Today, the healthcare industry is changing colours like a chameleon. From the dominance of the primary colours of acute care, the shift is evident towards the softer hues of chronic care. Popularly known as A2C Shift, the phenomenon is common to the developing as well as the developed world, albeit with a difference. Less developed countries will be hard-pressed to cope with the challenges given their lower levels of economic development and access to adequate health care.
In the current healthcare environment, several strategies are sought to break the clutter in acute care for infectious diseases, GI upsets, pain and the likes. Is there enough attention on the population ageing that sees an increase in demand for chronic care? Unless we study this emerging segment, we may be feeding problems and starving opportunities. Let’s look at factors which are influencing this shift.
An ageing population
The world’s population is aging, primarily as a function of declining fertility, coupled with increasing life expectancy. About 65 percent of the world’s population who are 60 years and above, lived in developing or underdeveloped countries in 2010, and this proportion is projected to be 80 percent by the year 2050 (U.S. Census Bureau, 2012).
The health status of the aging population is essential not only to those who comprise this age group, but also to the population as a whole, because of the impact on social and economic system. As the older population grows not only in size, but more importantly in their proportion of the total population, the potential implications for society will be increasingly salient1
Population aging is likely to be accompanied by an increase in chronic disease burden.
It is estimated that 26 percent of the total burden of disease in India in 2004 was from people aged 45 and older, and this figure is projected to increase to over 46 percent by the year 2030 (Chatterji, et al., 2008). The aged population in India has grown very steadily since 1951, but at a much faster rate as compared to that of general population.
Whereas socioeconomic development tends to be associated with healthy behaviours, rapidly improving socioeconomic status in India is associated with a reduction of physical activity and increased rates of obesity and diabetes. Coupled with a sedentary lifestyle, energy dense food consequential obesity, an ageing population suffers from one or more common chronic diseases such as stroke, hypertension, arthritis, cancer, cardiac problems, respiratory problems, arthritis and mental problems along with the queen of chronics – diabetes.
In the 1970s, only 2.1% of Indians living in urban areas had diabetes. Today, that figure is 12.1% for adults over the age of 20. It is estimated that almost 41 million Indians are diabetic, and that figure is expected to reach 73.5 million by 2025. The total annual cost to treat India’s diabetic patient (including direct and indirect expenses) is estimated at $420 per capita. If that per capita expenditure were to remain constant, the total estimated cost of treating the disease would reach $30 billion by 2025.
Crumbling informal support
India has strong familial structure and hence dependency. Elderly in India have relied heavily on their families for personal care and material support. Among economically dependent elderly men 6-7% was financially supported by their spouses, almost 85% by their own children, 2% by grand children and 6% by others. Of elderly women, less than 20% depended on their spouses, more than 70% on their children, 3% on grand children and 6% or more on others including the non-relatives 2
Today, this support is under pressure. Decreasing fertility rates (fewer children as caretakers), increased longevity, migration of children (from rural to urban and urban to international) are shaking the foundations of traditionally strong familial support which means that either center, state or the elderly themselves will have to take care of their chronic ailments. Overall the government has been sympathetic, through the adoption of the ‘National Policy on Older Persons’ in January, 1999. The policy provides broad guidelines to State Governments for taking action for welfare of older population.
Expanding Middle Class
While on one hand we have the dwindling incomes of the elderly in rural India, the urban India is witnessing an expansion of the upper middle class.
% of entire Middle class population
2009–10 (estimate) 62.95
Source: CRIS Infac, 2005
India’s thriving economy is driving urbanization and creating an expanding middle class with greater disposable income to spend on healthcare. While per capita income was $620 in 2005, over 150 million Indians have annual incomes of more than $1,000. So there may be an upcoming segment of the economically comfortable elderly with sizeable disposable incomes.
The need for cost sensitive alternatives
In India, most of those who have worked in organized sector get pension and other retirement benefits after attaining the age of superannuation varying between 60 to 65 years. But for others, Government of India and State Governments, at present, have very nominal old-age pension coverage. It varies from Rs. 75/- to 150/- in a month. In addition some other additional benefits for the elderly are also being provided by the Central and State Governments. But much is to be done as at the old age their medical expenses go up and dependency on children / relative goes up for physical, mental and economic support.
Risk factors and awareness
Estimates of deaths attributable to nine chronic disease risk factors4
Awareness programs to propagate physical activities, nutrition, hazards of tobacco use, weight control, blood pressure control, diabetes management, arthritic management and regular preventive checkups will be in the forefront. The risk factors in chronic care will be a burning agenda.
Mortality and disease burden attributable to nine risk factors for chronic diseases have been quantified for India.
As the burden increases on HCP-managed care along with costs, patients are bound to look for alternatives. A large fall out of this could be the emergence of consumer-managed care and hospital-managed care. In response to reduced central funding and restricted opportunities for states to raise more money for public funding of health services, Indian hospital services have become an investment opportunity for corporate and multinational enterprises and a strong health insurance market is emerging. Since more patients will seek care, the gravity may shift from treatment to prevention. A whole new world of “preventive care” may emerge as an answer to the growing demand for health care and for improved quality of life for the elderly.
Primary prevention looks at target populations before a disease develops. This could include private, government and corporate funded preventive health care and awareness initiatives. Even for the current cost-effective prevention strategies available, implementation is generally low. Companies with chronic care portfolios may well be looking at this window of opportunity, besides the new age corporate hospital chains such as Fortis, Apollo, etc.
Secondary prevention involves identifying and treating high risks and preventing recurrences. This may see the increasing use of preventive medicines such as aspirin, B-blockers, statins, nicotine replacement therapies and the much touted poly-pills.
Treatment or tertiary care involves managing clinical diseases to prevent them from progressing or to avoid complications. Escalation in the number of pharmaceutical providers and the expansion of their offerings basket is inevitable. However, it’s interesting to note that according to WHO reports, adherence to long-term therapy for chronic illnesses is only 50% in developed countries. In developing countries, the rates are even lower. This is particularly important in certain markets, such as smoking cessation and obesity, where launch products are susceptible to boom and bust early. Very strong launch uptake, followed by an equally rapid decline, either as patients abandon the course midway, or physicians cease to initiate, due to disenchantment with the product.
Supply chain dynamics
As focus spreads from HCP managed care to self managed care, the growing wellness, OTC and self help diagnostics may need alternate supply chains.
The A2C shift is evident. The demographic and epidemiological transitions that are in progress have important implications for individuals, families, corporate and healthcare setup in India.
It’s time to master the A, B of the C.
Rashmi Thosar, Director – Brandcare
- Shades of Gray: A Cross-Country Study of Health and Well-Being of the Older Populations in SAGE Countries, 2007–2010
- Central Statistics Office Ministry of Statistics & Programme Implementation Government of India
- See more detailed discussions on the worldwide trends in population aging in Kevin Kinsella et al., An Ageing World: 2001 (Washington, DC: Government Printing Office, 2001)
- India: Towards Universal Health Coverage 3 Chronic diseases and injuries in India – Lancet 2011; 377: 413–28
- Healthcare in India Emerging market report 2007 – A report by Price Waterhouse Cooper
- WHO – Adherence to Long term therapies. Evidence for action (Geneva : WHO 2003)
- Haynes RB. Interventions for helping patients to follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2001, Issue 1
- Chronic Care Driving a Fundamental Shift in Healthcare Supply Chains, Dr. Mahender Singh