Health Policy 66 (2003) 61 /72

www.elsevier.com/locate/healthpol

Global policy: aspects of diabetes in India

Stefan Bjork a,*, Anil Kapur b, Hilary King c, Jyotsna Nair d,
A. Ramachandran e
a
Novo Nordisk A/S, Krogshoejvej 31, D-2880 Bagsvaerd, Denmark
b
Novo Nordisk Pharma India Ltd, Health Care Regional Office, Rajesh Chambers, 14/2 Brunton Road, Bangalore 560 025, India
c
World Health Organization, Geneva, Switzerland
d
ORG-MARG Research Ltd, No. 305 (First Floor), 6th Main, H.A.L. II Stage, Indiranagar, Bangalore 560 038, India
e
Diabetes Research Centre and M.V. Hospital for Diabetes. No. 4 Main Road, Royapuram, Chennai 600 013, India

Received 3 September 2001; accepted 28 January 2003

Abstract

Diabetes has already been described as an epidemic, but predictions for future increases in prevalence, especially in
developing countries, point to a major healthcare crisis for the future. Very little is known about the economic impact of
diabetes in the developing world where predicted increases in prevalence are greatest. This paper discusses the
implications of a recent study of the economic aspects of diabetes in India. The study aims were to estimate the costs of
diabetes care and to assess the awareness of patients and healthcare professionals about the prevention and treatment of
diabetes. The findings confirm reports from earlier studies of the high costs of treatment amongst all socio-economic
patient groups resulting in a serious burden on both patients and state resources alike. Both patients and medical
practitioners displayed a lack of comprehension of the need for constant disease monitoring and consistent approaches
to tight glycaemic control. The long term economic implications are worrying. With the Indian diabetic population
predicted to rise to
/80.9 million by the year 2030, immediate health policy restructuring and investment will be
needed if the best use is to be made of the scarce healthcare resources.
# 2003 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Diabetes; India; Healthcare policy

1. Introduction newly industrialised countries [1]. It has been

Diabetes is one of the top five leading causes of
death in most developed countries and substantial
evidence is accumulating to suggest that it will
reach epidemic proportions in developing and
* Corresponding author. Tel./fax:
/45-4444-8888.
E-mail address: stbj@novonordisk.com (S. Bjork).
0168-8510/03/$ - see front matter # 2003 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S0168-8510(03)00044-7
estimated that 2.1% of the world population may
have diabetes, predicted to rise to 3% by the year
2010 [2]. The World Health Organisation (WHO)
predict that the current diabetic population of 177
million (estimate 2000) people will increase to 370
million by the year 2030 [3].
Diabetes has become a major health issue in
South-East Asia. It has been estimated by the
International diabetes federation (IDF) that 23
62 S. Bjork et al. / Health Policy 66 (2003) 61 /72
million people currently have diabetes, which
accounts for a sixth of the world’s diabetic
population. India has the largest diabetic popula-
tion and one of the highest diabetes prevalence
rates in the world. The prevalence rates for type 2
diabetes in India are still increasing sharply with
the number of sufferers predicted to rise from 19.4
million in 1995 to 80.9 million in 2030 [1,4]. There
is also a large pool of individuals with impaired
glucose tolerance (IGT), many of who will develop
type 2 diabetes later in life [5]. The largest increases
in the diabetic population in developing countries
are projected to be in the most economically
productive age groups [1]. With the current high
mortality and morbidity rates associated with
diabetes, this represents a real threat to the
economic productivity of countries such as India.
Most major diabetes health initiatives are cur-
rently aimed at integrating diabetes healthcare into
existing disease-prevention programmes e.g.,
against heart disease and hypertension, which
have similar risk factors. The aim of such initia-
tives is to create active programmes of education
for diagnosed patients about the risk factors that
they face and organised systems for the appro-
priate referral of patients to specialists, where
needed. However, despite the large number of
studies that have been published on the increasing
prevalence of diabetes, and the general acceptance
that it has become a major global health problem,
there is a persistent lack of awareness amongst
policy makers and healthcare planners as to the
seriousness of the situation. Several major studies
have demonstrated a clear correlation between
good disease management and a decrease in
disease burden [6 /9]. Such studies are a clear
indication that the economic and social burdens
imposed by diabetes are at least partly avoidable
given a suitable treatment programme.
Comparatively little work has been done to
assess the costs of diabetes in developing countries.
It is clear, however, that families with the lowest
incomes bear the highest relative financial burden
of diabetes [10]. In the USA, diabetes costs have
been estimated at 9% of household expenditure for
low-income families [11]. For the poorest Indian
families, this figure increases to approximately
25% of household expenditure [12]. This study,
carried out by Shobana et al. in Southern India,
also demonstrated the same trends as studies
carried out in developed countries, where the
greatest component of diabetes costs was incurred
through hospitalisation and surgery.
The primary objective of this study was to
generate detailed data on all economic costs faced
by patients in the management of diabetes in
India. In addition, study specific aims included
the generation of data on the epidemiology of
diabetes in India and patient awareness of preven-
tion and treatments. Together this information is
essential for healthcare policy makers to develop
strategies of care and prevention to reduce the
growing population of diabetes patients in devel-
oping countries and lessen their impact on an
already fragile economy. A number of strategies
are suggested.
2. Methods and data
The study was conducted between January and
September 1999 in two phases. During phase I,
primary data for the study were collected from
patients using a structured questionnaire. In phase
II, details on clinical aspects and costs were
collected from doctors treating the patients.
For the purpose of sampling, India was divided
into zones */Delhi/Punjab/Haryana, Rajasthan,
Uttar Pradesh and Himachal Pradesh (north
zone), Assam/North East, Bihar, Orissa and
West Bengal (east zone), Gujarat, Madhya Pra-
desh and Maharashtra and Goa (west zone) and
Andhra Pradesh, Karnataka, Kerala and Tamil-
nadu/Pondicherry (south zone) (Fig. 1). The urban
areas within these states were divided by size of
town. From all the towns within the zones, a
proportionately representative sample of 187
towns was drawn for the study. The distribution
of the sample was proportional to the size and
population of the state. Within the towns, number
of patients recruited was proportional to the size
of the town and care was taken to have represen-
tation of type 1 and type 2 patients (Table 1). Type
1 patients were defined as those aged under 30
years, diagnosed with diabetes and prescribed
insulin at the diagnosis stage, while the remaining
 S. Bjork et al. / Health Policy 66 (2003) 61 /72 63

Fig. 1. Regions sampled for the all-India study.

patients were categorised as type 2. A purposive
sampling method was adopted to identify the
respondents; therefore it was not possible to have
all sections of society represented, in fact, the
sample may be biased towards the middle and
upper strata of society. Diabetic patients were
identified through chemist shops, public or private
clinics, hospitals and specialist diabetes clinics and
were selected in a ratio of 75/25% urban to semi-
urban respondents to reflect the higher incidence
of diabetes in urban areas. The study was also
conducted in rural areas of the states participating
in the study, although ‘rural’ respondents were not
from remote villages, but recruited mostly from
villages located at the periphery of the towns that
were visited. These have been designated ‘semi-
urban’ respondents.
2.1. Questionnaire
The questionnaire was developed by ORG
Centre for Social Research, a division of ORG-
 64
Table 1
Sample distribution

Zone/States Total Metro Town Class I Town Class II Town Class III Town Class IV

S. Bjork et al. / Health Policy 66 (2003) 61 /72

P A P A P A P A P A P A
Delhi/Punjab/Haryana 500 501 200 189 100 153 100 71 50 50 50 38
Himachal Pradesh 100 100 / / 50 28 / / / 22 50 50
Rajasthan 300 300 100 98 50 67 50 49 50 43 50 43
Uttar Pradesh 600 600 200 200 200 305 100 50 50 24 50 21
West Bengal 300 298 100 99 50 61 50 63 50 40 50 35
Bihar 400 400 150 151 100 105 50 53 50 45 50 46
Orissa 300 299 / / 100 100 100 98 50 50 50 51
Assam and North East 500 506 / / 400 401 50 48 50 53 / 4
Gujarat 300 300 100 81 50 66 50 91 50 62 50 /
Madhya Pradesh 400 400 100 100 100 99 100 101 50 50 50 50
Maharastra and Goa 600 600 200 204 150 166 150 119 50 79 50 32
Karnataka 350 350 100 103 100 165 50 44 50 12 50 25
Andhra Pradesh 350 362 100 108 100 117 50 73 50 44 50 20
Kerala 200 202 / 44 50 105 50 13 50 21 50 19
TN and Pondicherry 300 298 100 118 50 98 50 30 50 35 50 17

Total 5500 5516 1450 1495 1650 2036 1000 903 700 630 700 451

P, proposed; A, approached; Metro/More than 1 Million population; Town Class I/0.1 /1 Million; Town Class II/50 000 /0.1 Million; Town Class III/20 000 /
50 000; Town Class IV/Less than 20 000.
 S. Bjork et al. / Health Policy 66 (2003) 61 /72
MARG, and Novo Nordisk. It was designed to
elicit information on six aspects */(i) socio-eco-
nomic profile of the patient and household mem-
bers, (ii) diagnosis of diabetes and other
complications, (iii) monitoring and treatment of
diabetes, (iv) estimation of direct costs, (v) estima-
tion of indirect costs and (vi) awareness of
diabetes. Doctors were questioned about their
background, familiarity with their patients, fre-
quency of laboratory tests undertaken and expen-
diture on laboratory tests and hospitalisation. The
questionnaire was pre-tested on a sample of 120
patients in four regions of India */Lucknow
(north), Madras (south), Calcutta (east) and
Mumbai (west). The questionnaire was subse-
quently finalised, and has been developed in a
pilot study on 611 patients in Bangalore. The
interviews were conducted by Field Research
Officers (FROs) of ORG-MARG at the patient’s
home and in the patient’s own language. The
authenticity of the interview was checked by
ORG-MARG and each questionnaire was scruti-
nised for quality of data. In case of any discre-
pancy or incomplete information, the FRO was
asked to re-visit the patient. In addition, 5% of
questionnaires were checked independently by
Novo Nordisk.
The data were analysed by seven major vari-
ables, namely, type of diabetes (1 or 2), sex, area of
residence (urban or semi-urban), zone (north, east,
west or south), educational status (illiterate, school
or college), working status (working, not working,
retired or housewives) and monthly household
income (MHI) (B/Rs. 5000, Rs. 5000 /10 000 or

/Rs. 10 000). No formal statistical analyses were
performed.
3. Results
A total of 5516 patients completed the ques-
tionnaire drawn from a representative sample of
187 towns in India, graded by number of inhabi-
tants. While the total number of respondents
appears small for a country with a population of
greater than 1 billion, the sampling procedure used
strives to achieve as high representativeness as
possible of the diabetic patient population. Pa-
65
tients from semi-urban areas constituted 24% of
the sample. The method of identification of
diabetes patients resulted in bias towards patients
of a higher socio-economic status who could
afford diabetes treatment.
The mean age of all 5516 patients interviewed
was 53.79/13.2 years; type 1 patients were aged
27.19/12.9 years and type 2 patients 55.29/11.6
years. Type 1 patients constituted 5% of the total
sample. Level of education was high: 65% of
patients had attended school and 27% had at-
tended college. Approximately half of the respon-
dents (54%) were engaged in economic activity and
88% of the females performed unpaid household
chores. The majority of the sample (70%) was in
the two upper income groups, being employed by
small businesses, shops, government service and
private organisations. Average MHI was Rs.
11 200.
3.1. Diagnosis of diabetes
In India as a whole, the general practitioner
(GP) was the point of contact for the first
diagnosis of diabetes in 70% of patients. More
than 70% of these patients approached their GP
for consultation without being aware of any
diabetes-related symptoms. Patients were referred
for urine and/or blood (fasting blood sugar (FBS)
or postprandial blood glucose (PPBS)) tests in
/
90% of cases (Table 2). At diagnosis, the propor-
tion of patients who received any kind of other
assessment was small: 19% of patients underwent
an oral glucose tolerance test (GTT), 22% had an
electrocardiogram and 43% had a blood pressure
measurement. Only 4/6% of patients reported any
kind of glycated haemoglobin (HbA1c), lipid,
blood circulation or kidney function assessment.
At the time of diagnosis, a low prevalence of
severe diabetic complications was recorded
although 27.4 and 26.5% of patients were diag-
nosed with elevated blood pressure and diminished
eyesight, respectively. A higher proportion of type
2 patients had complications compared with type
1.
More than 46% of respondents had been
diagnosed as having diabetes within the past 5
years. Patients classed as living in semi-urban
66 S. Bjork et al. / Health Policy 66 (2003) 61 /72

Table 2
Tests undergone at diagnosis and post-diagnosis

At diagnosis Post-diagnosis

% of cases tested

All n/5516 Type 1 n /282 Type 2 n/5234 All n/5516 Type 1 n/282 Type 2 n/5234
Urine test 93.3 95.7 93.2 93.8 97.9 93.6
FBS 90.4 95.4 90.1 91.8 94.7 91.6
PPBS 90.3 91.1 90.3 93.2 96.1 93
OGTT 19.3 20.9 19.2 17.9 19.1 17.8
HbA1c 5.9 10.3 5.6 7.6 18.4 7.0
Lipid 4.2 5.3 4.2 7.4 9.9 7.3
Kidney function 6.0 9.2 5.8 11.1 17.4 10.8
Blood pressure 43.0 34.4 43.4 54.3 51.8 54.4
Eye examination 17.7 18.8 17.6 35.1 37.6 35.0
Blood circulation 5.4 4.3 5.4 11.77.5 11.7 7.2

FBS, fasting blood sugar; PPBS, postprandial blood glucose; OGTT, oral glucose tolerance test; HbA1C, glycated haemoglobin.

areas had a higher likelihood of being diagnosed
more recently than those in urban areas, suggest-
ing that diabetic patients in these areas may be
undiagnosed for a longer period of time than their
urban counterparts. Patients with a lower level of
education or a lower MHI were also more likely to
have been diagnosed later.
3.2. Treatment and monitoring
All patients diagnosed with type 1 diabetes had
been prescribed insulin since diagnosis, 29% in
combination with oral hypoglycaemic agent
(OHA) therapy. The first line therapy for 82% of
type 2 patients was OHA, indicating that the
severity of most diabetes cases was considered to
be low by the prescribing GP. Of all respondents,
2.4% were advised solely to control their diet and
take regular exercise and were not prescribed
medication. The treatment offered to patients did
not vary from region to region or with socio-
economic status apart from in the west zone and in
non-working patients where a higher number of
patients were prescribed insulin alone with corre-
spondingly fewer patients receiving OHAs (Table
3). Approximately 35% of all patients had been
treated with insulin at least once within 3 years of
diagnosis. The prescribed dosage of insulin
amongst these patients varied from zone to zone
with the highest number of units consumed in the
west zone (46 U) compared with the east zone (27
U). Nearly half (47%) of these patients were
injecting insulin themselves while 51% visited a
doctor or nurse for their injections.
Ongoing treatment of diabetes was undertaken
by GPs in 59% of patients, with only 16% of
patients seeking specialist treatment from a diabe-
tologist. Of this subgroup, patients with a higher
level of education or higher MHI were more likely
to visit a diabetologist. A higher proportion of
type 1 patients (26%) visited a diabetologist
compared with type 2 patients (15%).
The frequency of disease monitoring subsequent
to diagnosis was very low. Type 2 diabetes patients
monitored the status of their disease 10 times a
year on average. Patients with type 1 diabetes had
a markedly more regular regimen of testing (mean
32 times a year; Table 4). Overall, B/6% of
patients monitored the status of their disease
more than once a month, 48% every 1 /2 months
and 47% of patients reported monitoring only
once in 3 months or more. Urine- and blood-test
strips were the best known and most popular
methods of glucose monitoring amongst respon-
dents. More than 85% of all patients preferred to
carry out these tests at pathology laboratories.
Government institutions, which provide treatment
free of charge to the general public, were utilised
by only 10% of respondents. Self-testing was
exclusively relied upon by only 2% of patients.
Table 3
Prescription pattern at diagnosis

Zone Type Status Zones

All India Type 1 Type 2 Working Not working Retired HW North East West South

S. Bjork et al. / Health Policy 66 (2003) 61 /72

Base: All 5516 282 5234 2996 396 760 1364 1501 1503 1300 1212
Tablets n 4305 / 4305 2376 217 1234 1205 944 922
% 78.0 / 82.2 612 1100 82.2 80.2 72.6 76.0
Insulin n 435 200 235 79.3 54.8 101 68 167 99
% 7.9 70.9 4.5 80.5 80.6 6.7 4.5 12.8 8.2
Insulin and tablets n 579 82 497 212 104 121 156 141 161
% 10.5 29.1 9.5 41 78 8.1 10.4 10.8 13.3
Ayurveda n 31 / 31 7.1 26.2 12 5 9 5
% 0.6 / 0.6 5.4 5.7 0.8 0.3 0.7 0.4
Homeopathy n 15 / 15 285 67 3 8 1 3
% 0.3 / 0.3 74 153 0.2 0.6 0.1 0.3
Diet control n 2 / 2 9.5 17.0 2 / / /
% 0.03 / 0.04 9.7 11.2 0.1 / / /
Treatment not known n 14 / 14 23 / 3 5 4 2
% 0.3 / 0.3 6 2 0.2 0.3 0.3 0.2
No medicines advised n 135 / 135 0.8 / 24 56 34 20
% 2.4 / 2.6 0.8 0.1 1.6 3.7 2.6 1.7

HW, housewife.

67
68 S. Bjork et al. / Health Policy 66 (2003) 61 /72
Table 4
Frequency of disease status monitoring
Frequency All Type 1 % of cases
B/Once a month 6.2 18.4
Once a month 30.7 34.0
Once in 2 months 16.4 8.9
Once in ]/3 months 46.7 37.9
Respondents regarded the success of, or need
for, treatment as being determined by their sense
of well-being. Seventy-two percent of patients
regarded their disease as being under control.
The mean PPBS level reported by those patients
who ‘felt well’ was more than 180 mg/dl at their
last monitoring session.
The irregularity of self-testing or patient mon-
itoring after diagnosis is concomitant with a
continued lack of further or advanced testing
beyond the conventional FBS and PPBS measure-
ments (Table 2). Less than 18% of all patients had
undertaken a GTT. A total of 54% of all patients
reported having their blood pressure measured
since diagnosis. Only 7/11% of patients reported
being tested for HbA1c levels, lipid analysis, blood
circulation and kidney function after diagnosis.
There is little variation in these figures across
respondents from different regions or between
semi-urban and urban populations indicating
that medical approaches to monitoring are uni-
form across India.
3.3. Costs
A substantial proportion of costs are borne by
the patients themselves. Mean total direct costs of
diabetes in India were Rs. 7159 per individual per
annum. The components of this total cost were: (1)
mean direct costs of diabetes in India (Rs. 4724)
which included drug therapy, disease monitoring
tests and check-up, and (2) mean annual hospita-
lisation costs (Rs. 2435).
Type 1 diabetes patients incurred mean total
costs similar to type 2 patients, although the
expenditure by each patient group appeared to
be concentrated in different areas: patients with a
higher level of education and MHI spent more on
treatment and monitoring.
Type 2
There is a clear correlation between the number
of complications that a patient is suffering from
5.5 and their healthcare expenditure. There was a
30.4 tendency towards fewer complications in urban
16.8
47.2
patients with a higher educational status who
spent more on treatment and monitoring although
no clear link was evident. Some regional differ-
ences in patterns of expenditure exist, with patients
in the west of India likely to spend 26% more on
laboratory fees, check-ups and medicines than any
other region (Rs. 5550 vs. 5/Rs. 4394). The basis
for this variance is not clear.
4. Discussion
The ever-increasing costs of healthcare make
diabetes prevention a priority, and cost-effective
treatment a necessity. This is particularly applic-
able to India, a developing country that already
has the largest diabetic adult population in the
world, the growth of which is predicted to
continue [1]. In a country that currently does not
have a national strategy for the treatment of
diabetes and has only allocated 2% of the total
budget for all healthcare expenditure, increasing
prevalence of diabetes is a serious concern [13 /17].
The IDF estimated that adequate treatment of the
estimated 17.3 million diabetic patients in India
would cost Rs. 75.2 million [18]. In 1997, the total
healthcare budget was Rs. 24.7 billion. There is,
therefore, a massive shortfall in funds and the
inevitable consequence is the creation of a health
service that prioritises emergency care over pre-
vention. It is clear from the findings of this study
that there is a very real gap between best and
actual practice for diabetes treatment in India.
4.1. Primary care
Recommended practice for initial screening of
patients by their GPs through measurement of
FBS was observed. However, the low incidence of
haemoglobin, lipid, kidney, neurological, optical
or cardiovascular testing may reflect an inade-
quate appreciation by the physician that disease
 S. Bjork et al. / Health Policy 66 (2003) 61 /72
progression can lead to serious complications.
Lack of information rather than access to specia-
list equipment seems to be the limiting factor, as
these observations were not greatly affected by
socio-economic status or proximity to urban
centres. The consequences of this naivety are
already becoming evident. Although relatively
few complications were reported at first diagnosis,
the number of patients reporting clinical complica-
tions had significantly increased since initial diag-
nosis (from 58.4 to 67.3% over a mean disease
duration of 8 years) despite receiving treatment.
This study also indicates that within the primary
healthcare system of India, a lack of understand-
ing exists of the treatment requirements for
diabetes patients. The importance of glycaemic
control not only in the day-to-day maintenance of
life-style but also in the prevention of future
morbidity and mortality has been highlighted in
a number of studies [6 /9].
4.2. Patient self-monitoring
A general lack of understanding of diabetes was
apparent in the patients assessed for this study.
Results show that patients were unaware of the
potential seriousness of their condition, with B/6%
of patients monitoring their condition more than
once a month. Compounding this problem is the
belief by many patients that their disease is under
control because they are ‘feeling well’. The absence
of comprehension that patients exhibit with regard
to the risks they are facing is a serious concern.
The intermittent frequency of disease monitor-
ing may also be due to the costs involved. The
numbers of patients that owned a meter for blood
glucose testing was low (1.8% of total) and the vast
majority (85.5%) of patients visited pathology
laboratories for disease monitoring tests. As a
result, a large proportion of direct costs was
expended on laboratory fees, the cost of the tests
and transport costs, which in itself is a disincentive
to regular monitoring.
4.3. Costs of diabetes
The direct costs of healthcare for a diabetic
patient are generally higher than that of a non-
69
sufferer [19,20]. The actual cost of treatment can
vary between countries as a result of country-
specific methodologies and pricing. In the present
study, the greatest proportion of direct costs
resulted from hospitalisation fees due to diabetes
complications. Little information has been avail-
able about the comparative cost of treatment in
the Indian sub-continent, although a recent report
did examine the costs of hospital based secondary
care in a small patient sample [12]. This study
confirmed that the cost of inpatient care is more
expensive than outpatient treatment, and that
length of disease duration has a significant impact
on total cost to the patient.
The financial burden on the individual and their
family can be very high if the costs of prevention
and treatment are borne out of household income.
With an average MHI of Rs. 11 200, the estimated
mean expenditure of Rs. 20 625 is equivalent to a
7% burden on household income, which would
increase further if the family contained more than
one diabetic patient (Fig. 2). Given that most of
the respondents that took part in this study are
classified as belonging to the top two economic
brackets, it may be surmised that the burden on
the majority of diabetes patients in India could be
much greater, according to percentage of the MHI
spent on diabetes and its complications.
5. Conclusions
5.1. Primary prevention
Available evidence suggests the sharp increase in
diabetes in the developing world is related to
lifestyle changes taking place as a result of global
economic development. Primary preventative mea-
sures aimed at life-style changes such as altering
dietary behaviour and educating people to the
risks that they face could be an effective method of
combating diabetes.
With a high ethnic susceptibility for developing
diabetes, a regular screening programme of the
Indian population could also be a vital and cost-
effective measure for lessening the impact of
diabetes. However, in countries with severely
limited resources such as India, prevention is a
70 S. Bjork et al. / Health Policy 66 (2003) 61 /72

Fig. 2. Household income and educational status vs. number of complications. MHIB/5000, monthly household income Rs.B/5000;
MHIB/10 000, monthly household income Rs.B/10 000; MHI 10 000
/, monthly household income Rs.
/10 000. (b) Household
income and educational status vs. expenditure on treatment and monitoring. MHIB/5000, monthly household income Rs.B/5000;
MHIB/10 000, monthly household income Rs.B/10 000; MHI 10 000
/, monthly household income Rs.
/10 000.

low priority and the likelihood of funds becoming
available for screening strategies is extremely low.
5.2. Secondary prevention: detection and
monitoring
Early detection, prevention and treatment of
diabetic complications (secondary prevention) can
be especially beneficial in terms of patient quality-
of-life and cost effectiveness [7,21]. As determined
in this study, any measure that can reduce
hospitalisation will reduce the major expenditure
associated with advanced diabetes. Several studies
have estimated that cost savings of up to 75% can
be made by re-focusing the provision of care
toward an outpatient basis [22,23].
Continued regular monitoring and treatment
have been demonstrated to have great positive
benefits to the diabetic patient over the long term
by reducing the incidence of a number of compli-
cations such as cardiovascular disease and nephro-
pathy [7 /9,21,24,25] and is most cost-effective in
diabetic complications such as retinopathy, foot
ulceration and amputation. Yet in an earlier study
in India, GPs did not carry out simple clinical
examination of the feet, eyes and blood pressure in
more than 80% of diabetes patients [26].
In all zones of this study, as in most countries,
the family physician is the primary point of
contact for diagnosis and treatment of the diabetic
patient [27,28]. This preference provides an ex-
cellent opportunity to develop a strong, GP-based
framework as a basis for a comprehensive strategy
to target those in need of treatment. This will,
however, be dependent on the ability of the GP to
understand and communicate effectively with
patients about diabetes issues. At present, GPs
appear to be either unaware of, or unable to
communicate these concerns to their patients.
Education programmes for GPs and their patients
will clearly be a priority.
A model of shared care amongst primary-care
workers i.e., GPs, and more specialised care
workers has often been advocated [29 /31]. Such
a model may be particularly suitable to the diverse
patient environment of India where there is a clear
preference for consulting the family practitioner.
This study shows that few Indian patients utilise
government-approved hospital facilities with only
5/16% of patients taking advantage of the avail-
able free access to testing, check-ups and medica-
 S. Bjork et al. / Health Policy 66 (2003) 61 /72
tion. Generating patient confidence in these ser-
vices could be vital to the future success of any
national strategy for diabetes control.
5.3. Tertiary prevention
This study suggests that the Indian healthcare
system perceives a lack of immediacy with regard
to the threat posed by diabetic complications. The
large projected rises in the incidence of diabetes
and IGT and the increase in age of the current
diabetic population mean that there is a great risk
of a future explosion in the occurrence of diabetes-
related disease [1]. The ability of the Indian health
service to cope with such an eventuality is reliant
on the establishment of a complete tertiary care
infrastructure and clear treatment guidelines.
There are no specific treatment guidelines pro-
posed by the WHO for India or SE Asia. As a
result, there are serious deficiencies in the standard
of care that can be expected by patients when they
consult their physician for diabetes treatment. The
consolidation of the network of regional clinics
and national diabetes centres may be the organisa-
tional basis for educating less specialised physi-
cians such as GPs in India.
Investment in infrastructure must be matched
by investment in education. Success in reducing
the incidence of diabetes, and hence the burden of
disease on the Indian state, will only be achieved if
patients and their families fully understand the
issues that they face. The key to promoting this
message is the education of those healthcare
professionals who have direct contact with the
patients, such as GPs and all other healthcare
professionals involved in diabetes care. It will be
vitally important that policy makers are made
aware of not only the potential cost of diabetes,
but also of the vast savings that simple measures
such as education could provide in the long term.
5.4. Future planning in India and similarly
developing countries
The challenges that India faces are not unique.
In virtually all developing countries common
‘causal associations’ are contributing to the in-
crease in prevalence of type 1 and type 2 diabetes.
71
These include: changes in traditional diet, increas-
ingly sedentary lifestyles, general and visceral
obesity, increased life expectancy and better treat-
ments for other life-threatening diseases. In the
face of unrestrained economic globalisation and
industrialisation, it is predicted that diabetes is set
to become a major public health concern for most
countries in the twenty-first century. It is impor-
tant that the profile of diabetes is raised and that
governments initiate adequate investment in mon-
itoring and prevention strategies as soon as
possible.
Priority must be given to research into the
current cost and the impact that diabetes has on
the individual and on society. Only when armed
with the appropriate information can healthcare
policy be re-evaluated and adjusted to achieve full
prevention and treatment potential. Given the
expected explosion in diabetes costs in developing
countries, gathering information on economics of
diabetes will be an invaluable tool in the planning
and the resourcing of national strategies to combat
this disease.
References
[1] King H, Aubert RE, Herman WH. Global burden of
diabetes, 1995 /2025: prevalence, numerical estimates, and
projections. Diabetes Care 1998;21(9):1414 /31.
[2] Amos AF, McCarty DJ, Zimmet P. The rising global
burden of diabetes and its complications: estimates and
projections to the year 2010. Diabetic Medicine
1997;14(5):S1 /S85.
[3] World Health Organisation. The cost of diabetes. Fact
Sheet No. 236. Revised 2002.
[4] Over M. Economics of health sector analysis; concepts and
cases. Washington, DC: World Bank, 1991.
[5] Kapur A, Shishoo S, Ahuja MMS, Sen V, Mankame K.
Diabetes care in India */Physicians’ perceptions attitudes
and practices (DIPPAP */1 study). International Journal
of Diabetes Development in press.
[6] Reichard P, Nilsson BY, Rosenqvist U. The effect of long-
term intensified insulin treatment on the development of
microvascular complications of diabetes mellitus. New
England Journal of Medicine 1993;329(5):304 /9.
[7] Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S,
Motoyoshi S, et al. Intensive insulin therapy prevents the
progression of diabetic microvascular complications in
Japanese patients with non-insulin-dependent diabetes
mellitus: a randomized prospective 6-year study. Diabetes
Research and Clinical Practice 1995;28(2):103 /17.
72 S. Bjork et al. / Health Policy 66 (2003) 61 /72
[8] UK Prospective Diabetes Study (UKPDS) Group. Inten-
sive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of com-
plications in patients with type 2 diabetes (UKPDS 33)
[published erratum appears in Lancet 1999 Aug
14;354(9178):602]. Lancet 1998;352(9131):837 /853.
[9] The Diabetes Control and Complications Trial Research
Group. The effect of intensive treatment of diabetes on the
development and progression of long-term complications
in insulin-dependent diabetes mellitus. New England
Journal of Medicine 1993;329(14):977 /986.
[10] Pharmaco Economic Affairs, Novo-Nordisk A/S Den-
mark. Economic aspects of diabetes in India. A Pilot
Project. 1999.
[11] Songer TJ, LaPorte R, Lave JR, Dorman JS, Becker DJ.
Health insurance and the financial impact of IDDM in
families with a child with IDDM. Diabetes Care
1997;20(4):577 /84.
[12] Shobhana R, Rama Rao P, Lavanya A, Williams R, Vijay
V, Ramachandran A. Expenditure on health care incurred
by diabetic subjects in a developing country */a study from
southern India. Diabetes Research and Clinical Practice
2000;48(1):37 /42.
[13] Zargar AH, Khan AK, Masoodi SR, Laway BA, Wani AI,
Bashir MI, et al. Prevalence of type 2 diabetes mellitus and
impaired glucose tolerance in the Kashmir Valley of the
Indian subcontinent. Diabetes Research and Clinical
Practice 2000;47(2):135 /46.
[14] Raman Kutty V, Joseph A, Soman CR. High prevalence of
type 2 diabetes in an urban settlement in Kerala, India.
Ethnic Health 1999;4(4):231 /9.
[15] Ramachandran A, Snehalatha C, Krishnaswamy CV.
Incidence of IDDM in children in urban population in
southern India. Madras IDDM Registry Group Madras,
South India. Diabetes Research and Clinical Practice
1996;34(2):79 /82.
[16] Ramachandran A, Snehalatha C, Abdul Khader OM,
Joseph TA, Viswanathan M. Prevalence of childhood
diabetes in an urban population in South India. Diabetes
Research and Clinical Practice 1992;17(3):227 /31.
[17] Singh RB, Bajaj S, Niaz MA, Rastogi SS, Moshiri M.
Prevalence of type 2 diabetes mellitus and risk of
hypertension and coronary artery disease in rural and
urban population with low rates of obesity. International
Journal of Cardiology 1998;66(1):65 /72.
[18] The economics of diabetes and diabetes care. A report of
the diabetes health economics study group. Brussels: IDF;
1997.
[19] American Diabetic Association. Economic consequences
of diabetes mellitus in the US in 1997. Diabetes Care
1998;21:296 /309.
[20] Selby JV, Ray GT, Zhang D, Colby CJ. Excess costs of
medical care for patients with diabetes in a managed care
population. Diabetes Care 1997;20(9):1396 /402.
[21] Pyorala K, Pedersen TR, Kjekshus J, Faergeman O,
Olsson AG, Thorgeirsson G. Cholesterol lowering with
simvastatin improves prognosis of diabetic patients with
coronary heart disease. A subgroup analysis of the
Scandinavian Simvastatin Survival Study (4S) [published
erratum appears in Diabetes Care 1997 Jun;20(6):1048].
Diabetes Care 1997;20(4):614 /620.
[22] Bruce DG, Clark EM, Danesi GA, Campbell LV,
Chisholm DJ. Outpatient initiation of insulin therapy in
patients with diabetes mellitus. Medical Journal of Aus-
tralia 1987;146(1):19 /22.
[23] Bakker K, Dooren J. A specialized outpatient foot clinic
for diabetic patients decreases the number of amputations
and is cost saving. Ned Tijdschr Geneeskd
1994;138(11):565 /9.
[24] Hansson L, Zanchetti A, Carruthers SG, Dahlof B,
Elmfeldt D, Julius S, et al. Effects of intensive blood-
pressure lowering and low-dose aspirin in patients with
hypertension: principal results of the hypertension optimal
treatment (HOT) randomised trial. HOT Study Group.
Lancet 1998;351(9118):1755 /1762.
[25] Frick MH, Elo O, Haapa K, Heinonen OP, Heinsalmi P,
Helo P, et al. Helsinki heart study: primary-prevention
trial with gemfibrozil in middle-aged men with dyslipide-
mia. Safety of treatment, changes in risk factors, and
incidence of coronary heart disease. New England Journal
of Medicine 1987;317(20):1237 /45.
[26] Rayappa PH, Raju KNM, Kapur A, Björk S, Sylvest C,
DilipKumar KM. The impact of socio-economic factors
on diabetic care. International Journal of Diabetes in
Developed Countries 1999;19:7 /16.
[27] Nutbeam D, Thomas M, Wise M. National action plan.
Diabetes to the year 2000 and beyond. Canberra: Aus-
tralian Diabetes Association, 1993.
[28] Mazze RS. A systems approach to diabetes care. Diabetes
Care 1994;1:5 /11.
[29] Branger PJ, van’t Hooft A, van der Wouden JC, Duisterh-
out JS, van Bemmel JH. Shared care for diabetes:
supporting communication between primary and second-
ary care. Medinfo 1998;1:412 /6.
[30] Pond D, Knowlden S, Harris M. News from the divisions:
diabetes shared care. Australian Family Physician
1996;1(10):S9 /S10.
[31] Sinclair AJ. Diabetes in the elderly: a perspective from the
United Kingdom. Clinical Geriatric Medicine
1999;15(2):225 /37.