Health is a key driver of economic development. Poverty creates poor health and poor health leads to poverty. Yet the role of health in economic growth is greatly undervalued, according to the World Health Organization (WHO). Countries with the lowest levels of health and education have more difficulty in achieving sustained growth. A new study compares treatment in Bangladesh and Denmark.

Denmark: modest investment, large gains - Bangladesh: many barriers to optimal treatment - Costs and benefits of alternative scenarios

Poor control of diabetes translates into lost lives, lost quality of life and lost national productive capacity. Proper treatment, including early detection, prevention and treatment of diabetes and its complications, means that people with diabetes can live an almost normal life and reduces the risk of disabilities and premature death. But proper treatment of diabetes is far from universal, particularly in the developing world, and leads to spiralling healthcare costs.

Since understanding the economic burden of diabetes is the first step towards doing something about it, Novo Nordisk is working with the University of Aarhus and the University of Southern Denmark to examine more closely the economic impact on society of diabetes and its treatment. We began by looking at the economic impact in Denmark and in 2003 extended the study to Bangladesh.

In both countries, it was shown that increased production value and additional years of life more than outweighed the investment in improved treatment (see table below). When these additional years were adjusted for quality of life, the gains were even more significant. In other words, not only do more people survive under an improved or ideal scenario of diabetes treatment; they survive in a much better state of health so that they can enjoy a full quality of life.

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In 2002, we began by looking at the cost of treating type 1 diabetes in Denmark over one year (2001), concluding that the availability of insulin has resulted in a gain of 15,703 additional years of life or a gain of 13,816 quality-adjusted life-years, and DKK 2.3 billion in increased production value, compared to 1,041 life-years in a scenario in which no insulin was available.

In 2003, looking at the treatment of type 2 diabetes in Denmark, we found that 136,047 people currently have type 2 diabetes. The study showed that if more patients with type 2 diabetes were offered insulin treatment and more patients in need were put on tablet treatment, significant gains in longevity and quality of life could be achieved: an additional 11% gain of 15,453 years of life with significantly improved quality of life. While costs for medical treatment would increase, the total healthcare costs, in particular hospitalisation costs, could be reduced. Improved diabetes care at almost half the total costs could result in a potential gain of more than 40% in production value. The reduction in total costs is primarily caused by lower nursing costs, as there would be fewer people with complications. In the long term, our study estimates that if perfect treatment were available, the costs of treating complications could be eliminated. This would also reduce healthcare costs by as much as 50% if no excess mortality or morbidity existed.

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Changing the state of diabetes care in Bangladesh, as elsewhere in the developing world, is a challenge to all players in the healthcare sector. Barriers to effective treatment of diabetes in both the developed and the developing world include lack of awareness and education about the seriousness of diabetes and the optimal way to treat it. In the developing world, however, the problem is exacerbated by lack of economic resources and inadequate healthcare infrastructure.

The presence of these barriers was clear in our study of Bangladesh. Because the current state of diabetes care in the country is poor, the benefits of greater investment in diabetes care were particularly striking. In an improved scenario, assuming free access to the current level of diabetes care for the estimated 3 million people who currently have type 2 diabetes in Bangladesh, the number of years of life would double to 5.8 million and the production value almost triple. Achieving these gains for all people with diabetes would require 7–8 times the current investment in diabetes care in Bangladesh.

The WHO has estimated that each five-year improvement in life expectancy is associated with an increase in economic growth of about 0.3–0.5% a year, other growth factors being equal. Our study estimates that after a 20-year period the production value could be at least 6–10% higher than today as a consequence of the gains in the improved diabetes care scenario. Obviously, Bangladesh is not able to accomplish this alone. According to the United Nations Development Programme (UNDP), about 83% of the population lives on less than USD 2 a day. We estimate that only 10% of the population have an income that enables them to afford healthcare and medication. An additional 13% (primarily living in the urban areas) are able to visit free clinics. Thus, only 23% have access to relevant healthcare.

We believe the private sector has a role to play in addressing the problems of access to adequate diabetes care in the developing world. We have made a start in Bangladesh – recognising that it is only a modest beginning – by funding the establishment of a diabetes foot clinic at a leading hospital, which is operated by the Diabetes Association of Bangladesh. This is part of the company’s National Diabetes Programme. Foot problems are a common complication of diabetes and Bangladesh did not previously have a foot care clinic. In many studies, prevention of diabetes complications has been shown to be beneficial in terms of patient quality of life and cost effectiveness. In addition, we are educating and training several hundred doctors in Bangladesh who are not specialists in diabetes through a distance- learning programme in collaboration with experts from the UK.

Such initiatives can at least begin to make a difference to the economic burden of diabetes in Bangladesh, but the task is huge. The study shows that the costs to Bangladesh of lost production value are enormous. Our study estimates that some 40% of people with diabetes in Bangladesh are not able to support themselves productively because of complications related to their diabetes. But the lack of diabetes treatment also affects the productivity of people working in the informal sector, who represent an estimated 45% of the Bangladesh economy. The formal sector is based on monetary flows and people working for wage income, but a large part of consumption comes from production in the informal sector based on a barter economy and household production such as subsistence farming and care-giving, trading and small-scale production, and is therefore not registered as GDP. Nursing of people in poor physical health is typically done informally by family members, who therefore cannot work to support their family.

Health economics studies are necessary for policy-makers to understand the importance of creating healthcare systems that better meet the needs of people with diabetes and thus avoid a high economic cost to society. In our view, the results of our study present a strong argument for the need to invest in better diabetes care in societies, both rich and poor. Novo Nordisk will continue to examine the role of health and economic  development in order to better understand the most effective ways to treat and eventually prevent diabetes worldwide.

Costs and benefits of alternative scenarios  
(click to view pdf file)