Thirty-eight million people die each year from chronic diseases and over 14 million of these deaths are among those aged 30 to 70. Chronic disease is the leading cause of death and disability worldwide, surpassing infectious disease. In response to the rising rates of chronic disease, it’s no surprise that countries are crying for help. What poses to be problematic is the fact that these premature deaths are largely preventable if governments implement frameworks to reduce the risks of chronic disease and promote healthy living. As such, the World Health Organization (WHO) launched a Global Action Plan in 2013, for the prevention and control of non-communicable diseases. This action plan outlines a trajectory for WHO Member States to follow, based on nine global targets to reduce chronic disease. The WHO hopes to reduce premature mortality from chronic diseases by 25% by the year of 2025. More specifically, WHO Member State countries Canada, Australia and Tanzania, have developed frameworks to mitigate the personal and financial costs of chronic disease, which will be explored further in this blog post.
Chronic disease not only has negative repercussions on individuals, but it also has a significant economic impact on our healthcare system. People who suffer from chronic conditions are high-system users, which means that they use health services and medicines more frequently and for an extended duration. Subsequently, the issue not only lies in the rise of chronic conditions, but the fact that individuals are being diagnosed with multiple morbidities, which is associated with high healthcare expenditure. This expenditure is often a direct result of admitted patient hospital services, outpatient services and medications. In addition to the direct impact that chronic disease has on the healthcare system, there are also indirect costs to individuals. Namely, loss of independence, isolation, stigma, caregivers’ burden, and discrimination, to name a few. Further, chronic disease can play a significant role in economic productivity, as individuals with chronic conditions often have to take time away from work, which not only places them in a position of financial constraint, but negatively affects the system as a whole.
It is estimated that major chronic diseases and injuries account for over 33% of Canada’s direct healthcare costs. Including both indirect and direct healthcare costs, Ontario’s chronic diseases and injuries account for 55% of costs. Namely, Ontario suffers from healthy life lost due to premature mortality, loss of productivity as a result of disability, and direct healthcare costs. It is also becoming increasingly more common for Ontarians to be diagnosed with multiple chronic conditions. This, in turn, has a negative impact on the healthcare system as these individuals are frequent users of the system and resources. Despite the alarming rates and costs of chronic disease in Ontario, these conditions are largely preventable by targeting modifiable behaviours and intermediate biological risk factors. However, to actually enact this requires a system re-design, as our current healthcare system was designed to treat acute illness, rather than chronic disease. This means that we need to shift from a reactive approach to care, towards a proactive approach to care. To account for this shift, the Ministry of Health and Long-Term Care (MOHLTC) has developed a framework to guide the redesign of healthcare practices and system changes. Ontario’s Chronic Disease Prevention and Management (CDPM) Framework is an approach that is evidence-based, client-centred and focuses on the prevention and management of chronic conditions. The CDPM Framework aims to provide multi-faceted care in which clients are actively involved in managing their chronic diseases and are supported doing so. Additionally, the CDPM works to not only improve the health of Ontarians, but also reduce rates of chronic disease through increased prevention and promotion in clinical practice and the community. Thus, in theory, the Framework’s approach will save the healthcare system a significant amount of money by reducing hospitalizations and emergency department visits and supporting individuals in living healthily. Further, this blog post will compare and contrast Canada’s approach to chronic disease prevention and management, to that in Australia and Tanzania.
Similar to Canada, chronic disease is the leading cause of illness in Australia. Cardiovascular diseases, oral health, mental illness and musculoskeletal conditions account for the costliest disease groups in Australia, costing the healthcare system $27 billion dollars in 2008-2009. This is equivalent to 36% of Australia’s allocated health expenditure, which is comparable to Canada, as noted above. Like Canada, Australia also suffers from the direct and indirect costs of chronic disease. Namely, most of Australia’s health expenditure is a result of admitted hospital services, out-patient services, medications and dental services. In contrast, indirect costs of chronic disease in Australia include loss of independence, social isolation, stigma, and disability impacts. Also similar to Canada, Australia’s health care system was mainly reactive, which meant that it focused on treating illness rather than preventing it. As a result, Australia has had to adapt to support individuals dealing with chronic conditions and has taken an integrated approach to do so.
Australia’s National Strategic Framework for Chronic Conditions (NSFCC) focuses on the prevention of chronic disease, provides efficient, effective and appropriate care, and targets priority populations. Australia is similar to Canada in its approach; however, something that differs between the two is Australia’ focus on individuals who are disproportionately affected by chronic disease. Australia notes that some populations are at a higher risk for chronic disease due to their physical environment, social and cultural determinants and behavioural risk factors. As such, Australia claims that equal focus is not sufficient, as priority populations face unique barriers that cannot be solved with a broad lens. Instead, Australia recognizes the diversity of people and the different strategies to be employed for urban, regional, rural and remote locations. Though Canada also has priority populations (i.e., Indigenous people, seniors), the CDPM framework does not take into account the diverse needs of such populations. Rather, the CDPM targets chronic disease in Canada as a whole, which proves to be problematic as the needs of priority populations and the general population are often incompatible. In contrast, Australia considers those who are negatively impacted by chronic disease more than the general population, by explicitly outlining objectives to reduce risk of chronic conditions in the specific populations. Though Australia’s framework is relatively recent, and its success is unknown, Canada could learn from the goals that Australia sets out to achieve, as priority populations face unique barriers and predispositions to chronic disease that are worth exploring and targeting on their own.
In contrast to the frameworks implemented in Ontario and Australia, Tanzania faces a double burden of disease. This means that the country is impacted by both chronic and infectious disease, with chronic disease recently surpassing. This proves to be problematic for Tanzania, as they are accustomed to treating infectious disease and as a result, resource allocation is skewed. In 2005, chronic disease in Tanzania accounted for 20% of all deaths. This is mainly due to the nutritional transition, which is becoming increasingly more common in low-income countries, such as Tanzania. The nutritional transition is a term used to describe the increase in consumption of highly refined and processed foods, as well as sedentary lifestyle. This transition is driven by urbanization, and globalization, which although can improve economic development, also have major costs on the health of individuals. Additionally, in 2005 it was estimated that chronic disease cost the healthcare system $100 million USD, and this number is expected to rise to $500 million USD by 2025. Related direct and indirect costs include financial costs associated with treatment and medication, loss of income due to illness, reduced productivity, and stigma associated with lifestyle changes. Further, the role of the family is extremely prevalent in Tanzania, which means that children are often required to leave school in order to care for an ill family member, or in turn, join the work force. This is unique to Tanzania, as the country also faces the burden of poverty. In response to the rise of chronic disease, Tanzania’s NCD Strategy takes a culture and gender centred approach, by promoting equity through ensuring that health care services are accessible, available and affordable, throughout the country. This approach is unique to Tanzania, and a perspective that Ontario could consider in the CDPM framework. Tanzania’s approach is multisectoral and involves relevant stakeholders from the private, public, national and international sectors, which promotes collaboration and integration, something that Canada could adopt. Tanzania’s NCD Strategy is evidence based, similar to Canada and Australia, and focuses on promotive activities, preventative services, care and treatment activities, and rehabilitation services.
It is difficult to determine whether or not the countries described above are progressing towards the WHO goal of mitigating chronic disease by 2025, as each country is on a different timeline. Key metrics have been recognized as improving though it is difficult to attribute it to the frameworks specifically. However, it is interesting to note, that though vastly different in terms of economy and population characteristics, Canada, Australia and Tanzania are unified in their approach to targeting chronic disease, as the primary focus of each country was preventative measures. Despite the fact that countries differ in income level and face unique barriers to mitigating chronic disease, all three of the countries deemed disease prevention as crucial in targeting chronic conditions. More specifically, the focus on prevention in Canada and Australia required a system re-design. Historically, both countries’ health care systems were reactive, an approach that evidently was not working to mitigate chronic disease. As a result, Canada and Australia have shifted towards proactive, preventative measures. Similarly, Tanzania’s NCD Strategy focused on prevention; however, unlike Canada and Australia, Tanzania deemed primary prevention to be a crucial focus as it was the most cost-effective, especially in a resource constrained environment. Thus, though there was homogeneity in utilizing primary prevention methods, there was evidently diversity in reasoning behind such utilization, between low- and high-income countries.
Though chronic disease is a global concern, countries are taking steps in the right direction to reduce its effects. Through the development of frameworks and strategies, WHO member states, Canada, Australia and Tanzania, are committed to improving the health of their countries. It is unfortunately difficult to determine if the efforts by countries are reducing the costs associated with chronic disease and improving the health of individuals; however, we can hope that the system re-design and shift towards prevention will be the change in perspective the healthcare system needs. Additionally, inviting individuals to be active members in managing their health shifts the focus away from the healthcare providers and towards an approach that is patient-centred. In doing this, we are creating a culture rooted in support, autonomy, and self-efficacy – all of which are assets to mitigating chronic disease globally.
Katie Shillington is practicum student working as a Student Research Analyst at the Ivey Centre for Health Innovation. She is in her fourth year pursuing a Bachelor of Health Sciences with an Honours Specialization in Health Promotion.