Historical Perspective on Non-Communicable Diseases Worldwide
The blooming of incidence and prevalence of “prosperity diseases” among the broad
layers of modern day populations is rather novel phenomenon in demographic history
of the human race (1). Illnesses such as obesity (2), diabetes mellitus, hypertension,
cerebrovascular and cardiovascular consequences of atherosclerosis, renal insufficiency,
mental disorders, and even cancer are closely related to the increased longevity of
most contemporary societies (3). In previous centuries, they were mostly reserved
for elite social groups enjoying rather luxurious life style. Vast majority of citizens
of the time were living in rural communities on the verge of poverty. Their structure
of morbidity even in Europe until late 19th century was dominated by burden of infectious
diseases and injury while neonatal and maternal mortality rates were huge. Industrial
revolution led to the growth of living standards, invention of vaccines, and antibiotics,
and ultimately development of organized publicly funded health systems. The prominent
European health policy makers in the 19th century properly believed that effective
public health measures will diminish huge burden of infectious diseases. Consecutively,
they expected that overall costs of medical care provision should decrease substantially
and ultimately reach plateau level. This second step turned out to be a great miscalculation
and a surprise. Like no time in written past, people began living longer and healthier
lives. But it happened at the cost. Simultaneously, from many industrialized nations,
evidence were accumulating of accelerated occurrence of non-communicable diseases.
Accomplishment of evidence-based medicine succeeded to control many of these initially
incurable diseases, thereby transforming them into life time disorders as in the typical
cases of diabetes and terminal renal insufficiency. Acute bacterial infections, dominating
morbidity in the old days, were usually successfully treated within few weeks. Unlike
these, chronic illnesses were bringing long-term burden for both the patients and
the society. Malignant disorders with its complex treatment strategies present particularly
demanding medical conditions. Cancer leaves permanent footprint in a life of a patient
in terms of poor survival rates, decreased life quality, and working ability.
Non-Communicable Diseases Expansion in Developing Countries
The ultimate demographic transition consisting of ascending portion of elderly, falling
fertility rates, and bold growth of median age within contemporary nations became
broadly recognized as population aging (4). Most of this transformation of morbidity
and mortality structure happened in rich industrial countries of Western Europe, North
America, and Japan many decades ago. The same pattern of population aging associated
with huge incidence and prevalence rates of major non-communicable diseases repeated
on wider scale much later in developing countries. The worldwide transformation of
public health landscape to the large extent is attributable to the accelerated pace
of globalization after the end of Cold War era (5). Particularly interesting, current
developments belong to the economies responsible for most of global growth that are
recognized as the emerging markets. The countries whose reshaped structure of morbidity
is most likely to affect global health in the future are definitely the BRICS [Brazil
(6), Russia, India, China, South Africa] (7). BRICS’s far extended long-term influence
in health arena worldwide will be related to their mammoth sized populations. Their
increased domestic demand for medical technologies and medicines is already shaping
investment strategies of major pharmaceutical and medicinal device industries. Another
significant issue is their bold foreign medical assistance programs particularly targeted
for emerging markets of Sudanese Africa, Latin America, Central and South East Asia
(8). These leading countries are closely followed by a set of smaller scale economies
mostly marked as N-11 (Bangladesh, Egypt, Indonesia, Iran, South Korea, Mexico, Nigeria,
Pakistan, the Philippines, Turkey, and Vietnam) (9). Very similar process is simultaneously
taking place in dynamically developing Southern (10) and South-East Asian (11), Latin
American, Eastern European (12), and Arab speaking MENA region (13). Eradication of
poverty currently taking place in these regions is coupled with changed dietary habits
(14) (higher salt and fat and lower carbohydrate intake), wide spread tobacco abuse,
and sedentary life styles (15). The mentioned factors contributing to the growing
burden of non-communicable diseases. It became obvious that contribution of emerging
markets and Third World countries to the global economic burden of NCDs will grow
further. It will, highly, likely, soon have greater share than the one of established
mature market economies (16). As basic assumption of most forecasts remains the fact
that such growth will be dominated by developments in China (17) and India (18). High
toll of this unfortunate change for developing countries is coupled impact of communicable
and non-communicable diseases (19). At the same time, many national health systems
throughout Asia and beyond expose poor responsiveness to the NCDs related population
needs. There seems to be serious barriers in access to medical care and its affordability
to the ordinary citizens.
The increasing awareness on approaching of almost unbearable burden of NCDs (20) led
to the high profile United Nations meeting on the subject in 2011 (21). Such UN gatherings
are so uncommon on health related topics that it happened only once in past due to
AIDS. NCDs recognized as the core global health challenges were cardiovascular disorders,
cancer, diabetes, and chronic respiratory illness. These changes are beginning to
profoundly change the landscape of even the poorest countries around the globe. So
far, NCDs have already overarched burden of infectious diseases and injury in terms
of disability adjusted life years, as well as work load and economic burden to the
most national health sectors (22).
Promising Cost-Effective Solutions for the Future
The blossoming of prosperity disease did not happen suddenly. It was a consequence
of long chain of evolutionary events in civil society development. We will mention
only some of them such as technological revolution, improved housing conditions, sanitation
and sewage disposal, public health successes in eradication of major infectious diseases,
policy efforts to tackle hunger and starvation among the world’s poor, and ultimately
tobacco (23) and alcohol abuse (24). As its preconditions took so long to be created,
it is unlikely that we shall be able to tackle NCD’s burden effectively in near future.
Rich countries as well as developing ones concluded that orchestrated efforts will
be needed in the international arena. World Health Organization has adopted a package
of measures, whose implementation and progress are being monitored (25), broadly known
as “Global coordination mechanisms on NCDs” (26). As most cost-effective and feasible
measures were identified, control of tobacco consumption to the targeted 5% consumers
worldwide until 2025 and reduction of salt intake by general populations of at least
15% in the order of significance. These interventions that were named “best buy” solutions
offering best attainable compromise between the need for investment and outcomes that
will be gained (27). Promotion of active life style and healthy diet, as well as other
preventive and screening measures, comes at the second place. If such efforts are
followed closely by national authorities, WHO expects that these measures should achieve
25% reduction of NCD attributable premature mortality until 2025 (28). Many of the
proposed strategies were previously tested within a sound methodological framework
applied on a second largest emerging market of the America, Mexico (29).
The most challenging issue for the emerging markets’ health systems appears to be
universal health coverage (30). These systems were built up on diverse historical
legacies and should find each one its own way to handle the upcoming pressure of prosperity
diseases coupled with accelerated population aging. Profound transformation of current
network of medical facilities in Third World countries, as well as human capacity
building, will be forced to move priority from acute care toward complex, chronic
illnesses (31).
Growing Burden of NCDs Coincided with Increasing Health Expenditures
As witnessed by current WHO estimates given in Table 1, we may see that overall burden
of non-communicable disease has consolidated in some countries such as Russia recording
even slight decrease over the past decade. Nevertheless, leading emerging markets
of China and India followed by a large distance in absolute terms by Brazil and South
Africa exhibited clear pattern of increasing burden of NCDs expressed in terms of
Years of Life Lost, Years Lost due to Disability, and Disability-Adjusted Life Year
(DALY). According to WHO, NCDs attributable mortality increased substantially among
the same four countries with notable promising exception of Russia. Russian partial
success in containing but not decreasing toll of prosperity diseases over 2000–2012
observation period might be attributable to the strong public health legacy of Soviet
era as well as reform policies implemented in recent past (32). The rates of hospital
discharges increased substantially in the emerging markets across the globe following
the increased presence of NCDs in the overall morbidity and mortality structure. This
was mainly the case with clinical admissions that could be attributed to the malignant
disorders (33) and circulatory diseases (34), followed by chronic obstructive pulmonary
diseases (35) and diabetes (36). National level spending on medicines indicated to
treat these conditions followed at the same pace, so entire regional pharmaceutical
markets adjusted to these changes as was the case in South Eastern Europe (37). Extensive
presence of chronic prosperity illnesses supported stronger demand for medical imaging
(38), laboratory testing (39), outpatient visits, prescription and dispensing of novel
pharmaceuticals (40), surgical, radiation oncology (41), and rehabilitation services.
These phenomena were relying on strengthened civil expectations for advanced medical
technologies supported by growing living standards and domestic consumption in BRICS
markets. If we take into account serious challenge of home-based care for the disabled
and growing portion of elderly citizens with special needs, bold growth of national
health expenditures should have been predicted (42). China is absolutely leading in
terms of purchase power parity of its health spending. Huge lag of all other major
emerging economies behind People’s Republic of China is most obvious when compared
to the India, rapidly developing nation of a similar population size.
Table 1
Non-communicable diseases burden-related indicators; WHO estimates for BRICS in 2000
and 2012; total health expenditure and out-of-pocket health expenditure in terms of
current international $ purchase power parity basis (source: Global Health Expenditure
Database).
Brazil
Russian federation
India
China
South Africa
2000
2012
2000
2012
2000
2012
2000
2012
2000
2012
Population (millions)
174.5
198.6
146.8
143.2
1,042.3
1,236.7
1,287.7
1,384.8
44.8
52.4
Years of Life Lost [YLL (′000)]*
22,532
24,915
44,566
40,597
150,751
175,435
165,905
186,591
5,534
7,398
Years Lost due to Disability [YLD (′000)]**
14,600
18,077
16,586
16,206
78,150
96,886
84,450
99,877
3,436
4,233
Disability-Adjusted Life Year [DALY (′000)]***
37,132
42,992
61,152
56,803
228,901
272,321
250,355
286,468
8,970
11,631
Estimated deaths (′000) NCDs caused, both sexes
777
978
1,819
1,801
4,579
5,869
6,839
8,577
176
264
Total expenditure on health (in million current $ PPP)
$87,681
$220,240
$54,200
$211,008
$68,816
$193,969
$138,131
$664,644
$24,728
$51,458
Out of pocket expenditure (in million current $PPP)
$33,277
$68,168
$16,242
$72,417
$46,771
$111,673
$81,469
$228,245
$3,227
$3,695
*WHO estimated Years of Life Lost (YLL) due to premature mortality NCDs caused, both
sexes (′000).
**WHO estimated Years Lost due to Disability (YLD) for people living with NCDs or
its consequences (′000).
***WHO estimated Disability-Adjusted Life Year (DALY) NCDs caused, both sexes (′000).
Catastrophic household expenditure presents particularly crucial issue throughout
the countries of Sudanese Africa with very low incomes, whose medical care is dominantly
supported by out-of-pocket spending (43). This happens due to absence of strong national
health insurance funds whose revenues would come out of mandatory taxation supported
by governmental and external financial sources. Huge, occasionally sevenfold growth
of out-of-patient expenditure is clearly visible among the top BRICS markets. Such
socioeconomic vulnerability seriously affects the poor members of the community. This
might be the crucial issue for long-term affordability (44) of medical care to the
ordinary citizens because almost all of the emerging markets own massive rural populations.
Urbanization process, which began in Europe in 18th century, is still rapidly evolving
throughout Asia, Africa, and Latin America (45). Extensive development of medical
facilities network covering remote areas will remain one of the key difficulties for
national governments. This is worsened by inevitable concentration of most professional
staff in large cities with much more rewarding personal career opportunities. The
primary goal for the future of these health systems wiil be provision of accessible
medical care. It should have decent quality supported by universal health insurance
coverage and full reimbursement of at least essential medicines. The speed of economic
growth, political stability, and effectiveness of health reforms remain highly diverse
among the top 20 emerging markets. Some global forecasting agencies as well as international
financial organizations were pointing out that some smaller scale N-11 economies were
top performers on some criteria. Nevertheless, the prevailing consensus is that BRICS
(46) health care markets will inevitably outpace all others and remain well ahead
of their competition shaping the global health challenges in the first half of 21st
century.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.