The $68 billion challenge: Quantifying and tackling the burden of chronic diseases in the GCC
Gabriel Chahine, Jad Bitar, Pierre Assouad, and Samer Abi Chaker

The GCC is confronting near epidemic levels of non-communicable diseases such as cardiovascular and respiratory illnesses, cancer, and diabetes. Governments urgently need to introduce a range of new and effective policies to curb these diseases’ prevalence, otherwise the economic burden that they impose will reach $68 billion in 2022.



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The $68 billion challenge Quantifying and tackling the burden of chronic diseases in the GCC

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Contacts

Beirut Gabriel Chahine Partner +961-1-985-655 gabriel.chahine @strategyand.pwc.com Walid Tohme Partner +961-1-985-655 walid.tohme @strategyand.pwc.com Berlin Marcus Steffen Bauer Senior Executive Advisor +49-30-88705-0 marcus.bauer @strategyand.pwc.com Peter Behner Partner +49-30-88705-841 peter.behner @strategyand.pwc.com Buenos Aires Ariel Fleichman Partner +55-11-4131-0432 ariel.fleichman @strategyand.pwc.com

Chicago Gary D. Ahlquist Senior Partner +1-312-578-4708 gary.ahlquist @strategyand.pwc.com Dubai Dr. Nikhil Idnani Principal +971-4-390-0260 nikhil.idnani @strategyand.pwc.com Frankfurt Dr. Rainer Bernnat Partner +49-69-97167-414 rainer.bernnat @strategyand.pwc.com Kuala Lumpur Edward Clayton Partner +60-3-2095-3188 edward.clayton @strategyand.pwc.com

Mumbai Abhishek Malhotra Partner +91-22-6128-1104 abhishek.malhotra @strategyand.pwc.com San Francisco DeAnne M. Aguirre Senior Partner +1-415-627-3330 deanne.aguirre @strategyand.pwc.com São Paulo Fernando Fernandes Partner +55-11-5501-6205 fernando.fernandes @strategyand.pwc.com Shanghai Sarah Butler Partner +86-21-2327-9800 sarah.butler @strategyand.pwc.com

Sydney Chris Manning Managing Director +61-2-9321-1924 chris.manning @strategyand.pwc.com Tokyo Kenji Mitsui Partner +81-3-6757-8692 kenji.mitsui @strategyand.pwc.com Washington, DC Rick Edmunds Senior Partner +1-703-682-5755 rick.edmunds @strategyand.pwc.com

This report was originally published by Booz & Company in 2013.

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Executive summary

Rapid economic advances in the Gulf Cooperation Council (GCC) countries1 have been accompanied by the population adopting a seden­ tary lifestyle among other unhealthy habits. This has contributed to a rising incidence of non-communi­ cable diseases (NCDs), such as cardiovascular illnesses, cancer, and respiratory diseases. NCDs have become a leading cause of death in the GCC. Their prevalence is at epidemic levels and is undermining the societal gains from economic develop­ ment. The nature of NCDs means patients typically require frequent contact with the healthcare system. This means larger consumption of healthcare services, which imposes a steep cost burden on government budgets and decreases economic productivity. With current prevalence rates, we calculate that the total direct and indirect cost of the most common NCDs for the GCC will be close to US$36 billion in 2013 — one and a half times official healthcare spending. If governments fail to enact measures to curb the rising prevalence of NCDs, the total economic burden is expected to reach $68 billion by 2022. To restrain this epidemic, governments should enact a comprehensive agenda that targets those at risk of developing NCDs. The core elements of this agenda are short- and long-term programs that run in parallel. Short-term programs deal with such structural factors as financial incentives/disincentives (such as taxes on tobacco), regulations (for example, limiting the availability of unhealthy food in schools), and clinical interventions (for instance, screening the population for risk factors). Long-term programs seek to change individual behavior, along with regulations and funding in the healthcare system with a stress on preventative care. They educate those who care for children, inform adults, and raise awareness among health providers about NCDs. Given the magnitude of the problem, GCC governments must act rapidly. They must develop national and GCC-wide NCD agendas that will enact short-term and long-term programs before the epidemic imposes a heavy toll on their societies.
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Breaking the bank

The economic development of the GCC countries has brought with it a significant cost — a rising incidence of NCDs. In a little over a generation, GCC countries have improved their standards of living from developing country levels to those of advanced economies. There have been similar forward strides in education and health — healthcare has never been more accessible and the population has never been more educated. Social and economic development across the board has unfortunately resulted in a population with public health problems that are typically associated with developed countries. NCDs have been linked to developed economy lifestyles, namely bad eating habits, high-sugar and fat-heavy diets, and a lack of physical exercise. Increasing wealth has, of course, had positive public health effects, such as funding large-scale public health awareness and vaccinations campaigns to tame the threat of communicable diseases, such as polio, measles, rubella, and others. However, in the GCC, as elsewhere, these gains to public health and individual well-being are now being offset by the increasing prevalence of NCDs and associated mortality rates. The result is that NCDs have become the leading causes of death and disability, thus making the GCC one of the regions worst affected by the global increase in these diseases. This trend is projected to result in NCDs causing over three-quarters of all deaths globally by 2030, up from 63 percent in 2008, with significant cost implications for healthcare systems.2 In September 2011, the UN held its first summit on NCDs to highlight the growing threat to public health. Dr. Margaret Chan, the Director-General of the World Health Organization, called NCDs “the diseases that break the bank.”3

NCDs have become the leading causes of death and disability.

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A chronic problem

NCDs, also known as chronic diseases,4 impose a tremendous human and economic cost because such illnesses affect multiple organ systems and can have a wide range of symptoms. Their generally gradual development negatively affects individuals’ quality of life, diminishes their ability to contribute economically, and drains healthcare resources. This report focuses on five of the most common NCDs in the GCC, which we have taken from the 14 NCDs listed by the WHO’s Global Burden of Diseases study.5 Although diverse in symptoms, the five NCDs highlighted here share common lifestyle-related, or behavioral, risk factors such as tobacco use, a fat-heavy diet, and physical inactivity. • Cardiovascular diseases (heart disease and stroke), responsible for 29 percent of deaths from NCDs globally. • Malignant neoplasms (cancer), which caused 13 percent of global NCD deaths. • Chronic respiratory diseases (chronic obstructive pulmonary disease and asthma), the cause of 7 percent of global NCD deaths. • Neuropsychiatric conditions, which were responsible for 2 percent of NCD deaths worldwide. • Diabetes mellitus, the cause of 2 percent of NCD deaths around the world.6 A recent Harvard–World Economic Forum (WEF) study of the economic impact of these NCDs estimates that they were responsible in 2010 for economic losses equivalent to 10 percent of global output and for fourfifths of all deaths from NCDs.7

NCDs are a drag on economic expansion.

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The economic burden

Until now there has been no credible estimate of the current and future cost of NCDs to the GCC countries. Such an estimate is important because it allows policymakers to assess the impact of these diseases, prioritize their actions in response, and hence plan how to fund the growing cost of NCD treatment. Critically, this estimate also guides policymakers as to where interventions and preventative action are needed. NCDs are a drag on economic expansion. They slow real GDP per capita growth by reducing the size and the productivity of the labor force and by diverting funds away from savings and investment (see Exhibit 1).8

Exhibit 1 NCDs constrain economic growth
Vicious Economic Cycle Caused by NCDs

Chronic diseases diminish individual health

- Reduce labor force size (mortality, absenteeism, disability, early retirement)

- Higher dependency ratio on others - Diminished labor productivity - Reduced access to factors of production - Increased consumption of health services - Reduced savings - Reduced investment in physical capital Stunted economic growth, more poverty and inequality

Lower GDP per capita

- Increase economic costs (increased spending on care, reduced saving)

Source: Adapted from Abegunde and Stanciole, “An Estimation of the Economic Impact of Chronic Noncommunicable Diseases in Selected Countries,” WHO, 2006

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The economic burden of NCDs comes in two cost forms, direct and indirect. Direct costs are typically those associated with the treatment of patients, such as consultations, medications, and clinical operations. These direct costs, however, are just part of the problem. More significant is the indirect economic penalty that NCDs impose. From a national perspective, NCDs reduce life expectancy, which means less output. In addition to the immense burden on the patients, NCDs also affect their families, causing them to contribute less to economic activity. Chronic illness and shorter life spans deplete the quality and quantity of the work force. Labor productivity is diminished because workers are less effective. Similarly, NCDs lead to increased absenteeism, because of work missed due to sick days. Measuring these direct and indirect costs is challenging because various methods exist for calculating them and because the data can be elusive. The Harvard–WEF study used three approaches to estimate the economic burden of NCDs: Cost of Illness, Epic Model (Value of Lost Output), and Value of Statistical Life. We have adopted the cost of illness approach because it is more comprehensive, relies more on tangible data, and is a better fit with available data sets. We have also collected data from local ministries, centers of statistics, and regional reports linked to the selected NCDs from all six GCC member states. By developing an econometric model using the cost of illness model and the latest available and reliable statistics, we were able to generate accurate estimates for the direct and indirect costs of NCDs in 2013, and forecasts for the expected burden in 2022. Total direct and indirect costs We calculated that the total direct and indirect cost for the five selected NCDs in 2013 will be $36.2 billion for the GCC (3.7 percent of non-oil GDP), rising to $67.9 billion (3.8 percent of non-oil GDP) by 2022 (see Exhibit 2, page 9). The burden is greater, and clearly less sustainable, when the total cost of NCDs is compared to healthcare spending. In 2013, the five top NCDs in the GCC will impose an economic penalty equivalent to close to one and a half times all six of the governments’ healthcare budgets. The economic burden per capita for the different GCC countries in 2013 will range from $516 in Saudi Arabia (3.6 percent of non-oil GDP per capita, 1.9 percent of total GDP per capita), to $2,001 in Qatar (4.1 percent of non-oil GDP per capita, 1.9 percent of total GDP per capita). By 2022, the total cost per capita will reach $758 in Saudi Arabia (3.5 percent of non-oil GDP per capita, 2.0 percent of total GDP per capita) and $2,778 in
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Qatar (3.7 percent of non-oil GDP per capita, 1.9 percent of total GDP per capita). The lowest economic burden will be in Oman, which in 2022 will have a NCD per capita cost of $603 (3.3 percent of non-oil GDP per capita, 1.7 percent of total GDP per capita). For comparison, in 2011 OECD economies spent $3,327 per capita on healthcare.

Exhibit 2 NCDs will cost the GCC close to US$36 billion in 2013
Direct and Indirect Costs of the Five Most Prevalent NCDs, 2013 US$ billions

2%

$31 25% 11% 22%

$37

40% 26% 18% 28% Direct costs Diabetes mellitus Cardiovascular diseases Respiratory diseases Neuropsychiatric conditions Malignant neoplasms $6 17% 11% Indirect costs Total

Source: Strategy&

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Direct costs The direct cost for the five selected NCDs will be $5.6 billion (0.6 percent of non-oil GDP, 0.3 percent of total GDP) in 2013 for the whole GCC, rising to $12.9 billion (0.7 percent of non-oil GDP, 0.4 percent of total GDP) by 2022. These figures were achieved by combining volumes of visits and admissions due to the five selected NCDs with different direct costs associated with use of healthcare services. NCDs will lead to a rising volume of outpatient visits that will outstrip the region’s already rapid population growth (see Exhibit 3, page 11). Saudi Arabia, the largest country in the GCC with over 60 percent of the population, will incur 43 percent of the direct cost in 2013. The UAE, with 18 percent of the regional population, will shoulder close to 30 percent of the total direct cost in the GCC. The burden of NCDs is already clear from the ratio of the direct costs of NCDs to overall healthcare expenditures per country. The lowest ratio will be 8 percent in Oman, with the highest 25 percent in Qatar in 2013. The NCD imposing the highest direct costs, cardiovascular diseases, will account for 28 percent of all direct NCDs costs in 2013. Indirect costs As for indirect costs, those linked to productivity loss were derived from non-oil GDP data associated with the number of working days lost due to each of the NCDs and the number of individuals with NCDs. Early mortality costs were also accounted for by deriving the value of years lost due to each of the selected NCDs from GDP data. Our study evaluated the indirect costs for the selected NCDs at $30.6 billion (3.14 percent of non-oil GDP, 1.79 percent of total GDP) in 2013, rising to $55.1 billion (3.08 percent of non-oil GDP, 1.82 percent of total GDP) by 2022. In terms of indirect costs, the most burdensome NCD is malignant neoplasms, which will account for 40 percent of indirect costs in 2013. This finding is different from other studies, which often estimate a very high economic burden associated with diabetes. Our analysis showed a far smaller burden linked to diabetes, indeed the least significant in terms of indirect costs of the five major NCDs. This is because we allocated the burden of diseases caused by diabetes, such as cardiovascular and neurological conditions, to these respective NCDs. By contrast, other analyses have put these costs into the diabetes category, thereby significantly increasing their estimate of the burden of this disease.

In terms of indirect costs, the most burdensome NCD is malignant neoplasms.

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Exhibit 3 NCDs will cause outpatient visits to rise rapidly

Visits and admissions, 2013–2022 11.9

Outpatient visits by country, 2013 4% 8% 32% 5% 1%

12 10 (millions) 8 6 4 2 0 0.4 9.3

9.9

10.5

11.2

0.4

0.5

0.5

0.5 50% Bahrain Kuwait Oman Qatar Saudi Arabia United Arab Emirates

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Inpatient admissions Outpatient visits

Source: Strategy&

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NCDs impose a heavy burden on national healthcare spending
An important part of the cost of NCDs is their share of healthcare spending. Despite expanding healthcare budgets, NCDs are steadily taking more and more of public health expenditure. Although GCC countries have some private insurance, they still rely heavily on public expenditure to cover their healthcare costs. The public share of expenditure is expected to remain at high levels and will probably increase in the future because of the NCD burden. Individual country studies (see Exhibits 4 to 9) show that NCDs currently account for 9 to 30 percent of public health spending. This share will only rise if governments continue to take a direct treatment approach, rather than a preventative one, to the NCDs epidemic. The highest spending per capita is in Qatar, where NCDs will cost $416 per capita of total healthcare spending in 2013, 22 percent of the total. Bahrain, Kuwait, Saudi Arabia, and the UAE occupy a middle position in which NCDs take from 7 percent to 11 percent of healthcare spending. For example, in the UAE total healthcare spending per capita will be $2,219 in 2013, of which $198 will be on NCDs. Oman, with its still relatively traditional lifestyle, has the lowest per capita healthcare spending, just $734 in total and spends just 6 percent of total healthcare expenditure on NCDs.

Exhibit 4 Bahrain
Total Healthcare Costs per Capita, 2013 (In US$)

739 225 11% of total healthcare expenditure

514 82 Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

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Exhibit 5 Kuwait
Total Healthcare Costs per Capita, 2013 (In US$)
1,514 230 9% of total healthcare expenditure 1,285 132 Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

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Exhibit 6 Oman
Total Healthcare Costs per Capita, 2013 (In US$)

734 123 6% of total healthcare expenditure 610 46 Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

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Exhibit 7 Qatar
Total Healthcare Costs per Capita, 2013 (In US$)

1,884 466 22% of total healthcare expenditure 1,418 416

Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

Source: Strategy&

Exhibit 8 Saudi Arabia
Total Healthcare Costs per Capita, 2013 (In US$)

1,078 320 7% of total healthcare expenditure 759 80 Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

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Exhibit 9 UAE
Total Healthcare Costs per Capita, 2013 (In US$)

2,219 412 9% of total healthcare expenditure 1,807 198 Per capita private expenditure on health Per capita public expenditure on health Per capita expenditure on NCDs

Source: Strategy&

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Risk factors

To tackle the crippling financial and human costs of NCDs, GCC governments and other stakeholders need to identify and understand the underlying risk factors associated with these illnesses. These risk factors have a strong influence on the prevalence of NCDs as they are the root causes of these illnesses. By mitigating the risk factors, governments, healthcare sector providers, and individuals can restrain the rising incidence of NCDs and tame the economic costs. Non-modifiable and modifiable risk factors There are two kinds of primary NCD risk factors that are root causes of these illnesses: non-modifiable and modifiable. In terms of policy responses, modifiable risk factors are the most amenable to change and have the highest impact on individuals. Non-modifiable risk factors lie outside the control of the individual and are linked to age, hereditary/genetic conditions, and other socioeconomic, cultural, and environmental determinants. Governments, through appropriate regulations and policies, can improve some nonmodifiable risk factors, such as environmental influences, including toxicity levels of products and air quality. Modifiable risk factors are behavioral in nature and include tobacco use, physical inactivity, and an unhealthy diet. From a public health perspective, modifiable risk factors are the most amenable to policy interventions and to changes in individuals’ behaviors. Non-modifiable risk factors influence and shape modifiable risk factors in direct and indirect ways. For example, the limited availability of fresh produce in some areas, a non-modifiable factor given the regional climate and water shortage, is correlated with unhealthy dietary patterns (modifiable risk factors). This then leads to intermediate risk factors (such as hypertension, excess weight) that are the most frequent causes of NCDs (see Exhibit 10, page 17).

In terms of policy responses, modifiable risk factors are the most amenable to change and have the highest impact on individuals.

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Exhibit 10 Socioeconomic determinants influence NCD risk factors
How Risk Factors Lead to NCDs

Socioeconomic, Cultural, Political, and Environmental Determinants

Primary Risk Factors

Intermediate Risk Factors

Main NCDs

Aging Population

Globalization

Modifiable: Unhealthy Diet Physical Inactivity Tobacco Use Other

Hypertension

Respiratory Diseases

Hypercholesterolemia

Malignant Neoplasms

Urbanization

Other

Non-Modifiable: Age Environment Heredity

Hyperglycemia Impaired Pulmonary Functions

Diabetes

Cardiovascular Diseases

Source: Adapted from WHO, “Facing the facts #1: Chronic diseases and their common risk factors,” 2005

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Modifiable risk factors are also associated with intermediate risks. For example, lower-income individuals typically have higher rates of smoking and bad eating habits, such as high sugar and fat intake, which raise their intermediate risk factors. This exposes them to conditions such as hypercholesterolemia (high cholesterol), hypertension (high blood pressure), and hyperglycemia (high glucose level). These conditions are likely to lead to NCDs such as ischemic heart disease, stroke, or diabetes. Worsening risk factors The rising incidence of NCDs in the GCC mainly arises from the high prevalence of modifiable risk factors. For example, risk factors such as smoking and obesity have already reached alarming levels where almost one-third of the male population smokes and more than one-quarter does not exercise enough (see Exhibits 11 to 14).

The rising incidence of NCDs in the GCC mainly arises from the high prevalence of modifiable risk factors.

Exhibit 11 Smoking is a major risk factor for men
Smoking Prevalence for Males (Age 15+), 2012

Bahrain Kuwait Oman Qatar Saudi Arabia UAE 18% 15%

34% 35%

32% 37%

Source: Qatar STEPS survey 2012; Obesity Reviews, Zaghloul, 2010; Fares Bugshan, “Most GCC Residents Not Getting Frequent Exercise,” Gallup World, May 16, 2012 (http://www.gallup.com/ poll/154691/gcc-residentsnot-getting-frequentexercise.aspx); Strategy& analysis

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Exhibit 12 People do not exercise enough
Percentage of Respondents Who Exercise 30 Minutes on Three or More Days per Week

Bahrain Kuwait Oman Qatar Saudi Arabia UAE 22%

38% 35% 52% 38%

42%

Source: Qatar STEPS survey 2012; Obesity Reviews, Zaghloul, 2010; Fares Bugshan, “Most GCC Residents Not Getting Frequent Exercise,” Gallup World, May 16, 2012 (http://www.gallup.com/ poll/154691/gcc-residentsnot-getting-frequentexercise.aspx); Strategy& analysis

Exhibit 13 Younger people often have less healthy diets
Percentage of Respondents Who Eat a Lot of Fruits/Vegetables at Least Four Days per Week
Bahrain Kuwait Oman Qatar Saudi Arabia UAE 15–29 years of age 30–64 years of age 38% 33% 33% 49% 54%

59% 58% 55% 65%
Source: Qatar STEPS survey 2012; Obesity Reviews, Zaghloul, 2010; Fares Bugshan, “Most GCC Residents Not Getting Frequent Exercise,” Gallup World, May 16, 2012 (http://www.gallup.com/ poll/154691/gcc-residentsnot-getting-frequentexercise.aspx); Strategy& analysis

52% 44% 49%

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Exhibit 14 Women are more likely to be obese
Obesity Prevalence (BMI ≥ 30 Kg/M², Age15+)

Bahrain Kuwait Oman Qatar Saudi Arabia UAE Males Females

21% 38% 30% 55% 32% 27% 40% 43% 23% 36% 25% 42%

Source: Qatar STEPS survey 2012; Obesity Reviews, Zaghloul, 2010; Fares Bugshan, “Most GCC Residents Not Getting Frequent Exercise,” Gallup World, May 16, 2012 (http://www.gallup.com/ poll/154691/gcc-residentsnot-getting-frequentexercise.aspx); Strategy& analysis

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There are important country-by-country variations, although the overall picture remains worrisome. For example, some 37 percent of adult males in Saudi Arabia smoke. Widespread tobacco consumption is a public health policy challenge given the risk factors involved and the contrast with developed countries, which have reduced smoking rates considerably. Oman, which has the second lowest GDP per capita of the GCC, still has a less sedentary lifestyle, as yet unaffected by the unhealthy habits of developed countries. As a result, Oman has the highest incidence of individuals who exercise frequently and the lowest smoking rate. Similarly, there is a trend toward unhealthy dietary habits across the GCC, with the exception of Kuwait. Thi s tendency is worsened by the more frequent intake of energy-dense foods that are high in fat and sugars (fast food), but low in vitamins, minerals, and other micronutrients. More and more individuals pick the low-cost fast food alternative to home cooking, in part because of the popularity of malls in the GCC (which are attractive social hangouts given extreme weather conditions). Young individuals (ages 15–29) are even less likely to eat fresh fruits and vegetables than older individuals (ages 30–64) in most GCC countries. Unsurprisingly, there is an increased prevalence of certain NCDs, such as type II diabetes, in younger populations. There is also a gender aspect to the increasing frequency of modifiable risk factors. Most GCC countries have high prevalence rates of obesity, with women worse affected than men — except in Oman. The broader issues that intensify modifiable risk factors — such as the region’s weather conditions, cultural restrictions, and social limitations, all of which discourage physical activity — have a greater impact on women. The region’s women often lead more sedentary lives, in particular in countries where their workforce participation is limited, and they are more likely to have unhealthy eating patterns. For example, more than half of the women in Kuwait are considered obese, with a body mass index over 30.

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A strategy for tackling NCDs

With risk factors growing, and healthcare budgets already under strain, GCC governments need to sound the alarm within their societies and embark upon national programs to stem the NCD epidemic. Given the steep societal and financial penalties imposed by NCDs, GCC countries face serious social and financial risks. As such they must start to take effective measures in the short term. Currently the resources committed by GCC governments to fighting these illnesses are not commensurate with the magnitude of the problem — considerable amounts are spent on treating NCDs, but too little on preventing them. The goal of national programs that combat NCDs should be to disseminate positive behavioral messages that educate the population about the imminent health risks, rather than to simply defensively focus on restraining the growing incidence of chronic diseases. GCC countries therefore need to urgently factor NCDs into their long-term health planning, and they should aim for a better quality of life for residents, a reduction in unnecessary medical costs, and improved productivity. Coordinate and educate A national NCD approach has two main attributes, coordination and education. Coordination is important because the nature and magnitude of the required interventions demand a centrally led, collaborative effort involving key public and private stakeholders. The support and engagement of these stakeholders is needed to formulate and implement the NCD strategy. Education is vital to convince all stakeholders to accept the imperative of slowing the progression of NCDs; and education is the most effective tool for empowering patients and encouraging them to change their lifestyles. One approach to coordination can involve appointing an NCDs coordinator at the highest level of government. The NCDs coordinator can have an effective and rapid impact, if empowered, to coordinate

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efforts across the different healthcare stakeholders. In particular, the NCDs coordinator should possess the power of the purse and be able to disburse, or withhold, funds allocated to supporting the fight against NCDs. Resources need to be centralized under the coordinator’s control to ensure that programs are in harmony with each other. The NCDs coordinator can ensure reporting to the government on the progress of anti-NCD efforts, thereby monitoring and refining them. By focusing the NCDs policy in one high-level post, the government can advance its agenda by having a nationally identifiable convenor who will engage with all stakeholders, such as public health officials, payors, providers, employers, and patients, to establish a national NCD strategy and coordinate with stakeholders to implement it. The two levels of an NCD strategy In practical terms, any national strategy should tackle NCDs at two different levels: • direct curative care or early disease management • prevention Historically, the most common — and costliest — level of intervention has been direct curative care. Patients typically do not seek care until their condition becomes a serious hindrance to their daily activities. However, at this point the condition has generally reached an advanced stage with irreversible injury to body cells and systems — the risk factors that lead to NCDs. Patients are forced then to follow a strict diet or medication plan for the remainder of their lives. Symptomatic intervention is the most expensive as it requires advanced treatment at secondary or tertiary care facilities, including hospital admissions and surgery. Early disease management, also a form of curative care, is generally more efficient and cost-effective than direct care because it targets the disease risk factors. Although this still involves some cost in terms of medication and medical appointments, the cost of provision of such services is less than that of direct care because the disease symptoms are still manageable. If effective, early disease management can prevent NCD patients from deteriorating. Lately, the focus has shifted toward prevention programs to target the modifiable risk factors. Health systems that focus on prevention are in a better position to manage risk factors as they target their root causes and

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decrease their chances of developing further. This was emphasized by several leading healthcare stakeholders who we interviewed during the course of this study. Laila Al Jassmi, the former CEO of Health Policy and Strategy at the Dubai Health Authority, stressed that “Dubai needs to double down on prevention and early detection of chronic diseases.” Encouraging structural and behavioral changes Preventative action to lower the prevalence of modifiable risk factors requires the development and implementation of a combination of shortterm and long-term collaborative programs. Governmental authorities will have to lead each of the programs and will have to drive collaboration with other relevant actors in the field. Each of the five major stakeholders has a role to play and a program that it can lead (see Exhibit 15). Typically, short-term programs should tackle structural issues and are best driven by public health bodies. Long-term programs target social behaviors with the aim of introducing and encouraging the adoption of a set of “preferred norms.” In parallel, there needs to be an effort to develop system-wide capabilities to prevent, detect, and treat NCDs.

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Exhibit 15 Preventative programs call for stakeholder collaboration

Categories

Nature of Programs

Description of Programs - Taxes on unhealthy products - Subsidies for healthy products - Discriminatory pricing for insurances - Incentives for achieving exercise goals

Public Institution

Regulator

Provider

Payor

Employer/ School

Financial

Short-Term

Structural Programs Regulatory

- 9 a.m. to 6 p.m. workday for smokers - Limit availability of unhealthy products - Ban smoking in public places - School health programs - National screening programs Clinical - Diseases management programs - Occupational wellness program - Education programs for teachers Youth - Course material development to educate youth on NCDs - Communication campaigns to raise awareness of risks related to NCDs - Education aimed at patients Professional - Targeted education on NCDs screening for professionals - Patient ownership program

Long-Term

Behavioral Programs

Adult

Source: Strategy&

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Short-term programs Short-term programs can be rapidly designed and implemented by GCC governments. These efforts aim to alter or strengthen current structures to limit the impact of modifiable and non-modifiable primary risk factors. Although some of these measures may be experimental, they will be consistently educational in that they will communicate the need to lower modifiable risk factors. There are three main areas in which governments can make immediate changes: financial, regulatory, and clinical. Financial These measures financially reward, or penalize, individuals to reduce the impact of primary risk factors. This includes taxes on unhealthy products, such as fast food, soft drinks, and cigarettes, and subsidies for healthy ones, for example, healthy breakfasts for schoolchildren. Experience in developed countries shows that a steep tax on tobacco is associated with lower tobacco consumption. Other measures could include discriminatory pricing for insurance policies that take into account the individual’s health profile. This approach would levy a higher co-pay, or premium, on higher-risk populations such as smokers or sedentary individuals (as the state is the main healthcare player in the GCC there is no risk of people being priced out of the insurance market). Such a financial approach can be extended to social services by encouraging companies to engage in selective recruiting, only hiring non-smokers for example, or selective working hours, such as requiring smokers to work extended hours. Other options include free or subsidized gym subscriptions for employees, or cash incentives/gift cards for achieving specific health goals. Regulatory These measures involve adopting and enforcing rules and regulations that limit the availability and promotion of unhealthy products and ensure the availability of healthy alternatives in different settings, such as schools and government buildings. Measures could include banning the promotion and advertising of tobacco products, smoking in public places, and the sale of unhealthy food in schools’ refectories. The government could require that all schools and government cafeterias serve fresh produce.

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Again, there is an educational aspect to these measures, in particular in schools. The education system as a whole plays an essential role as it is the most effective medium to modify the younger generation’s behavior. Schools can instill “preferred norms” such as healthy eating and regular exercise.9 In particular, GCC countries would benefit from developing comprehensive school health programs and enlisting their school systems in the fight against the NCDs epidemic.10 Such programs have already been initiated in the region, such as the UNICEF partnership with the UAE Ministry of Education to organize seminars that include health education sessions and physical activities. Clinical The aim of clinical measures is to leverage existing health services and infrastructure to limit the impact of primary risk factors. Clinical programs include comprehensive national screening programs to identify at-risk groups and to ensure early detection of NCDs. Mass screening allows the government to better target treatments, and can be used as an opportunity to encourage patients to change their behavior and better address their risk factors, and to require high-risk individuals to purchase premium insurance policies. The Health Authority — Abu Dhabi (HAAD) invests heavily in primary care and screening. An example of the screening programs is Weqaya (Protection) which initially targeted cardiovascular diseases in Abu Dhabi. In time, Weqaya will also cover respiratory and mental diseases and a larger geographic area. Weqaya has already had multiple successes. The first round of screening covered 94 percent of Abu Dhabi nationals, and discovered 11,000 diabetes, 12,000 hypercholesterolemia, 27,000 hypertension, and 57,000 dyslipidaemia (abnormal cholesterol) cases.11 Screening programs are typically complemented with disease management programs to limit the impact and progression of NCDs. In Bahrain, Dr. Naeema Sabt, Chief of Health Centers Medical Services at the Ministry of Health, highlights the achievements of the disease management programs of the Ebrahim Khalil Kanoo Community Medical Center. Volunteers from the center regularly follow up with NCD patients to monitor their progress in person and remotely, and accompany them to physical exercise sessions. Those who end up in the emergency room, whether as NCD patients or just with intermediate risk factors, are assigned after being discharged to primary care physicians to hasten their recovery and steer them in the right direction by providing continuous monitoring and encouraging lifestyle changes.

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Long-term programs Stakeholders should design and launch long-term programs in parallel with short-term programs to ensure continuity of effort and sustainability of results. Long-term programs typically focus on behavioral change at the individual level and at the healthcare system level, and may have an effect on regulations and funding. The results of such programs will not be visible overnight. Rather, they aim to alter ingrained unhealthy lifestyles. Such changes in lifestyles should aim to be long-lasting, as they will dramatically improve the health status of GCC populations and contribute to economic development. There are three types of long-term programs: youth, adult, and professional. Youth programs These will complement the short-term school health programs. The aim of these programs is to educate teachers and others (e.g., sports coaches) who care for young people and can educate them on NCD risks and healthy lifestyles. These programs can shape the behavior of the young within schools and their communities. For this approach to succeed, it is important to equip these caregivers with tools, such as accessible and accurate educational material along with NCD-specific training. The public health authorities could start such a program by launching a media campaign or conducting workshops aimed at teachers and caregivers that would introduce foundational concepts on child development, child motivation, and healthy nutrition. Adult programs Programs aimed at adults will focus on select audiences to improve their knowledge and ability to manage their conditions and to reduce the impact of primary risk factors. For example, the NCDs coordinator can launch educational programs that would explain to adult consumers the significance of nutrition labels and how to use them on a daily basis. Other programs would focus on patients and would be linked to the outcome of screening programs. These programs would reach the appropriate audiences with healthy messages through such communication channels as Friday prayers in mosques, mobile applications, or traditional marketing channels.

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One example of an adult program is Qatar’s emphasis on physical exercise. The country has tried to position itself as the sports capital of the region with institutions such as the Aspire Zone and its Aspire Active program. Aspire Zone includes a sports academy and sports hospital (Aspetar). The goal of programs such as Aspire Active is to enhance the quality of life of the community by educating people about the value of exercise as part of their daily routine. Professional programs The aim of professional programs is to sensitize health providers about NCDs and direct them toward resources they can use to prevent, detect, and treat such diseases. For example, these programs can support the educational development of such specialists as nutritionists. They can ensure that the curricula at medical schools include foundational NCDs courses to properly train the future health workforce. Dr. Kazem Behbehani, Director-General of the Dasman Diabetes Institute in Kuwait, has worked on different diabetes-related education programs. According to Dr. Behbehani, around 500 professionals, mainly from primary health care centers, will be graduating in coming years with degrees focused on diabetes. Dr. Behbehani argues that “education is the best way forward to tackle NCDs — education tailored to everyone’s needs and to all age groups.” In addition, healthcare payors can play a key role in curbing healthcare costs by enacting tailored disease management programs that follow patient cases diligently to ultimately impede further advancement of their diseases. The impact of these programs can be significantly enhanced by using health information technologies. Given the widespread adoption of digital devices in the GCC, particularly by the younger generation which is the most at risk from NCDs, such approaches are innovative and promising. Health information technologies can help programs become more effective and more efficient. For example, remote monitoring of patient blood sugar levels allows healthcare professionals to better track the performance of patients’ treatment regimens and to modify medications accordingly.

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Conclusion

GCC countries must urgently take action to push back the rising tide of NCDs. These illnesses are already costing the regional economy three times what GCC governments currently spend each year on healthcare. Without comprehensive programs that enable better allocation of healthcare resources to treat the root causes of NCDs, as well as their symptoms, the human, the societal, and the economic burdens associated with these diseases will reach crippling levels. Governments will need to involve a wide array of public and private stakeholders in such programs to help create the optimal enabling environment for lifestyle changes. They should also implement screening programs for all NCDs and utilize the wealth of information collected to design more effective and targeted interventions. Programs to lower risk factors and better manage NCDs necessarily involve a degree of innovation and experimentation. With proper monitoring and measurement, successful schemes can be institutionalized, and lower-impact programs can be curtailed. Over time, investment of resources in effective programs dealing with NCDs should restrain the growth of GCC healthcare spending and improve the region’s health landscape.

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Endnotes

The Gulf Cooperation Council consists of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates.
1 2

WHO World Health Statistics, 2008 (http://www.who.int/whosis/whostat/2008/en/).

Dr. Margaret Chan, “Noncommunicable diseases damage health, including economic health,” September 19, 2011, WHO (http://www.who.int/dg/speeches/2011/un_ncds_09_19/ en/).
3

Center for Disease Control (CDC), “Global Health - Noncommunicable Diseases” (http:// www.cdc.gov/globalhealth/ncd/).
4

Alan D. Lopez, Colin D. Mathers, Majid Ezzati, Dean T. Jamison, and Christopher J.L. Murray (eds), Global Burden of Disease and Risk Factors, Oxford University Press and The World Bank, 2006, pp. 96–98 (http://files.dcp2.org/pdf/GBD/GBD.pdf#page=126).
5

Diabetes Mellitus is known to be associated with multiple chronic diseases. This study mitigates for the overlap between diabetes and the other four NCDs under examination.
6

D. E. Bloom et al., The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum 2011 (http://www.weforum.org/EconomicsOfNCD).
7

Dele Abegunde and Anderson Stanciole, “An Estimation of the Economic Impact of Chronic Noncom­ municable Diseases in Selected Countries,” World Health Organization, Department of Chronic Diseases and Health Promotion (CHP), Working paper, 2006 (http://tinyurl. com/97fwagc).
8

Richard Shediac, Dr. Leila Hoteit, and Dr. Mounira Jamjoom, “Listening to students’ voices: Putting students at the heart of education: Reform in the GCC,” Strategy&, 2013.
9

Dr. Matthias Buente, Ali A. Hashemi, Chadi N. Moujaes, and Hatem Samman, “GCC school health programs: Health and wellness through early intervention,” Strategy&, 2010.
10

Health Authority-Abu Dhabi, Weqaya, October 27, 2011 (http://www.who.int/tobacco/ mhealth/weqaya.pdf).
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This report was originally published by Booz & Company in 2013.

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© 2013 PwC. All rights reserved. PwC refers to the PwC network and/or one or more of its member firms, each of which is a separate legal entity. Please see www.pwc.com/structure for further details. Disclaimer: This content is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.

 

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© 2014 PwC. All rights reserved.
PwC refers to the PwC network and/or one or more of its member firms, each of which is a separate legal entity. Please see www.pwc.com/structure for further details.