Non-communicable diseases (NCDs) are responsible for 60% of global deaths, posing a serious threat to low and high income countries alike. Previously a major concern in developed countries, NCDs rapid spread in the developing world has a severe impact on individuals, communities and economies. Today, nearly 80% of NCD deaths—29 million—occur in low-and middle-income countries.
Health innovators around the world are developing new models and approaches for the NCD epidemic. The Center for Health Market Innovations has identified 124 programs that are focused on NCD care. Within NCD care, major focuses include eye care, cancer, and diabetes. NCD programs are most common in South and Southeast Asia (see table two).
How are NCD programs organizing delivery?
Of the programs reporting on organizing delivery, 47% use a health service chain model, a group of health outlets operating under the same brand and owned by a single parent organization. 41% of programs operating a health services chain to treat NCDs are in India while 24% are in Central and South America. Clinicas del Azúcar is a low-cost diabetes care chain operating in Mexico. The chain was opened in response to a dire need for affordable and accessible diabetes care—90% of Mexicans lack nearby access to a treatment facility and wait times at the public clinic average 5-6 hours per patient. Clinicas del Azúcar offers fixed-cost membership options that are cheaper or comparable to the cost of public services. Using low-cost screening devices, evidence-based algorithms, and mobile health solutions, Clinicas has reduced the price of care by 60%, from USD $700 to $250 per year. This exciting, revenue-based startup aims to open fifty clinics in its first five years of operation.
Aravind Eye Care also operates under a health service chain model. Founded in 1976 to help eradicate blindness, Aravind is now one of the largest providers of eye care in the world, both in terms of service delivery and provider training. Operational efficiency, cross-subsidization, and health outcomes—which are on average better than those of a UK hospital—have made Aravind a model of high quality, low-cost care.
Achieving Financial Sustainability through Cross-Subsidization
56% of NCD programs that report on financing utilize cross-subsidization. This trend is particularly strong in eye care, where 9 out of 10 programs cross subsidize in order to provide affordable care to the poor, and is also common among cardiovascular programs. The Heart Institute of the Caribbean (HIC), for example, keeps costs low by buying durable, multiuse equipment, using telemedicine to connect specialists to multiple HIC sites, and utilizing electronic medical records to lower costs and improve accuracy. By providing affordable care that is comparable to US standards, HIC gives high-income Jamaicans an incentive to stay in-country instead of flying to the U.S. for treatment, generating local profits from cardiac services. Through HIC’s cross-subsidization model, this profit is re-invested to increase access to quality care domestically—every one high income patient who pays out of pocket subsidizes the same quality of care for four low-income patients in Jamaica.
Variations in Funding Sources
63% of NCD programs are primarily donor financed, with another 24% relying largely on revenue. Taking a closer look at those statistics shows a large variation in funding source by disease; for example, 80% of mental health programs and 75% of diabetes programs are donor financed, while 71% of kidney programs are non-donor financed. This trend maps onto patterns in funding source by prevention type; the majority of primary prevention programs are donor financed, while non-donor funding, including government and revenue, is common in tertiary prevention programs. One might speculate that donors are more attracted to primary prevention because of the ability to integrate it into existing programs and its relative low-cost, while tertiary care generally requires more funding, staff specialization, and permanent infrastructure. Similarly, low-income consumers might be more willing to pay for treatment out of pocket, but less willing to pay for diagnostic tests, preventative care, or counseling services, hence a need to subsidize those services with donor funding.
Cardiac care is financed equally by donor and non-donor funds, with some variation in the types of programs each funding source supports. As predicted by the larger database trend, donor financed cardiac programs often focus on primary prevention, while non-donor financed programs concentrate on tertiary prevention. On the donor financed side, programs are mostly concentrated in Africa, often have parent organizations, and target bottom of the pyramid patients. For example, FHI360 Cardiovascular Disease and HIV Prevention Program, in Kenya, is an FHI360-USAID financed pilot program which uses existing HIV clinic infrastructure to screen patients for cardiovascular disease. In contrast, revenue-based cardiac programs are clustered in India, serve a wider variety of income levels including the bottom 20%, and are more focused on improving treatment and quality of care in a hospital setting.
Using ICT to Increase Access
Reaching rural patients is a key challenge of preventing and treating NCDs. To meet this need, nearly 40% of NCD programs in the database use ICT to diagnose patients or virtually connect them with providers; this is most common among primary prevention programs. For example, Forus Health in India developed a pre-screening ophthalmology device called 3nethra, which can detect the five major ailments that cause 90% of preventive blindness cases. Those requiring further care are linked via telemedicine to secondary or tertiary care providers.
Working to solve a similar challenge, AMCARE in Bangladesh is an innovative diabetes care program that connects patients with providers through a call center; membership is open to all diabetic patients through a monthly subscription fee, ranging from US$.60 to US$20.00. By strengthening the relationships between patients and doctors and increasing monitoring, AMCARE increased patient’s adherence to treatment plans by 62% and reduced doctor/hospital visits from 5-6 per year to 1-2 per year. Due to AMCARE’s ability to improve health outcomes in its pilot phase, the Diabetic Association of Bangladesh is now working to scale the model, aiming to reach six million diabetic patients.
Not all access problems are due to a lack of infrastructure or providers in rural areas, however. In mental health, the barrier to access is predominantly social stigma. ICT innovations can provide a solution to overcoming that barrier by giving individuals valuable privacy and anonymity. E-counseling PULIH in Indonesia provides direct counseling services—free of charge—through text message, internet chat functions and emails. Similarly, Teen SMS to Stop Suicide in South Africa connects teenagers to a professional counselor in seconds. Teens can request help, get practical advice on depression and suicide, request in-person school talks, or be directed to local mental health resources. This program was created after learning that teenagers felt uncomfortable asking for these services verbally, but would communicate via SMS.
Globally, the NCDs burden is projected to rise by 17% in the next ten years; in Africa, it will increase by 27%. Health systems around the world are struggling to meet increased demand for NCD care, but innovators are continuously finding new ways to reach hard-to-access groups, increase affordability, and provide high quality services worldwide.
Stay tuned to the CHMI blog to learn more about NCD solutions!
Photo: Nurses and assistants receive training regarding eye care in the Swasth office in Goregaon, Mumbai. ©2013 Karen Dias for CHMI