Despite the increased coverage schemes of universal health insurance, unresolved challenges
still remain in the current health care model. The expected epidemiological changes
for chronic diseases in Latin American countries (LACs), will lead, in economic terms,
to catastrophic expenditures for the health systems (more than 10% of the health budget)
and for patients (more than 30% of the household income). Moreover, the governments,
institutions and societies of these countries will have to face strong competition
in the allocation of resources to universal coverage for other diseases [1].
Undoubtedly, talking about chronic diseases, diabetes is a global public health problem
of great relevance in LACs. In this sense, we will take diabetes as a tracer problem
of chronic disease challenges for universal coverage schemes in these countries. The
rapid growth of diabetes is a global event with broad challenges for public health
systems at a world level. Diabetes and its complications are a great economic challenge
for any scheme of universal coverage, particularly when it is present in older people
[2]. The challenges increase because in LACs, financial resources for health services
are more and more limited, a great part of these is allocated to curing and few resources
are used for prevention; on the other hand, a culture of self–care and healthy behaviors
is not very present in these countries [3].
We want to highlight the fact that in LACs, just as in other countries, we are also
facing a global problem that is generating a high catastrophic expenditure for all
of those who are involved. For example, in the case of Mexico, the same methodology
of a study conducted in 2004 was used to identify the costs generated in 2015 by diabetes
in the national population [4]. Results show the high impact on public health systems,
but also on patients’ pockets. Indeed, the demand for health care for older adults
goes beyond the capacity of the public health system and patients end up financing
most of the care for diabetes and its complications [5]. Indeed, of every US$ 100
spent on diabetes in Mexico in 2015, patients contributed US$ 54 and the public health
system contributed US$ 46. This evidence has considerable implications in terms of
equity and access to public health programs. In this sense, patients’ catastrophic
expenditures will increase and, above all, the high costs of lost productivity attributable
to temporary disability, permanent disability and premature death, generated by diabetes
[6].
The main objective of this essay is to highlight that the epidemiological and economic
trends reported by several studies in different years (2000, 2010 and 2025), show
a constant increase, despite the efforts made by the new universal coverage schemes
to reduce the impact of diseases such as diabetes. Also, we highlight the achievements
and challenges of universal coverage and how it relates to the prevention of diabetes,
and finally, we conclude with a list of possible strategies for the solution of this
problem in LACs.
WHAT IS THE PROBLEM?
In the context of universal coverage schemes without substantive changes in the health
care model of, diabetes has assumed one of the top trends in morbidity and mortality
in most countries of the world, generating great challenges for medicine and public
health. The World Atlas of Diabetes registry for 2015, reports 415 million adults
with diabetes [7]. This number will continue to Increase globally due to an aging
population, growth of population size, urbanization and high prevalence of obesity
and a sedentary lifestyle.
With respect to the place of diabetes in the epidemiological burden to the Latin American
region, a recent study reported diabetes and other chronic diseases as main causes
of mortality for all LACs. The relative weight of these diseases on the total burden
are in a minimum range of 62% in Costa Rica, with a maximum range of 84% in Chile
[8]. With respect to the impact on DALYS for 2011, the main reported causes are major
unipolar depression, alcohol consumption, asthma, dental cavities, cardiovascular
diseases and diabetes. For example, in the results by country, Brazil had a greater
impact, with a total of 37.5 million DALYS, a rate of 232 per one thousand inhabitants.
In Brazil, as in most LACs, diabetes mellitus was in first place, having 5.1% of DALYS,
followed by ischemic heart disease (5%), cerebrovascular diseases (4.6%) and depressive
disorders and asphyxia at birth (3.8%). In women, diabetes mellitus was in first place
(6.9%), depressive disorders in second (6.3%) and cerebrovascular diseases in third
place (4.5%). In men, assaults stood out (5.6%), ischemic heart disease (5.6%), cerebrovascular
diseases (4.6%) and diabetes (4.4%) [8].
With respect to the epidemiological burden at the global level in 2015, the top ten
countries, from greater to lesser impact, were (millions of adults with diabetes):
China (109.6), India (69.3), USA (29.3), Brazil (14.3), Russia (12.1), Mexico (11.5),
Indonesia (10.0), Egypt (7.8), Japan (7.2), and Bangladesh (7.1) Evidently, the DALYS
with greater impact are also for these 10 countries, led by China and India at the
global level, and by Brazil and Mexico at the level of LACs [9].
Moreover, from the perspective of the epidemiological transition, the latest Global
Burden of Disease study (GBD) reported that by 2010, diabetes [10], as a tracer of
the epidemiological transition in the world, is one of the biggest challenges being
faced by health systems and society. The challenges get more complicated, not only
in terms of mortality but also by generating growth and diversification in the demand
for health care services for resolution, in the framework of the health transition.
With regards to diabetes, contrary to the main purpose of the strategy of universal
coverage, the epidemiological transition phenomenon in economic terms, represents
a heavy burden in direct costs to the users’ pockets, to the health system and society,
and indirect costs attributable to premature mortality, temporary disability and permanent
disability attributable to the complications of diabetes [11]. Indeed, integrating
a database of several published studies, we analyze findings in seven Latin American
countries selected under criteria of diabetes prevalence, data on the epidemiological
and economic burden of diabetes, and income level: Cuba, Venezuela, Chile, Colombia,
Argentina, Brazil and Mexico. The comparative analysis of the 7 countries includes
epidemiological and economic trends reported by other studies for the years 2000 and
2010 and expected for 2025 [12]. The costs from epidemiological changes observed in
a group of countries selected for this essay, have increasing trends if current epidemiological
conditions and current models of care are maintained, mainly in Mexico, Argentina
and Brazil (
Figure 1
).
Figure 1
Comparative data of economic burden from epidemiological trends (observed 2010, 2010,
and expected 2025) in diabetes for selected Latin American countries (millions of
US$). Source: Developed by author with data from references [4,9–11].
On the other hand, in Latin America and the Caribbean, even with new universal coverage
schemes, many people with diabetes have limited access to health care; this means
that indirect costs may exceed direct health care costs. In terms of the response
of the health system, in recent years, health systems in most LACs have undertaken
adjustment, changes or reforms in national health programs trying to meet the goal
of universal health insurance. Longer life expectancy and fewer families who are impoverished
due to health reasons, are some of the results obtained in recent years following
the adoption of universal health insurance in these countries. Indeed, since 2005,
the new Health Insurance Program in Argentina has helped introduce historical changes
in universal coverage by the health system [13]. In the case of Brazil, the tax–funded
Unified Health System modernized the Brazilian health system, creating a national
coordinated service that the entire population can access. Investing heavily in a
“Family Health” primary care strategy in particular has been the vehicle used to carry
out major reforms allowing families greater access to health care through home visits
and community activities for better health.
In Chile, the “Social Health Insurance” program ensures nearly universal health coverage
for its 17 million inhabitants. From 2005, all Chileans have access to a basic package
that guarantees treatment for 80 health problems [14], establishing maximum waiting
times for treatment and discretionary spending. In Colombia in 1991, after establishing
the right to health in its constitution, 20 years later, access to health services
has improved considerably thanks to a national system of subsidized health insurance
[15].
In the case of México, covering more than 50 million people, the Popular Health Insurance,
with universal coverage strategies, promotes access to health care for all those who
lack social security. At the heart of the 2003–2018 health reform, this coverage package
includes more than 230 primary and secondary treatments for the entire population,
including interventions for diabetes and its major complications [16].
Despite advances in coverage under schemes of “Universal Health Insurance” in all
those countries, the epidemiological and economic burdens of problems such as diabetes,
far from resolved, continue with constant incremental trends which can be seen in
Figure 1
. Expectations are nothing favorable if major changes are not implemented in the models
of care. The problem is that even with more coverage and access to health care, the
health care model remains the same as when it began in the 1940s. This model is based
on a fragmented scheme with several institutions providing health care for people
in the formal economy (social security institutes) vs institutions for the population
in the informal economy (ministries of health) [17]. These institutions, dated from
the 1940s, provide health services based on a model of care with a biomedical curative
approach. In this sense, most of the national health expenditure goes to curative
health programs (90–95% depending on the country) and the results in terms of benefits
for chronic diseases such as diabetes, have not been favorable.
Summarizing, we note that aside from interventions from universal coverage programs
aimed at diabetes, it is necessary to review and adjust prevention strategies. We
already have enough evidence on prevention strategies, costs and effectiveness in
all regions of the world. In the case of LACs, this review has defined a list of 10
major prevention strategies (
Table 1
). These strategies consider, from different perspectives, the effects of changes
in lifestyle and/or the use of metformin or other drugs used to control blood glucose
levels, as the best options.
Table 1
Diabetes prevention strategies and implementation – challenges in Latin American countries
Prevention strategy from universal coverage
Implementation challenges
Institutional intervention for lifestyle changes and/or use of effective pharmacological
agents to prevent damage–complications in patients with diabetes or to delay the appearance
of the disease in pre–diabetic patients.
Difficulties and inadequacy of international standards in defining lifestyle indicators
from a biomedical approach. This leads to high rates of treatment desertion due to
problems related to institutional cultural aspects, drug availability and resistance
to changes in lifestyle. Pre–diabetes programs are only mentioned but not implemented
in practice, mainly due to lack of resources.
Intra–institutional and inter–sectorial programs promoting changes in lifestyle through
mass media programs.
Intra–institutional and cultural barriers in the definition, promotion and communication
of lifestyle indicators by country or region. Because of the fragmentation of the
health system, each institution implements its program according to its resources
and organizational culture. When involving inter–sectorial actions that require participation
of the health and education sectors there is no agreement or coordination.
Community programs for lifestyle changes centered on eating habits and diet. Directed
to 4 age groups: children, adolescents, young adults and older adults
Lack of knowledge and / or limited availability of healthy foods. Conflict between
suggested diets and consumption patterns and social and cultural determinants that
are difficult to change.
Community programs for changes in lifestyle focusing on physical activity
Lack of time and space for physical activity. Obesogenic environments determined by
cultural aspects depending on the country or region.
Programs to eliminate obesogenic environments at macro, meso and micro levels.
No proposal for intervention vs obesogenic environments involving actors from the
health–education and environment areas, working together.
Development of an integrated multicenter, multidisciplinary and inter–sectorial approach
for prevention of diabetes and its complications.
A biomedical approach continues to dominate, which is fragmented within each institution
and without involvement of social science disciplines. In health teams, doctors and
other professionals from the health sciences predominate but only rarely involve psychologists,
sociologists or anthropologists, despite the large indigenous population that generally
does not speak Spanish and with habits and customs that health personnel do not know.
Community prevention programs as part of universal coverage.
Lack of efficiency in the allocation of resources to start a phase of universal coverage
strategies. Problems of financial sustainability for consolidation stages of programs
focused on diabetes prevention.
National strategies for prevention of diabetes and obesity involving all actors.
Absence or very low participation of key stakeholders of civil society, community
leaders and entrepreneurs.
Strategy to impact on the assessment of prevention interventions.
Lack of financial resources, research teams and a culture of accountability at the
institutional or national/international levels.
Partnership Program for the Health System and Companies/Institutions working on prevention
of complications and to reduce disability from diabetes.
The health system has been unable to build solid partnerships with companies to develop
these programs. The social costs of disability attributable to complications continue
to grow in all countries.
The challenge for the universal coverage strategy in LACs is the design and implementation
of effective prevention strategies.
Table 1
also highlights the main challenges or problems that must be solved for a more effective
prevention of diabetes. These challenges are those subsequently taken up for analysis
of possible alternative solutions.
SUGGESTIONS FOR A POSSIBLE SOLUTION
Increased coverage by “Universal Health Insurance” schemes has not been sufficient
to meet the challenges of chronic health problems in LACs. In terms of changes in
the health system with any scheme of universal coverage, the main adjustment should
be related to the transition from one system of care based on a biomedical, curative,
fragmented and inequitable model toward a socio–medical model, preventive medicine,
which is comprehensive and equitable. This will enable more effective detection and
control with a consequent decrease in the effect of complications and treatment desertion.
In most LACs, of every 100 patients with diabetes, only 50 are diagnosed and of these
50, only 30 remain in control. With a more effective universal coverage, these indicators
should change with new strategies for detection and control.
Effective universal coverage involves approaching diabetes from an interdisciplinary
perspective to promote a change in the concept and determinants of diabetes, as well
as a change in the social meaning of the disease and greater involvement of users,
civil society and businesses. It requires allocating more resources to design, implement
and monitor strategies to move from addressing diagnosed patients to strategies for
the pre–diabetes population. In all LACs, there is little or no intervention for this
population.
Development and validation of new methods are need to evaluate the epidemiological
and economic burdens in terms of direct costs of care and indirect costs (temporary
disability, permanent disability and premature mortality). For more effective coverage
schemes, in all LACs it is necessary to adjust/implement new models of care and health
management that can respond to the diversification and quantity of health services
that will be generated by the epidemiological transition in chronic diseases, particularly
in patients with diabetes or hypertension.
WHAT NEEDS TO HAPPEN NEXT?
As part of an effective universal coverage scheme by universal health insurance, the
proposed changes in reforms or adjustments in the health system in LACs, should put
emphasis on changes in the health care model with a greater focus on the level of
primary prevention. The following strategies are highlighted in order of priority:
The current model of care must go through a detailed review, to propose changes in
the physical infrastructure and the training of health personnel with a focus on prevention.
We must develop infrastructure to expand screening programs, for more detection, prevention
and control. We also have to implement changes in the continuing education programs
for health personnel to enable a greater focus on primary care (mainly for physicians
and nurses). We also suggest integrating social science professionals into health
programs (medical anthropologists and medical sociologists) to form part of the health
team to implement new strategies for detection, prevention and control of chronic
diseases.
Develop new financing schemes with greater allocation of resources to new programs
for screening and prevention in the pre–diabetes population.
Design and implement systems for epidemiological surveillance and monitoring of the
economic burden for a periodic measurement that allows us to know and assess (preferably
on an annual or biannual basis) the impact of new strategies on epidemiological trends
as indicators of direct and indirect costs.
Establish patterns of resource allocation to ensure the financial requirements to
address diabetes based on expected demand. These patterns must integrate indicators
on clinical efficiency (inpatient and outpatient cases), epidemiological efficiency
(new cases of diabetes from expected trends in the short term), organizational efficiency
(number of cases to be taken care of by level of care) and economic efficiency (average
cost of case management by level of care).
Knowledge of the relative weight of the management of diabetes based on the annual
family income, as well as required knowledge of the cost of complications to the users,
should be made available through a bulletin sent to patients and their relatives,
and to the community as a whole.
Photo: The difference infrastructure for curative care vs. primary care in Mexico.
Courtesy of the author.
A list of recommendations is needed to promote greater self–care, monitoring of risk
factors and the benefits of carrying out these measures, and more importantly to avoid
falling into a catastrophic situation because of the costs of diabetes (to avoid an
impact of >30% of the family income).
As a “Regional Observatory Citizen of Diabetes”, social civil organizations could
suggest and develop follow–up programmes for the costs of diabetes in different public
and private health institutions. The Observatory should function as a checking system
that would monitor how much is being spent on managing diabetes and what the money
is being spent on.
With regards to the indirect costs of premature mortality and temporary and permanent
disability attributable to diabetes, companies must establish new partnerships and
agreements with the health system and workers to have positive gain in economic competitiveness
and labor productivity. This will require developing new programs in the workplace
for increased detection, prevention, treatment and control of diabetes and its complications.
In most LACs, the strategy to expand coverage through various schemes of “Universal
Health Insurance” presents evidence of benefit and greater access to health care in
general but with some limitations in the current shape of the health systems. Indeed,
the structure of the health system in which they operate such strategy is the very
structure of the past half century, with a focus on curative care.
The groups of patients with diabetes could collaborate on joint actions with the health
system in order to promote universal coverage schemes, new actions based on the perspective
of “health behavior” with a vision of diabetes as a “life condition”, more than a
health problem.
All these strategies should place a greater emphasis on actions to move from a model
of biomedical care based on curative medicine to one of universal insurance focused
on socio–medical health care based on preventive medicine. Like this, LACs can more
effectively face the current public health challenges for chronic diseases like diabetes.