Often, the costs of health services are the reason that people fall into poverty. The poverty of many people with diabetes results in trade offs between expenditure for drugs and transportation on one hand, and food on the other. The lack of consumer information makes people vulnerable to marketing strategies.
There does not exist enough protection against such costs. From the sparse data that exist on this subject, it appears that chronic diseases sharply increase the risk for people to run into debt for health care. High risk debtors, which poor people typically are in the eyes of their creditors, pay the highest interest rates for such debts: 2% per day is not an unusual rate in an urban slum community. If the interest rates are high, the poor may lose one of their few valuable assets as a consequence. An often quoted survey shows that half of the poor who had lost their land, said it happened because of health care related costs (Making the poor more visible, landlessness and Development Research Report, where has all the land gone, Vol 4, Robin Biddulph, Oxfam GB Cambodia Land Study Project, 2000).
In the early nineties, Cambodia's public health system had to be rebuilt after decades of war. International experts and donor agencies designed a public health system where most resources are concentrated on communicable diseases, while ignoring the so called "non communicable" diseases, many of whom are in fact chronic diseases. As a result of this omission, Cambodia's "modernized" public health system is unsuitable for its future because it does not know how to deal with chronic patients. Diabetes and hypertension are much more prevalent than previously thought. The reasons for this are not well known, but experts think that a certain genetic predisposition of Cambodians plays a role as it does among people from Indian or Chinese origin. A new health reform is needed.
If we forget for a moment about the ethics, it appears to make sense that developed countries prioritize the communicable diseases such as AIDS and HIV when they commit their funds because it allows rich countries "to also help themselves by helping others".
Lack of policy also means that diseases are not recorded. As long as there are no data there are also no problems, which perpetuates the lack of policy and vice versa. But as every Cambodian medical doctor can tell you, Cambodia’s poor and extremely poor suffer from non communicable diseases such as diabetes, hypertension, gastric ulcers, arthritis and heart problems. Suffering from these and the chronic nature of the diseases cause people and their household members to remain trapped in poverty. The surprisingly high diabetes and hypertension prevalence in Cambodia are probably just the tip of the iceberg.
This invisible epidemic is an under-appreciated cause of poverty and hinders the economic development of many countries. Contrary to common perception, 80% of chronic disease deaths occur in low- and middle income countries.
If poverty is to be halved by 2015, the financial drain on households with a chronically diseased family member needs to be reduced. More agencies need to wake up to the challenges ahead and facilitate the design of appropriate low-cost technologies and interventions that are affordable for a country like Cambodia.
Findings of diabetes treatment in Cambodia:
- Supplies of essential anti diabetic drugs including insulin through the regular public health services need to be improved. At the moment, the public health system (except for vertical programs like AIDS, Tuberculosis, Leprosy) prescribes medicine only for 3 to 5 days, but diabetes and hypertension require medication for life.
- Insulin is sold at too high prices (USD 16 per 10 ml) and is difficult to get.
- There aren't enough medical doctors trained in treating diabetes and its co-morbidities. By using peer educato rs to teach other patients how to self-manage the continuum-of-care in diabetes and hypertension, treatment can be made "affordable".
Chronic illness and poverty: Exploring the links
One major component of work on social protection and heath within the Future Health Systems program is the POVILL (Poverty and Illness) research project. This was designed to better understand the potentially complex impacts of serious ill-health in rural areas of China, Cambodia and Laos. It focused on ‘major illnesses’, health problems with the potential to seriously damage household livelihood strategies and increase the risk of impoverishment.
In 2010, MoPoTsyo became member of the WHO's Alliance for Health Policy and Systems Research. This research unit based within WHO commissioned MoPoTsyo to start documenting its intervention. The work consists of 3 outputs. The first deliverable is a international literature review which can be downloaded here.