Non-communicable disease care in South Asia: utilisation, financial burden, and gaps in the care cascade

Abstract

The South Asian region, a quarter of the world’s population, experienced a 3.0% rise in the incidence of non-communicable diseases (NCDs) from 2010 to 2021. The rising number of patients with NCDs has significantly intensified the burden on health systems that were originally developed to combat communicable diseases. This discrepancy undermines current service delivery methods, which frequently lack the capacity to address the complex and long-term needs of people with NCDs. Evidence suggested South Asian countries lack research on healthcare utilisation (HCU), particularly in the context of NCDs. It is unclear how people obtain and interact with NCD care and what barriers and facilitators influence their healthcare-seeking behaviour. The financial burdens for utilising NCD care at the household level are also not investigated in-depth. Another important gap in the research is the NCD care cascade, referring to the sequence of steps individuals go through in managing NCDs. Considering these research gaps, my PhD research initially (1) aimed to appraise and synthesise the available evidence from published literature on HCU and NCDs in South Asia and identify any gaps in the current evidence base. My review identified a limited number of studies across South Asian countries, with India being the sole exception. Subsequently (2), as a country case, my thesis explored the patterns of HCU among people with NCDs in Bangladesh, specifically consultation-seeking behaviour and access to medication across different types of healthcare providers. Findings showed that the majority of the population did not choose public health facilities. Next (3), I investigated the effect of COVID-19 on HCU and medication use in three South Asian countries. Findings highlighted that respondents from all three countries (Afghanistan, Bangladesh, and India) who sought assistance managing NCDs were more likely to experience non-adherence to medication use after the COVID-19 outbreak compared to the pre-COVID phase. Thereafter (4), the gaps in diabetes screening, awareness, treatment, and control in the three South Asian countries were quantified. Results indicated that in Bangladesh, Bhutan, and Nepal, 85.3%, 64.3%, and 95.1% of the diabetic population, respectively, had unmet needs for care. Afterward (5), I analysed the crowding-out effects of NCD-related out-of-pocket (OOP) health expenditures on household consumption in Bangladesh. This research demonstrated that NCD-related spending in households reduced budgets for both food and non-food expenditures, with a stronger crowding-out effect on food items, particularly in lower-income households. Finally (6), I examined OOP expenditures and affordability for NCD care, disaggregated by type of healthcare provider, and assessed relative changes over a six-year period in Bangladesh. Findings suggested that one in two unaffordable OOP households were seen among those who utilised mixed healthcare providers (refers to households that utilise healthcare services from multiple provider types, such as public and private or public and non-qualified providers, rather than relying on a single provider type). The result of this thesis collectively indicates that health systems in South Asia, notably in Bangladesh, are operating inefficiently, particularly with the management of NCDs. This thesis observed significant deficiencies in HCU, continuity of care, and affordability, which collectively deter effective management of NCDs. The findings highlight the pressing necessity to enhance health system performance throughout South Asia, particularly in Bangladesh, by augmenting public healthcare capacity, improving quality of care, implementing more effective regulation of private healthcare providers, increasing health system resilience for all-hazards emergencies, reinforcing continuity of care, enhancing availability and affordability of medicine, reducing OOP, and broadening financial protection mechanisms to ensure improved utilisation of healthcare services without financial hardship and, ultimately, to achieve improved health outcomes for individuals living with NCDs.

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