, the hazard ratios compared with the HbA_1c ≤5.5% group were significantly elevated: 2.3 (95%CI 2.0–2.5), 3.4 (95%CI 2.9–3.7), 8.8 (95%CI 8.0–10.1), 26.3 (95%CI 23.3–30.1), and 48.7 (95%CI 40.8–58.1) in the five HbA_1c groups (p < 0.0001).

Conclusion

By fractionating baseline HbA_1c levels into narrower HbA_1c range groups, accuracy of estimating the incidence of type 2 diabetes in subsequent years was increased. The risk of developing diabetes increased with increasing HbA_1c levels, especially with the HbA_1c level ≥ 6.2% in the first follow-up year.

Healthcare utilization and expenditures for chronic and acute conditions in Georgia: does benefit package design matter?

Background

In 2007 the Georgian government introduced a full state-subsidized Medical Insurance Program for the Poor (MIP) to provide better financial protection and improved access for socially and financially disadvantaged citizens. Studies evaluating MIP have noted its positive impact on financial protection, but find only a marginal impact on improved access. To better assess whether the effect of MIP varies according to different conditions, and to identify areas for improvement, we explored whether MIP differently affects utilization and costs among chronic patients compared to those with acute health needs.

Methods

Data were collected from two cross-sectional nationally representative household surveys conducted in 2007 and in 2010 that examined health care utilization rates and expenditures. Approximately 3,200 households were interviewed from each wave of both studies using a standardized survey questionnaire. Differences in health care utilization and expenditures between chronic and acute patients with and without MIP insurance were evaluated, using coarsened exact matching techniques.

Results

Among patients with chronic illnesses, MIP did not affect either health service utilization or expenditures for outpatient drugs and reduction in provider fees. For patients with acute illnesses MIP increased the odds (OR = 1.47) that they would use health services. MIP was also associated with a 20.16 Gel reduction in provider fees for those with acute illnesses (p = 0.003) and a 15.14 Gel reduction in outpatient drug expenditure (p = 0.013). Among those reporting a chronic illness with acute episode during the 30 days prior to the interview, MIP reduced expenditures on provider fees (B = -20.02 GEL) with marginal statistical significance.

Conclusions

Our findings suggest that the MIP may have improved utilization and reduce costs incurred by patients with acute health needs, while chronic patients marginally benefit only during exacerbation of their illnesses. This suggests that the MIP did not adequately address the needs of the aging Georgian population where chronic illnesses are prevalent. Increasing MIP benefits, particularly for patients with chronic illnesses, should receive priority attention if universal coverage objectives are to be achieved.

Redesigning primary care to tackle the global epidemic of noncommunicable disease

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Out-of-pocket expenditure on chronic non-communicable diseases in sub-Saharan Africa: the case of rural Malawi

In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.

Nutrition transition in South Asia: the emergence of non-communicable chronic diseases

Overview: South Asian countries have experienced a remarkable economic growth during last two decades along with subsequent transformation in social, economic and food systems. Rising disposable income levels continue to drive the nutrition transition characterized by a shift from a traditional high-carbohydrate, low-fat diets towards diets with a lower carbohydrate and higher proportion of saturated fat, sugar and salt. Steered by various transitions in demographic, economic and nutritional terms, South Asian population are experiencing a rapidly changing disease profile. While the healthcare systems have long been striving to disentangle from the vicious cycle of poverty and undernutrition, South Asian countries are now confronted with an emerging epidemic of obesity and a constellation of other non-communicable diseases (NCDs). This dual burden is bringing about a serious health and economic conundrum and is generating enormous pressure on the already overstretched healthcare system of South Asian countries.

Objectives: The Nutrition transition has been a very popular topic in the field of human nutrition during last few decades and many countries and broad geographic regions have been studied. However there is no review on this topic in the context of South Asia  as yet. The main purpose of this review is to highlight the factors accounting for the onset of nutrition transition and its subsequent impact on epidemiological transition in five major South Asian countries including Bangladesh, India, Nepal, Pakistan and Sri Lanka. Special emphasis was given on India and Bangladesh as they together account for 94% of the regional population and about half world’s malnourished population.

Methods: This study is literature based. Main data sources were published research articles obtained through an electronic medical databases search.

Economic evaluation of the practical approach to lung health and informal provider interventions for improving the detection of tuberculosis and chronic airways disease at primary care level in Malawi: study protocol for cost-effectiveness analysis

BACKGROUND

Chronic airway diseases pose a big challenge to health systems in most developing countries, particularly in Sub-Saharan Africa. A diagnosis for people with chronic or persistent cough is usually delayed because of individual and health system barriers. However, delayed diagnosis and treatment facilitates further transmission, severity of disease with complications and mortality. The objective of this study is to assess the cost-effectiveness of the practical approach to lung health strategy, a patient-centred approach for diagnosis and treatment of common respiratory illnesses in primary healthcare settings, as a means of strengthening health systems to improve the quality of management of respiratory diseases.

METHODS/DESIGN

Economic evaluation nested in a cluster randomised controlled trial with three arms will be performed. Measures of effectiveness and costs for all arms of the study will be obtained from the cluster randomised controlled clinical trial. The main outcome measures are a combined rate of major respiratory diseases milestones and process indicators extracted from the practical approach to lung health strategy. For analysis, descriptive as well as regression techniques will be used. A cost-effectiveness analysis will be performed according to intention-to-treat principle and from a societal perspective. Cost-effectiveness ratios will be calculated using bootstrapping techniques.

DISCUSSION

We hope to demonstrate the cost-effectiveness of the practical approach to lung health and informal healthcare providers, see an improvement in patients' quality of life, achieve a reduction in the duration and occurrence of episodes and the chronicity of respiratory diseases, and are able to report a decrease in the social cost. If the practical approach to lung health and informal healthcare provider's interventions are cost-effective, they could be scaled up to all primary healthcare centres.

TRIAL REGISTRATION

PACTR: PACTR201411000910192.

The global impact of non-communicable diseases on households and impoverishment: a systematic review

The global economic impact of non-communicable diseases (NCDs) on household expenditures and poverty indicators remains less well understood. To conduct a systematic review and meta-analysis of the literature evaluating the global economic impact of six NCDs [including coronary heart disease, stroke, type 2 diabetes mellitus (DM), cancer (lung, colon, cervical and breast), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD)] on households and impoverishment. Medline, Embase and Google Scholar databases were searched from inception to November 6th 2014. To identify additional publications, reference lists of retrieved studies were searched. Randomized controlled trials, systematic reviews, cohorts, case-control, cross-sectional, modeling and ecological studies carried out in adults and assessing the economic consequences of NCDs on households and impoverishment. No language restrictions. All abstract and full text selection was done by two independent reviewers. Data were extracted by two independent reviewers and checked by a third independent reviewer. Studies were included evaluating the impact of at least one of the selected NCDs and on at least one of the following measures: expenditure on medication, transport, co-morbidities, out-of-pocket (OOP) payments or other indirect costs; impoverishment, poverty line and catastrophic spending; household or individual financial cost. From 3,241 references, 64 studies met the inclusion criteria, 75% of which originated from the Americas and Western Pacific WHO region. Breast cancer and DM were the most studied NCDs (42 in total); CKD and COPD were the least represented (five and three studies respectively). OOP payments and financial catastrophe, mostly defined as OOP exceeding a certain proportion of household income, were the most studied outcomes. OOP expenditure as a proportion of family income, ranged between 2 and 158% across the different NCDs and countries. Financial catastrophe due to the selected NCDs was seen in all countries and at all income levels, and occurred in 6-84% of the households depending on the chosen catastrophe threshold. In 16 low- and middle-income countries (LMIC), 6-11% of the total population would be impoverished at a 1.25 US dollar/day poverty line if they would have to purchase lowest price generic diabetes medication. NCDs impose a large and growing global impact on households and impoverishment, in all continents and levels of income. The true extent, however, remains difficult to determine due to the heterogeneity across existing studies in terms of populations studied, outcomes reported and measures employed. The impact that NCDs exert on households and impoverishment is likely to be underestimated since important economic domains, such as coping strategies and the inclusion of marginalized and vulnerable people who do not seek health care due to financial reasons, are overlooked in literature. Given the scarcity of information on specific regions, further research to estimate impact of NCDs on households and impoverishment in LMIC, especially the Middle Eastern, African and Latin American regions is required.

Dissemination and implementation of evidence based, mental health interventions in post conflict, low resource settings

The burden of mental health problems in (post)conflict low- and middle-income countries (LMIC) is substantial. Despite growing evidence for the effectiveness of selected mental health programs in conflict-affected LMIC and growing policy support, actual uptake and implementation have been slow. A key direction for future research, and a new frontier within science and practice, is Dissemination and Implementation (DI) which directly addresses the movement of evidence-based, effective health care approaches from experimental settings into routine use. This paper outlines some key implementation challenges, and strategies to address these, while implementing evidence-based treatments in conflict-affected LMIC based on the authors' collective experiences. Dissemination and implementation evaluation and research in conflict settings is an essential new research direction. Future DI work in LMIC should include: 1) defining concepts and developing measurement tools, 2) the measurement of DI outcomes for all programming, and 3) the systematic evaluation of specific implementation strategies.

Assessment of Unmet Clinical Need in Type 2 Diabetic Patients on Conventional Therapy in the UK

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is an increasing problem worldwide and a leading risk factor for cardiovascular disease. As beta cell function declines, the management of T2DM typically comprises of escalations in treatment from diet and exercise to oral therapies and eventually insulin. Treatment algorithms based on the attainment of blood glucose targets may not account for changes in other cardiovascular risk factors. The objective of this study is to describe unmet clinical need, defined as failure to reduce weight or meet targets for blood pressure, total cholesterol or glycated hemoglobin (HbA1c) levels.

METHODS

Anonymized UK patient data for those (1) initiating oral antidiabetic drug (OAD) monotherapy, (2) escalating to dual therapy, (3) escalating to triple therapy, and (4) escalating to insulin therapy over the study period (01/01/2005-31/12/2009) were obtained from The Health Improvement Network (THIN). Changes in risk factors were evaluated before and after therapy escalation, and the attainment of targets, assessed at the last recorded measurement, as follows: HbA1c <7.5%, systolic blood pressure (SBP) <140 mmHg, total cholesterol (TC) <5 mmol/L, and reduction in weight.

RESULTS

Prior to therapy escalation, mean HbA1c in each subgroup exceeded 7.5% and was higher respective to the number of OADs being used (monotherapy: 8.03%; double: 8.48%; triple: 8.71%). Insulin users displayed the highest HbA1c prior to treatment escalation (9.78%). Following escalation, a decline in HbA1c was observed in all subgroups. By contrast, mean SBP and TC levels decreased prior to the addition of a second and third oral therapy. Consistent improvements following treatment escalation were not observed across the other risk factors following therapy escalation. Overall, the proportion of subjects that attained all four targets ranged from 3% (monotherapy and insulin) to 6% (dual therapy).

CONCLUSION

The potential unmet clinical need among conventionally treated T2DM patients is significant, with respect to the control of blood glucose and other cardiovascular risk factors: SBP, TC, and weight. There clearly remains the need for new therapeutic approaches to alleviate the burden associated with T2DM.

The prevalence and determinants of catastrophic health expenditures attributable to non-communicable diseases in low- and middle-income countries: a methodological commentary

BACKGROUND

Non-communicable diseases (NCDs), while traditionally considered a "rich world"-problem, have been spreading fast in low and middle income countries and by now account for a large share of mortality and ill-health in these countries, too. In addition to the disease burden, NCDs may also impose a substantial economic cost. One way in which NCDs might impact people's economic well-being may be via the out-of-pocket expenditures required to cover treatment and other costs associated with suffering from an NCD.

METHODS

In this commentary, we identify and discuss the methodological challenges related to cross-country comparison of-out-of-pocket and catastrophic out-of-pocket health care expenditures, attributable to NCDs, focussing on low and middle income countries.

RESULTS

There is significant evidence of substantial cost burden placed by NCDs on patients living in low and middle income countries, with most of it being heavily concentrated among low socioeconomic status groups. However, a large variation in definition of COOPE between studies prevents cross-country comparison. In addition, as most studies tend to be observational, causal inferences are often not possible. This is further complicated by the cross-sectional nature of studies, small sample sizes, and/or limited duration of follow-up of patients. Most evidence for certain conditions (e.g., cancer) tends to be collected in high-income countries only.

CONCLUSIONS

The definitions for COOPEs should be standardized as much as possible, to enable comparison of COOPE prevalence between countries. Prospective study design using larger samples representative of broader sections of local population, collecting better data on both direct and indirect treatment costs is also needed.

Access to diagnostic tests and essential medicines for cardiovascular diseases and diabetes care: cost, availability and affordability in the West Region of Cameroon

OBJECTIVE

To assess the availability and affordability of medicines and routine tests for cardiovascular disease (CVD) and diabetes in the West region of Cameroon, a low-income setting.

METHODS

A survey was conducted on the availability and cost of twelve routine tests and twenty medicines for CVD and diabetes in eight health districts (four urban and four rural) covering over 60% of the population of the region (1.8 million). We analyzed the percentage of tests and medicines available, the median price against the international reference price (median price ratio) for the medicines, and affordability in terms of the number of days' wages it would cost the lowest-paid unskilled government worker for initial investigation tests and procurement for one month of treatment.

RESULTS

The availability of tests varied between 10% for the ECG to 100% for the fasting blood sugar. The average cost for the initial investigation using the minimum tests cost 29.76 days' wages. The availability of medicines varied from 36.4% to 59.1% in urban and from 9.1% to 50% in rural settings. Only metformin and benzathine-benzylpenicilline had a median price ratio of ≤ 1.5, with statins being largely unaffordable (at least 30.51 days' wages). One month of combination treatment for coronary heart disease costs at least 40.87 days' wages.

CONCLUSION

The investigation and management of patients with medium-to-high cardiovascular risk remains largely unavailable and unaffordable in this setting. An effective non-communicable disease program should lay emphasis on primary prevention, and improve affordable access to essential medicines in public outlets.

Financial risk protection and universal health coverage: evidence and measurement challenges

Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.

Global perspective on acute coronary syndrome: a burden on the young and poor

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Learning lessons from operational research in infectious diseases: can the same model be used for noncommunicable diseases in developing countries?

About three-quarters of global deaths from noncommunicable diseases (NCDs) occur in developing countries. Nearly a third of these deaths occur before the age of 60 years. These deaths are projected to increase, fueled by such factors as urbanization, nutrition transition, lifestyle changes, and aging. Despite this burden, there is a paucity of research on NCDs, due to the higher priority given to infectious disease research. Less than 10% of research on cardiovascular diseases comes from developing countries. This paper assesses what lessons from operational research on infectious diseases could be applied to NCDs. The lessons are drawn from the priority setting for research, integration of research into programs and routine service delivery, the use of routine data, rapid-assessment survey methods, modeling, chemoprophylaxis, and the translational process of findings into policy and practice. With the lines between infectious diseases and NCDs becoming blurred, it is justifiable to integrate the programs for the two disease groups wherever possible, eg, screening for diabetes in tuberculosis. Applying these lessons will require increased political will, research capacity, ownership, use of local expertise, and research funding.

Organising health research systems as a key to improving health: the World Health Report 2013 and how to make further progress

The World Health Report 2013 provides a major boost to the health research community and, in particular, to those who believe that health research will make its greatest impact on improving health when it is organised through a systems approach. The World Health Report 2013, Research for Universal Health Coverage, starts with three key messages. Firstly, that universal health coverage, with full access to high-quality services, needs research evidence if it is to be achieved; second, all nations should conduct and use research; and finally, the report states that systems are needed to develop national research agendas, to raise funds, to strengthen research capacity, and to make effective use of research findings. Each of these themes is elaborated in the report and supported by extensive references.

In this editorial, we first outline the key messages from the World Health Report 2013 and highlight the contributions made by papers from our journal, Health Research Policy and Systems. In addition, we discuss very recent papers that advance some issues even further. In particular, we consider new evidence both on how to achieve financial protection for those who use health services, and on whether healthcare professionals and organisations who engage in research provide an improved healthcare performance. Finally, we propose additional perspectives that add to the impressive body of evidence and analyses presented in the report. Specifically, we suggest that considering the needs of various stakeholders, as attempted in the UK, in parallel with analysing how to fulfil essential functions, should boost the prospects of successfully building and strengthening health research systems. This is important because research is vital for achieving universal health coverage, and consequently for improving the health of millions of people.