Are health systems ready for the chronic disease challenge?

A recent study documenting the shift of chronic disease from the rich to the poor is the latest piece of evidence generated by icddr,b scientists to highlight an alarming upcoming challenge for health systems in Bangladesh

Findings based on 24 years of surveillance data from icddr,b’s rural Bangladesh field site Matlab show that the burden of chronic disease—long-lasting conditions like diabetes and heart disease—is shifting from the rich to the poor at an increasing rate. This is due to longer life expectancies at birth, but the scientists say that it is also as a result of a self-sustaining cycle of poverty, because chronic disease is a heavy economic burden and household income can be negatively affected after the death of a family member. These findings join an already substantial body of research that suggests that chronic and non-communicable diseases are emerging epidemics in Bangladesh, and that they will be major challenges for existing health systems to overcome in the future.

Photo by Asian Development Bank. CC BY-NC-ND 2.0.

Last year’s Global Burden of Disease report, for example, shows that Bangladesh has been very successful at reducing mortality from threats like diarrhoeal disease – but that changing diets and increasing average life-expectancy in the general population mean that the disease burden has shifted towards non-communicable diseases like chronic obstructive pulmonary disease and diabetes. In another recent paper, two icddr,b surveys found that most female adult deaths in Bangladesh were due to maternal causes in 2001, but by 2010 they were primarily caused by malignancies like cancer.

Hypertension a particular concern

Hypertension, a precursor to diabetes and a serious medical condition in its own right, is a particularly important problem in Bangladesh. According to a recent review, approximately 20% of the adult population is affected by hypertension –high blood pressure. Worryingly, another study documented that as many as 11% of hypertensive adults under 60 in rural Bangladesh are unaware of their condition, partly due to poor diagnostic facilities. Of those that have been diagnosed, more than 50% do not control it properly with medication. This non-adherence to treatment has been found to be most likely when diagnosis and treatment was sought from unqualified health workers, or village doctors. These informal healthcare providers are estimated to diagnose almost 40% of all hypertension cases in the country.

Risk factors for these diseases, like overweight and obesity, are also on the rise. Surveillance data over 19 years in Bangladesh shows that the percentage of obese urban children increased from 0.6% in 1993 to 2.6% in 2012.

What are some solutions?

A recent non-communicable disease scorecard, published in The Lancet, called for a robust surveillance system to address these increasing rates. One solution could lie in training community health workers to assess chronic and non-communicable disease risk and make referrals—this strategy was used to some success in a multi-country study that trained community health workers to assess cardiovascular risk. However, referral outcomes were ultimately mediocre, due to the limitations of the healthcare systems and poor perception of disease by the patients themselves.

Although conditions of undernutrition like stunting and wasting have decreased, deaths from communicable diseases are less common and fewer women are dying during or as a result of childbirth, these studies show that overall progress in health does not necessarily mean fewer demands on health systems.