Health Delivery

Socio-economic determinants of the cost of diabetes in India

Anil Kapur, Stefan Bjrk, Jyotsna Nair, Sanjeev Kelkar, Ambady Ramachandran

Diabetes is rapidly emerging as a major health-care problem in India, especially in urban areas where the prevalence of Type 2 diabetes has been reported as 12% of the adult population.1 Furthermore, there is an equally large pool of people with impaired glucose tolerance (IGT), many of whom will go on to develop Type 2 diabetes in the future. The World Health Organization (WHO) estimates the number of people with diabetes in India in 2000 to be 31.7 million, which is likely to rise to 79.4 million by 2030. In this article the authors report on the socio-economic factors affecting the costs of diabetes care in India.
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this problem. Many sociological factors determine the long-term outcome of health conditions: the ability of people to access treatment is dependent on their proximity to health facilities, the resources necessary to travel to these, and even knowledge of their existence.

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Poverty and the lack of health education exacerbate the problem of limited health care in India. The wider consequences Long-term consequences An illness affecting the wage-earning member of a family often also has a significant effect on others. In the absence of protection during illness or bad times through an effective social-security system, many people in India rely on the physical and financial support of their family in order to overcome medical crises or other social problems. As a result, children and adolescents may be forced to start work prematurely and at low wages significantly reducing their

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The need to prioritize distribution of limited resources in India has resulted in a public health-care system that tends to concentrate on the care of people with acute illness. Diabetes care provided in government health centres is free or of low cost. However, given the limited funds and infrastructure for chronic progressive conditions like diabetes, the quality of care suffers: public hospitals and clinics are crowded and ill-equipped. Insurance cover and cost-reimbursement for treatment in the private sector is marginal or nonexistent; here too the infrastructure for chronic care is limited. The lack of adequate facilities and financial capacity indirectly worsens long-term prognosis. Prevailing poverty and illiteracy, and the lack of health education exacerbate

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Complications are responsible for most of the diabetes-related direct health costs in India.

education and negatively impacting their long-term earning capability. Excess costs People with diabetes use more health-care resources than those who do not have the condition. This excess expenditure is related to the high cost of treatment for late-developing diabetes complications, such as eye damage (retinopathy) or kidney failure (nephropathy), as well as indirect costs resulting from lost work days or unrealized economic opportunity. The Cost of Diabetes in India (CODI) study, sponsored by the Novo Nordisk Education Foundation and the pharmacoeconomics department of Novo Nordisk, was a large community-based survey of diabetes costs, designed to provide cost estimates of diabetes care at the national level.3, 4 Table 1 gives the total overall mean direct and indirect costs of diabetes in India. Ambulatory care constitutes 65% of cost while the hospitalization cost is 35%. Cost of medications is 31% of which specific diabetes drug costs are only 17%. Ambulatory care including monitoring and doctor visits constitute 34% of costs.

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Factors influencing costs of care Late vs early diagnosis Diabetes is often diagnosed late perhaps too late: 50% of people with diabetes even in developed countries have complications at diagnosis. Untreated or improperly managed diabetes leads to serious and often life-threatening complications. Complications requiring multiple therapies and prolonged hospitalization are responsible for most of the diabetes-related direct costs. Among people with diabetes who are

hospitalized, the average annual direct costs are more than double those for people with diabetes who are not hospitalized. Complications are also responsible for indirect costs in terms of productivity loss and absenteeism. Education Many socio-economic factors affect the time of diagnosis and thus the outcome of diabetes. Consequently they also affect the costs. The level of education appears to be important. Whether this is related to greater

Table 1: Total overall mean direct and indirect costs (57 INR = ~1 EUR)

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Complications The factors that influence delay in diagnosis also determine the rate of complications. Place of residence seems to play an indirect role: people with diabetes living in the semiurban or rural areas have higher rates of complications despite less duration of diabetes than those in urban settings. This would appear to reflect delayed diagnosis and the availability of less-than-optimum or indeed the total lack of care. A similar trend is noted with regard to employment and socioeconomic status. Employed and working people with diabetes have fewer complications compared to those not working or those in rural areas engaged in agricultural labour. Among people with similar diabetes duration, larger proportions from the higher socio-economic strata are free of or have fewer diabetes complications (54% complicationfree; 8% with three complications), compared to the lower socioeconomic group (22% complicationfree; 26% with three complications). As might be expected, education appears to play a role in the development of diabetes complications. For people with a similar duration of diabetes, 45% of those who finished higher education had no complications, compared to 20% for the no-literacy group. While awareness alone cannot overcome the socioeconomic barriers to health, within the same socio-economic groups, people who are aware of the problem suffer fewer complications than those who are not aware. Similar

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understanding of the condition and therefore greater commitment to self-care, or whether it is a reflection of a better socio-economic status and therefore better access to medical care (or both), is difficult to say. Diagnosis can be delayed by 3-7 years in the less-educated and uneducated sections of the population. In the CODI study, the age of diagnosis was directly related to the level of education: college-educated people were on average diagnosed 7 years before people with no literacy. Despite a longer average duration

of diabetes, those with a college education had a considerably lower rate of diabetes complications (45% complication-free) compared with people with low or no literacy (20% complication-free). Unemployment Type 2 diabetes produces few symptoms and acutely is not life threatening. Often, weakness and tiredness are the only manifestations of the condition. While it is common for inactive unemployed people to ignore these symptoms (consciously or otherwise), those who are working are more likely to notice the signs as these influence the capacity to work. In the CODI study, compared to working people in urban areas, people in lower-income groups were diagnosed on average 4 years later as were people living in remote rural areas. People who are aware of diabetes before diagnosis or those with a family member with diabetes may be diagnosed earlier.

A person has impaired glucose tolerance (IGT) when their blood glucose (sugar) levels are higher than normal, but below the level of a person with diabetes. Most people with IGT are at increased risk of developing Type 2 diabetes.

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findings have been reported from the USA see article by Lisa Chew in this issue of Diabetes Voice. While the average annual direct cost for out-patient care for all people with diabetes was 4724 INR (82.7 EUR), the cost of care for those without complications was 18% lower, but 48% higher for those with three or more complications. As with ambulatory care, the cost of hospitalization increased with the number of complications. Conclusions Uneducated, unemployed people with diabetes who cannot afford or do not have access to even minimum healthcare facilities especially those living in semi-urban or rural areas are likely to be diagnosed late. They are at increased risk of developing diabetesrelated complications due to delays in diagnosis and/or improper treatment. Those who need expensive care for diabetes-related complications are often the very people who cannot afford it. borrow money in order to pay for treatment. Thus they enter the trap of debt with disastrous consequences to the individual and society. The presence and severity of complications are the most important determinants of treatment, monitoring regimen and the need for hospitalization. Therefore these represent the most important cost-related factor. Adequate and appropriate management can prevent, delay or arrest the development of complications both in Type 1 and Type 2 diabetes. There is growing evidence to suggest that this can be achieved through improved diabetes education and health awareness, and the promotion of self-care. Without effective preventative intervention in the form of life-style changes at society level, the diabetes epidemic will continue to grow. Secondary prevention can reduce the burden of complications through early diagnosis and proper care. Clearly, those involved in diabetes care delivery need to be aware of the factors that drive health costs. Effective treatment of diabetes is not costly; however, in both human and economic terms, not treating the condition is extremely costly.

Anil Kapur, Stefan Bjrk, Jyotsna Nair, Sanjeev Kelkar, Ambady Ramachandran
Anil Kapur is Vice-chair of the World Diabetes Foundation, Denmark. Stefan Bjrk is Senior Advisor and Health Economist at Novo Nordisk A/S, Denmark. Jyotsna Nair is currently Research Director AC Neilsen ORG Marg. New Delhi, India. Sanjeev Kelkar is Medical Director at the Novo Nordisk Education Foundation, Bangalore, India. Ambady Ramachandran is Director of the Diabetes Research Centre and MV Hospital for diabetes, Chennai, India.

References
1 Ramachandran A, Snehlata C, Kapur A, Vijay V, Mohan V, Das AK, Rao PV, Yajnik CS, Prassana Kumar KM and Nair J D. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001; 44: 1094-101. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes Care 2004; 27: 1047-53. Kapur A. Cost of Diabetes in India The CODI Study Paper presented at the Novo Nordisk Diabetes Update, Bangalore, February 2000. Bjrk S, Kapur A, Kelkar S, Nair JD, Ramachandran A. Aspects of diabetes in India: A nationwide survey. Research and Clinical Forums 2003; 25(1): 5-34.

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This has important socio-economic significance: those who need more advanced, more expensive care for diabetes-related complications are often the very people who cannot afford such care. While some of these people may be able to afford routine care, when burdened with debilitating and often life-threatening complications requiring expensive advanced care, many of them are forced to

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