Economic impacts of chronic conditions in a country with high levels of population health coverage: lessons from Mongolia.

OBJECTIVE: To analyse the impact of non-communicable diseases (NCDs) on household out-of-pocket (OOP) expenses, catastrophic health payments and medical impoverishment in Mongolia, a middle-income country with a high population health insurance coverage rate. METHODS: Secondary data analysis of the Mongolian Household Socioeconomic Survey with 12 840 households, including information on standard of living, OOP spending, and health conditions of household members. Measures of catastrophic spending and medical impoverishment were constructed for Mongolia. The association of medical impoverishment and catastrophic spending with a range of socioeconomic and demographic covariates and health conditions was assessed using multiple regression models. RESULTS: OOP health spending contributed to an 8% increase in the incidence of poverty in Mongolia. The impoverishment associated with medical expenses is concentrated in the poorer quintiles, indicating some deepening of poverty among the already poor. Households with a member affected by NCDs and with multiple morbidities were more likely to experience catastrophic spending and medical impoverishment than those with infectious diseases. The main drivers of the financial distress were expenditures incurred for outpatient services, including for diagnostics and drugs. CONCLUSION: Despite high rates of population health insurance coverage, health expenditures have substantial impoverishing effects in Mongolia, with the impacts being greater among households containing individuals with chronic conditions. Addressing the goal of universal health coverage (UHC) in Mongolia needs attention to the depth of coverage, especially for expenditures on outpatient care and medicines, and targeting the poor effectively.

OBJECTIF: Analyser l'impact des maladies non transmissibles (MNT) sur les dépenses directes des ménages, les paiements de santé catastrophiques et l'appauvrissement médical en Mongolie, un pays à revenu intermédiaire avec un taux élevé de couverture d'assurance santé de sa population. MÉTHODES: Analyse secondaire des données de l'enquête socioéconomique sur les ménages mongols auprès de 12.840 ménages, y compris des informations sur le niveau de vie, les dépenses directes et les conditions de santé des membres du ménage. Des mesures des dépenses catastrophiques et de l'appauvrissement médical ont été élaborées pour la Mongolie. L'association entre l'appauvrissement médical et les dépenses catastrophiques à une gamme de covariables socioéconomiques et démographiques et de conditions de santé a été évaluée à l'aide de modèles de régression multiple. RÉSULTATS: Les dépenses directes de santé contribuaient à une augmentation de 8% de l'incidence de la pauvreté en Mongolie. L'appauvrissement associé aux dépenses médicales est concentré dans les quintiles les plus pauvres, ce qui indique une aggravation de la pauvreté chez ceux déjà pauvres. Les ménages avec un des membres atteint de MNT et avec des morbidités multiples sont plus susceptibles de connaître des dépenses catastrophiques et un appauvrissement médical que ceux souffrant de maladies infectieuses. Les principales causes de la crise financière étaient les dépenses engagées pour les services ambulatoires, notamment les diagnostics et les médicaments. CONCLUSION: Malgré des taux élevés de couverture de l'assurance santé de la population, les dépenses de santé ont des effets appauvrissants considérables en Mongolie, les impacts étant plus importants pour les ménages comptant des personnes atteintes de maladies chroniques. Pour atteindre l'objectif de la couverture santé universelle (CSU) en Mongolie, il est nécessaire de porter une attention particulière à l'étendue de la couverture, en particulier pour les dépenses en soins ambulatoires et en médicaments, et cibler efficacement les pauvres.

Access to medicines for asthma, diabetes and hypertension in eight counties of Kenya.

OBJECTIVE: To assess access to noncommunicable diseases (NCD) medicines in Kenya for patients diagnosed and prescribed treatment for asthma, diabetes and hypertension. METHODS: Households in eight purposively chosen counties were randomly selected. To be eligible, a household needed to have at least one member aged 18 years or older who had been previously diagnosed and prescribed medicines for one of the following NCDs: asthma, diabetes or hypertension. Using a logistic regression model, we explored the relationship between patient characteristics and the probability that patients had the medicines available at the time of the survey visit. RESULTS: A total of 627 individuals were included in the analysis. The highest percentage of medicines availability was in households with diabetes patients (83.1%), followed by hypertension (77.1%) patients. The lowest availability of medicines was found in households with asthma patients (53.1%). The median household expenditure on medicines per month was US$7.00 for households with diabetes patients; it was US$4.00 for asthma. In general, strong predictors of having medicines at home was being older, having some education compared to no education, few household members, wealth, being diagnosed at private nonprofit facilities and having only one patient with NCDs in the household. CONCLUSIONS: Our study found that nearly three-quarters of patients diagnosed and prescribed a medicine for hypertension, asthma or diabetes had the medicine available at home. Access challenges remain, in particular for patients from low-income households and for those diagnosed with asthma.

Non-communicable diseases and HIV care and treatment: models of integrated service delivery.

OBJECTIVES: Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. We describe models of NCD and HIV integration, challenges and lessons learned. METHODS: A literature review of published articles on integrated NCD and HIV programs in low-income countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration. RESULTS: Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models. CONCLUSIONS: Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. Operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.

Tuberculosis and diabetes: current state and future perspectives.

This review outlines the association between tuberculosis and diabetes, focusing on epidemiology, physiopathology, clinical aspects, diagnosis and treatment, and evaluates future perspectives, with particular attention to developing countries.

Cost of hospitalisation for non-communicable diseases in India: are we pro-poor?

OBJECTIVES: To estimate out-of-pocket (OOP) expenditure due to hospitalisation from NCDs and its impact on households in India. METHODS: The study analysed nationwide representative data collected by the National Sample Survey Organisation in 2014 that reported health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private). The recall period for inpatient hospitalisation expenditure was 365 days. Consumption expenditure was collected for a recall period of 1 month. OOP expenditure amounting to >10% of annual consumption expenditure was termed as catastrophic. Weighted analysis was performed. RESULTS: The median expenditure per episode of hospitalisation due to NCDs was USD 149 - this was ~3 times higher among the richest quintile compared to poorest quintile. There was a significantly higher prevalence of catastrophic expenditure among the poorest quintile, more so for cancers (85%), psychiatric and neurological disorders (63%) and injuries (63%). Mean private-sector OOP hospitalisation expenditure was nearly five times higher than that in the public sector. Medicines accounted for 40% and 27% of public- and private-sector OOP hospitalisation expenditure, respectively. CONCLUSION: Strengthening of public health facilities is required at community level for the prevention, control and management of NCDs. Promotion of generic medicines, better availability of essential drugs and possible subsidisation for the poorest quintile will be measures to consider to reduce OOP expenditure in public-sector facilities.

Prevalence and correlates of diabetes mellitus in Uganda: a population-based national survey.

OBJECTIVE: We analysed fasting blood glucose (FBG) and other data collected as part of a population-based nationwide non-communicable disease risk factor survey, to estimate the prevalence of impaired fasting glycaemia (IFG) and diabetes mellitus and to identify associated factors in Uganda. METHODS: The nationwide cross-sectional survey was conducted between April and July 2014. Participants were adults aged 18-69 years. A multistage stratified sample design was used to produce a national representative sample. Fasting capillary glucose was measured to estimate glycaemia. Data were managed with WHO e-STEPs software and Epi Info. Stata(®) survey procedures were used to account for the sampling design, and sampling weights were used to account for differential probability of selection between strata. RESULTS: Of the 3689 participants, 1467 (39.8%) were males, and 2713 (73.5%) resided in the rural areas. The mean age was 35.1 years (standard deviation = 12.6) for males and 35.8 years (13.2) for females. The overall prevalence of IFG was 2.0% (95% confidence interval (CI) = 1.5-2.5%), whereas that of diabetes mellitus was 1.4% (95% CI 0.9-1.9%). The prevalence of IFG was 2.1% (95% CI 1.3-2.9%) among males and 1.9% (95% CI 1.3-2.6%) among females, whereas that of diabetes mellitus was 1.6% (95% CI 0.8-2.6%) and 1.1% (95% CI 0.6-1.7%), respectively. The prevalence of IFG was 2.6% (95% CI 1.4-3.8%) among urban and 1.9% (95% CI 1.3-2.4%) among rural residents, whereas that of diabetes mellitus was 2.7% (95% CI 1.4-4.1) and 1.0% (95% 0.5-1.6%), respectively. The majority of participants identified with hyperglycaemia (90.5% IFG and 48.9% diabetes) were not aware of their hyperglycaemic status. Factors associated with IFG were region of residence, body mass index and total cholesterol; factors associated with diabetes mellitus were age, sex, household floor finish and abdominal obesity. CONCLUSION: The prevalence of IFG and of diabetes mellitus is low in the Ugandan population, providing an opportunity for the prevention of diabetes. The majority of persons with hyperglycaemia were not aware of their hyperglycaemic status, which implies a likelihood of presenting late with complications.

Trends in stroke admissions to a Tanzanian hospital over four decades: a retrospective audit.

AIMS: The aim of this study was to record stroke admissions to a tertiary referral hospital in Tanzania over four decades. METHODS: We audited the medical records held at a large teaching and tertiary referral hospital in northern Tanzania over four decades. We collected records for the years 1974-1976, 1984-1986, 1994-1995 and 2008. All patients admitted as inpatients with a primary diagnosis of stroke were included in the study. Data collected included age, sex, stroke subtype, predominant side of symptoms and survival to discharge. RESULTS: The number of stroke admissions rose from just four in the three-year period 1974-1976 (mean 1.3 cases annually) to 153 cases annually in 2008. The mean age of those admitted rose steadily during this period, as did the proportion of females admitted. CONCLUSIONS: The burden of stroke on health services in Tanzania appears to have increased rapidly. If this increase is to be slowed, then sustainable primary preventative measures to target known stroke risk factors will be required.

The health system burden of chronic disease care: an estimation of provider costs of selected chronic diseases in Uganda.

OBJECTIVE: To explore the chronic disease services in Uganda: their level of utilisation, the total service costs and unit costs per visit. METHODS: Full financial and economic cost data were collected from 12 facilities in two districts, from the provider's perspective. A combination of ingredients-based and step-down allocation costing approaches was used. The diseases under study were diabetes, hypertension, chronic obstructive pulmonary disease (COPD), epilepsy and HIV infection. Data were collected through a review of facility records, direct observation and structured interviews with health workers. RESULTS: Provision of chronic care services was concentrated at higher-level facilities. Excluding drugs, the total costs for NCD care fell below 2% of total facility costs. Unit costs per visit varied widely, both across different levels of the health system, and between facilities of the same level. This variability was driven by differences in clinical and drug prescribing practices. CONCLUSION: Most patients reported directly to higher-level facilities, bypassing nearby peripheral facilities. NCD services in Uganda are underfunded particularly at peripheral facilities. There is a need to estimate the budget impact of improving NCD care and to standardise treatment guidelines.

Duration of residence and disease occurrence among refugees and family reunited immigrants: test of the 'healthy migrant effect' hypothesis.

OBJECTIVES: The 'healthy migrant effect' (HME) hypothesis postulates that health selection has a positive effect on migrants' health outcomes, especially in the first years after migration. We examined the potential role of the HME by assessing the association between residence duration and disease occurrence. METHODS: We performed a historical prospective cohort study. We included migrants who obtained residence permits in Denmark between 1 January 1993 and 31 December 2010 (n = 114,331). Occurrence of severe conditions was identified through linkage to the Danish National Patient Register. Hazard Ratios (HRs) were modelled for disease incidence by residence duration since arrival (0-5 years; 0-10 years; 0-18 years) adjusting for age and sex. RESULTS: Compared with Danish-born individuals, refugees and family reunited immigrants had lower HRs of stroke and breast cancer within 5 years after arrival; however, HRs increased at longer follow-up. For example, HRs of stroke among refugees increased from 0.77 (95% CI: 0.66; 0.91) to 0.96 (95% CI: 0.88; 1.05). For ischaemic heart disease (IHD) and diabetes, refugees and family reunited migrants had higher HRs within 5 years after arrival, and most HRs had increased by end of follow-up. For example, HRs of IHD among family reunited migrants increased from 1.29 (95% CI: 1.17; 1.42) to 1.43 (95% CI: 1.39; 1.52). In contrast, HRs for TB and HIV/AIDS showed a consistent decrease over time. CONCLUSION: Our analyses of the effect of duration of residence on disease occurrence among migrants imply that, when explaining migrants' advantageous health outcomes, the ruling theory of the HME should be used with caution, and other explanatory models should be included.

Can the rural poor in India afford to treat non-communicable diseases.

OBJECTIVE: Non-communicable diseases (NCD) are on the increase in low-income countries, where healthcare costs are paid mostly out-of-pocket. We investigate the financial burden of NCD vs. communicable diseases (CD) among rural poor in India and assess whether they can afford to treat NCD. METHODS: We used data from two household surveys undertaken in 2009-2010 among 7389 rural poor households (39 205 individuals) in Odisha and Bihar. All persons from the sampled households, irrespective of age and gender, were included in the analysis. We classify self-reported illnesses as NCD, CD or 'other morbidities' following the WHO classification. RESULTS: Non-communicable diseases accounted for around 20% of the diseases in the month preceding the survey in Odisha and 30% in Bihar. The most prevalent NCD, representing the highest share in outpatient costs, were musculoskeletal, digestive and cardiovascular diseases. Cardiovascular and digestive problems also generated the highest inpatient costs. Women, older persons and less-poor households reported higher prevalence of NCD. Outpatient costs (consultations, medicines, laboratory tests and imaging) represented a bigger share of income for NCD than for CD. Patients with NCD were more likely to report a hospitalisation. CONCLUSION: Patients with NCD in rural poor settings in India pay considerably more than patients with CD. For NCD cases that are chronic, with recurring costs, this would be aggravated. The cost of NCD care consumes a big part of the per person share of household income, obliging patients with NCD to rely on informal intra-family cross-subsidisation. An alternative solution to finance NCD care for rural poor patients is needed.

[Epidemiologic Weight Of Noncommunicable Diseases In Burkina Faso : National STEPS Survey 2013]. / Poids Epidemiologiques Des Maladies Non Transmissibles Au Burkina Faso. Enquete Nationale STEPS 2013.

AIM: This study aimed to analyze the extent of major noncommunicable diseases and their common risk factors in Burkina Faso. MATERIALS AND METHODS: It was an analysis based on secondary data from the 2013 national STEPS survey in Burkina Faso. The analysis conducted in 2018 concerned behavioral risk factors and metabolic factors. A multiple regression model was used to determine the independent factors associated with these diseases. RESULTS: The independent variables associated with behavioral risk factors were 1) young age(OR=0, 4423; p< 0,001) and males(OR=0,0030 ; p< 0,001) for smoking, 2) older age (OR= 2,01 ; p= 0,0066 and OR=2,18 ; p< 0,001) and males(OR=2,18 ; p< 0,001) for drinking and harmful use of alcohol, and 3) young age(OR=0,34 ; p< 0,001) and the urban environment(OR=1,57 ; p= 0,0236) for physical inactivity. The independent variables associated with metabolic risk factors were 1) young age (OR=1,33 ; p= 0,0295) and urban (OR=0,31 ; p<0,001) for overweight, 2) female(OR=2,55 ; p= 0,0010) and urban(OR= 0,13; p< 0,001) for obesity, and 3) advanced age(OR=2,49 ; p< 0,001and OR= 2,12 ; p= 0,0115), and urban setting(OR=0,47 ; p< 0,001 and OR= 0,49 ;p= 0,0320) for high blood pressure and diabetes. CONCLUSION: In Burkina Faso, prevention and health promotion actions to reduce these risk factors need to be stepped up with a multi-sectoral approach.

BUT: L'objectif de cette étude était d'analyser l'ampleur des principales maladies non transmissibles et leurs facteurs de risque communs au Burkina Faso. MATÉRIELS ET MÉTHODES: il s'agissait d'une analyse basée sur des données secondaires de l'enquête par étape (STEPS)au Burkina Faso réalisée en 2013. L'analyse a concerné les facteurs de risques comportementaux et métaboliques. Un modèle de régression multiple a été utilisé pour déterminer les facteurs indépendants associés à ces maladies. RÉSULTATS: Les variables indépendantes associées aux facteurs de risque comportementaux étaient 1) le jeune âge (OR=0,4423 ; p< 0,001) et le sexe masculin (OR=0,0030 ; p< 0,001)pour le tabagisme, 2) l'âge avancé (OR= 2,01 ; p= 0,0066 et OR=2,18 ; p< 0,001) et le sexe masculin (OR=2,18 ; p< 0,001) pour la consommation et l'usage nocif d'alcool et 3) le jeune âge (OR=0,34 ; p< 0,001)et le milieu urbain(OR=1,57 ; p= 0,0236) pour l'inactivité physique. Les variables indépendantes associées aux facteurs de risque métaboliques étaient 1) le jeune âge (OR=1,33 ; p= 0,0295) et le milieu urbain (OR=0,31 ; p< 0,001) pour le surpoids, 2) le sexe féminin (OR=2,55 ; p= 0,0010) et le milieu urbain (OR= 0,13; p< 0,001) pour l'obésité et 3) l'âge avancé (OR=2,49 ; p< 0,001 et OR= 2,12 ; p= 0,0115) et le milieu urbain (OR=0,47 ; p< 0,001 et OR= 0,49 ;p= 0,0320) pour l'hypertension artérielle et le diabète. CONCLUSION: Au Burkina Faso, des actions de prévention et de promotion de la santé doivent être accentuées avec une approche multisectorielle pour lutter contre ces facteurs de risque.

[Active smoking: A major risk factor for human non-communicable diseases in a hospital survey]. / Le tabagisme actif : un facteur de risque majeur des maladies non transmissibles humaines dans une enquête hospitalière.

INTRODUCTION: Tobacco is the main preventable cause of death worldwide. Our study aimed to determine the role of tobacco in the occurrence of non-communicable diseases (NCDs). METHODS: We conducted a retrospective study including all NCDs patients during 2015-2016. NCDs include cardiovascular diseases (CVD), chronic respiratory diseases (CRD), cancers (CS) and diabetes mellitus (DM). RESULTS: We identified 3643 cases of NCDs (43%) among 8478 hospitalizations, all diseases combined. Active smoking was found in 1076 cases (29.5%). Among the NCDs groups, CVD was the most common (65%). Tobacco was significantly associated with CVD (P<0.001), CRD (P=0.002), bronchopulmonary CS (P<0.001), haematological malignancy (P=0.023), and DM (P<0.001). Multivariate analysis performing binary logistic regression revealed that tobacco was an independent factor associated with CVD (OR=2.6, P<0.001), CRD (OR=1.5, P<0.001), bronchopulmonary CS (OR=1.8, P=0.013) and DM (OR=3.6, P<0.001). CONCLUSION: Active smoking was a major risk factor in the occurrence of NCDs. Thus, smoking cessation represents the cornerstone for preventing the spread of these diseases, especially in countries with limited resources.

Non-Communicable Diseases on the Rise in Sub-Saharan Africa, the Underappreciated Threat of a Dual Disease Burden. / Anstieg von nicht übertragbaren Krankheiten in Subsahara-Afrika, die unterschätzte Bedrohung einer doppelten Krankheitslast.

In sub-Saharan Africa, the burden of non-communicable diseases (NCDs) remains under appreciated, but emerging evidence suggests it to be substantial. NCDs such as arterial hypertension, heart diseases, diabetes mellitus and chronic kidney diseases are especially relevant, and put additional strain on the already challenged health systems in this region. Moreover, NCDs appear to be associated with higher mortality and morbidity rates and are more common in younger population groups, in people from sub-Saharan Africa when compared to more developed countries. In this review, we summarize the current literature on the burden of NCDs in sub-Saharan Africa, and highlight the clinical implications of the most relevant etiologies, i.e. arterial hypertension, heart diseases, diabetes mellitus and chronic kidney diseases.

[Sustainably Anchoring Exercise as a Therapy in Health Care]. / Bewegung als Therapie nachhaltig in der Gesundheitsversorgung verankern.

Sustainably Anchoring Exercise as a Therapy in Health Care Abstract. Regular exercise reduces the risk of suffering from noncommunicable diseases such as cancer or diabetes. Within the framework of the National Strategy for the Prevention of Non-communicable Diseases, movement as a form of therapy is therefore to be anchored in health care in the future. Sports physicians have an important role as multipliers.