Diabetes – The Cost of Care

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Peter Rohloff has training in parasitology, internal medicine and pediatrics. He practices in Boston, MA at Brigham and Women's Hospital and Boston Children's Hospital. Since 2003, Peter has been working in Guatemala, where he serves as the medical director for a health systems NGO – Wuqu’ Kawoq | Maya Health Alliance. Peter’s interests include the management of chronic diseases of children and adults in resource poor settings and how indigeneity, cultural, and language barriers impact access to and utilization of health care. @wuqukawoq

The developing world is experiencing a massive, growing epidemic of noncommunicable diseases, a fact which is still largely overshadowed in the popular media by conversations about infections diseases like HIV, malaria, and tuberculosis. The majority of deaths in the world are caused by noncommunicable diseases, and over 80% of people living with conditions like diabetes or heart disease now live in lower income countries. The World Health Organization predicts that the number of global deaths from these disease will rise 20% over the next decade or so (1).

Developing policies and programs to target noncommunicable diseases is trickier, in some ways, than developing policies or programs for infectious diseases. Mostly this is related to the fact that almost none of the noncommunicable diseases are “curable” in the traditional sense of the word. A condition like diabetes, for example, can be controlled with diet, education, exercise, and mediations – but not cured. This means that treating noncommunicable diseases raises all sorts of questions about long-term financial costs, which explains in part why many countries still lack clear policies for tackling these diseases head on.

In Guatemala, where I work with Wuqu’ Kawoq | Maya Health Alliance, we’ve been involved in developing programs for rural indigenous patients with type 2 diabetes for about 6 years. Guatemala has followed the global trends towards diabetes prevalence. Recently for example, it was estimated that diabetes affects as many as 14% of the adult female population in the country, which is a rate higher than that in many developed countries (2)! Importantly, although we know quite a bit about diabetes in Guatemala’s urban population, we have almost no appreciation of diabetes epidemiology in the country’s rural indigenous population. This is a pressing issue, because the indigenous sector is a majority of the country’s population and because we know that, worldwide, diabetes rates are rising rapidly everywhere—not just in urban areas, but also in rural, agricultural communities. For example, one recent report estimates that the rate of diabetes in rural communities globally has gone up five-fold in the last 25 years (3). In other words, heart disease and diabetes are affecting everyone, everywhere—not just those with the most sedentary lifestyles, or the easiest access to fast food restaurants!

Recently, we finished completing an evaluation of our diabetes programming, complete both with a chart review as well as an ethnographic study of patient perceptions of their condition. One of the major findings of this study was that patients almost universally felt that the major barrier to good health was the cost of diabetic medications and care. Most of our patients self-referred to our clinic after exhausting their financial options in other health care venues. We’ve known this for a while actually, that cost was a major barrier to quality diabetes care, and this was a major reason why we have always provided all necessary medications and testing free of charge.

We’ve always felt pretty strongly that medical services should be free of charge. The neoliberal point of view that clients need to “buy-in” by paying nominal fees and that this also contributes to financial sustainability of the project ignores two important facts. First, in an impoverished setting, user fees are never likely to be a meaningful source of revenue, because the price point at which your target population will go away because they can’t pay will always occur before you ever meet the actual cost of the services delivered. If an institution raises its user fees to the level at which they become a significant source of revenue, then they are almost certainly no longer providing services to the poorest members of their target population. Second, the “buy-in” argument ignores the fact that the patient has already “bought-in.” It is not at all atypical for one of our patients to get up at 3 in the morning and spend 3 or 4 hours on a bus to get to the clinic, then spend several hours waiting in line to be seen by a physician, all in all spending $5-8 on food and transportation for the day (which is, in most cases, at least a day’s wages if not more), to say nothing of lost wages (no “sick days” in Guatemala). “User fees” seem to us just to add insult to injury in this scenario.

Anyway, it has been good to hear our clients echoing and reaffirming something that has always been a central belief of ours – in the treatment of chronic noncommunicable disease, cost is the issue. You can’t separate the cost issue for the adherence issue in most cases, because in most cases patients don’t take their medications simple because they can’t afford them.

I’m going to write a few more entries about other aspects of what we have learned about treating diabetes in Guatemala over the next few weeks or so—so stay tuned.

1. World Health Organization (WHO): Global Status Report on Noncommunicable Diseases 2010: Description of the Global Burden of NCDs, Their Risk Factors and Determinants. Geneva: WHO; 2011.

2. Danaei G, Finucane M, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, Lin JK, Farzadfar F, Khang Y-H, Stevens GA, Rao M, Ali MK, Riley LM, Robinson CA, Ezzati M. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 2011, 378:31-40.

3. Hwang CK, Han PV, Zabetian A, Ali MK, Venkat Narayan KM. Rural diabetes prevalence quintuples over twenty-five years in low- and middle-income countries: A systematic review and meta-analysis. Diab Res Clin Pract 2012, doi:10.1016/j.diabres.2011.12.001.