Sunday, April 4, 2010

Disease Management - The way forward for Healthcare

A call to Action - Best route to Healthcare ,The DM way
From time immemorial, man has been interested in trying to control disease. In ancient times, health and illness were interpreted in a cosmological and anthropological perspective. In the course of evolution, which proceeded by stages , with advances and halts, healthcare has truly undergone a momentous metamorphosis. From the initial disease control phase to the present “Health for all” phase, the journey has been truly remarkable.

Health and healthcare though used interchangeably, need to be distinguished from each other; for no better reason than that the former is often incorrectly seen as a direct function of the later. Health is not just absence of disease, it is about ‘Fitness’ and the ability to realise one’s potential to the fullest possible extent.

Higher healthcare spending is questionable from the very fact that US spends the most on healthcare per capita as a percentage of GDP, but ranks 22nd out of OECD countries in terms of life expectancy (OECD Health data 2005).

So it needs more than just spending on healthcare . It calls for ‘thinking small’ , organise care from a patient’s point of view , establish a patient centric care continuum, balance between private versus public interests in sharing risks and responsibilities, sharing an information platform and providing basic health benefits within the context of societal priorities.

The origin of Indian healthcare system can be traced to the colonial medical services that emphasized costly high technology , urban based , curative care catering exclusively to the imperial men. When we became independent in 1947, we inherited healthcare systems modelled after the systems in industrialised nations . This lead to a mismatch between service and demand as the existing problems of the time varied significantly from the available solutions.

The U.S. National Center for health statistics defines chronic diseases as one that persists for a long time i.e. for 3 months or more, e.g. Cardio vascular diseases , cancer, diabetes & obesity etc.

Let’s study some of the statistics

WHO estimates that 388 million people will die worldwide from chronic diseases in the next 10 years. WHO estimates that 36 million of these deaths could be averted.

Four out of five chronic disease related deaths happen in the low and middle income countries

Almost 66% of all deaths in 2020 would be from chronic diseases.

India being the largest democracy in the world, has 2.4 % of the land area , but it supports 16 % of the world population. 72 % of the population lives in rural India.

Population living below USD 1 a day is 44.2 % - Source UNFPA

More than 30 % of the population is illiterate

Density per 1000 population - Doctors -0.60 (2004), Nurses – 0.80, Dentist – 0.06, Pharmacist 0.56 – 2003 data, Hospital beds -0.70 . Source – WHO

Two persons die of TB every minute

75.3 % of children below 3 years in age in rural areas and 70.8 % in urban areas are anaemic

Chronic kidney disease affects about 175 to 200 million in India – Study by Indian society of nephrology and University of Harvard, reported in The Times of India, March 12,2008.

National Kidney Foundation in 1994 had found that every fifth person ( age 25-45 Years) had hypertension and every seventh person had diabetes.

At present, three million new people are diagnosed to be suffering from cancer every year. Fifty-three percent of all deaths in India are due to non-communicable diseases, and the estimated loss to India’s economy – just due to heart disease - was over US$ 9 billion in 2005.

Projected Deaths by cause , 30-59 years, 2005 (Annual report of MOHFW,GOI. 2006-7)

In India as per MOHFW Annual report GOI , 2006-7 . The number of deaths due to Cancer -826000 , CVD-2980000 , Diabetes – 175000, Respiratory diseases – 674000.
Per capita expenses ($) on health in India is 23 USD

Private health insurance coverage as a percentage of population < 2 %.

In India , medical cost of diabetes care from private healthcare providers could be as high as 15-25 % of the household income ( Shobana et al.2000)

Even Rural Bharat has not been spared- the prevalence of diabetes has gone up from 2.4 per cent of the population to 6.4 per cent. Chronic kidney diseases have a prevalence rate of 24.3 % in urban areas and 9.2 % in rural areas.

Clearly, centuries of medical science has not been successful in addressing sickness and disease, which cause social and economic upheaval for millions around the world. The time has come for a comprehensive paradigm change in basic healthcare delivery.
It is a fact that India would need 1.2 million doctors by 2012, and at present has about 600000 doctors. Suddenly, we cannot produce so many doctors . But what we can essentially do, is to create a system that can prevent people from reaching a stage where they need a doctor intervention.

Going forward , disease management is the way to healthcare.

How do we define disease management (DM ) – Some definitions :

A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare

DM consists of preventive, early identification and management processes providing a cost effective, quality care for individuals who have or are at risk for certain chronic illnesses.

A philosophy towards the treatment of the patient with an illness (usually chronic in nature) that seeks to prevent recurrence of symptoms, maintain high quality of life, and prevent future need for medical resources by using a comprehensive approach to health care.

Disease management (DM) is the concept of reducing healthcare costs and/or improving quality of life for individuals with chronic disease conditions by preventing or minimizing the effects of a disease through integrative care

DM has been proven to lead to better retention of patients & better compliance to therapy, thereby leading to better outcomes from the treatment.

India needs a different kind of Healthcare system. A system that focuses more on prevention .

We don’t need a survey on the incidence of chronic diseases. Take my point, and do a quick authentic survey right now . In the next two minutes you will be shocked at the findings. If you are sitting with a few colleagues or friends , Just ask them one question.

Is anyone in their immediate family having any of this chronic condition; arthritis, diabetes, High blood pressure , Cardiac ailment or cancer ? In all probability , you will get one person per family having at least one of such chronic disease. This is with people like us in urban India who have been diagnosed. Now think of 72 % of the rural population and 30 % of illiterate population ? Disease never differentiates between urban and rural or literate or illiterate . We are sitting on a ticking time bomb when it comes to healthcare.

The way forward for healthcare in India can be developed keeping in view the following
• 92 % of the healthcare spend comes from individual pocket
• Best of healthcare facilities are concentrated in the urban areas
• Healthcare at the later stages of chronic diseases is expensive and the diseases progress rapidly if unchecked .The process of progression is irreversible
• 44.2 % of the population in India lives below USD 1 per day.
• Per capita expenses ($) on health in India is 23 USD
• Awareness about symptoms and diseases is totally missing . Government is only talking of HIV / family planning
• US system proves that more spends does not lead to healthy population
• 1.5 lakh new patients get end- stage renal failure every year. Of these , only 3500 undergo kidney transplants. About 6000 get dialysis while the rest perish. In India as per MOHFW Annual report GOI , 2006-7 . The number of projected deaths due to Cancer were-826000 , CVD-2980000 , Diabetes – 175000, Respiratory diseases – 674000.

So going forward we need to do the following.
1. Focus more on prevention than cure
2. Government must give major thrust to self care.
3. Make basic health check ups like BMI, BP & Sugar mandatory. We could just start with BMI and those having BMI higher than 25 must be asked to do a further investigation. BMI could be checked by an individual as it does not require any diagnostic kits . Just needs a weighing machine and a height scale. No consumables are required , so it can be checked for free. This could be the starting point .
4. Set up instant testing centers across India , mobile vans to reach to the 72 % of the population- rural India
5. Get the best technology for remote monitoring and treatment and make it affordable
6. Government must promote healthy lifestyle and launch a massive drive against chronic diseases . ( point to note -In 2005 , the U.S. introduced new dietary guidelines and set up a website in which individuals can track their food intake and exercise . In the first 72 hours of the website’s existence , it logged 160 million hits , with 20 % of them originating from outside the U.S.-The Washington post, April 26, 2005.)
7. NHRM should essentially focus on prevention & early detection of chronic diseases
8. All hospitals should involve care givers for disease management post discharge of the patient who have undergone procedures for chronic ailments.
9. Government must initiate disease management in all its facilities
10. All chronic patients should be encouraged to voluntarily take disease management programs
11. Government must recruit counsellors to reach out to the population and encourage them to practice healthy lifestyle.
12. Fitness should be the aim of the healthcare efforts of the government of India
13. Private players must play a proactive role

I am aware that a lot of international players are looking at coming to India and make money from disease management . But it is still a good 2-3 years away. It is the right time for the Indian healthcare companies to act and occupy a dominant position in this arena, Disease management is a proven system which can reduce the healthcare cost and improve the healthcare outcomes for the beneficiaries. It has been developed over a period of time and is a big industry the world over today. In India , where the government spending is not only deficient but the facilities are also inefficient, I believe that we need to make a paradigm shift from the ‘System driven Care to a Care driven System’. If India does not introduce disease management or wellness programs, it stands to lose approx USD 200 billion in national income due to deaths from heart disease, stroke and diabetes from 2005-2015 ( Source : An estimation of impact of chronic non communicable diseases in selected countries, WHO 2005).

Do we take such a big hit ? Choice is ours , now. It is a call for action

Rajendra Pratap Gupta
Email :
Disease Management Association of India ( DMAI)
Website :