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Methods for costing NCD prevention and control

Methods for costing NCD prevention and control

Workshop on Country Perspectives on Workshop on Country Perspectives on Decision Making for control of chronic diseasesDecision Making for control of chronic diseases

Institute of Medicine of the National Academies July 19-21, 2011Institute of Medicine of the National Academies July 19-21, 2011

Karin Stenberg, Department of Health Systems FinancingKarin Stenberg, Department of Health Systems Financing

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AcknowledgementsAcknowledgements

The analysis was led by Dr Dan Chisholm, Dr Dele Abegunde and Dr Shanthi Mendis of World Health Organization, with contributions from many WHO experts.

The support and contribution of the American Cancer Society to this work is gratefully acknowledged.

For tobacco costing, the contributions of Dr Ioana Popovici of Nova Southeastern University and Professor Michael French of the University of Miami were funded by Bloomberg Philanthropies and the World Lung Foundation, while the time and contributions of Judith Watt was funded by the Framework Convention Alliance.

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Economic evidence for NCD prevention & control – a story with 3 parts –

Economic evidence for NCD prevention & control – a story with 3 parts –

1. Economic burden (the size of the problem): Micro-economic impact (at level of households and firms) Macro-economic impact (at aggregate level of society)

2. Priorities for investment (potential solutions): Synthesis of available cost-effectiveness evidence Identification of 'best buys' for low- and middle-income countries

3. Costs of scaled up action (financial 'price tag'): Resource needs associated with enhanced coverage / implementation Budgetary gaps and implications

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Cost of scaling-up for NCDs: immediate and future stepsCost of scaling-up for NCDs: immediate and future steps

1. Global 'price tag' for all Low and Middle Income Countries (LAMIC) (for input into NCD summit;

Sept 2011)– a financial planning tool for scaled-up delivery of a defined set of population-wide and individual health care

interventions.

2. Country-level use / contextualization (for national planning; 2011-2012)

3. Incorporation into OneHealth (for integrated health system planning; 2012)

4. Modelling of health gains / return on investment (impact analysis; 2012 ?)

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What to scale up?What to scale up?

1. Scope (WHO NCD action plan): Risk factors: tobacco & (harmful) alcohol use; unhealthy diet & physical inactivity Diseases: CVD and diabetes; cancers; respiratory disorders (asthma, COPD)

2. 'Best buys': Interventions that are very cost-effective but also feasible, low-cost and

appropriate to implement within the constraints of the local health system 'Very cost-effective' = one year of healthy life is obtained for less than average

annual income per person [GDP per capita] Interventions that do not meet all of these criteria - but which still offer good

value for money and have other attributes that recommend their use – can be considered as 'good buys' (we also cost this expanded intervention set)

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Summary of 'best buys'Summary of 'best buys'

ConditionInterventions

Tobacco use (4)Tax increases; smoke-free indoor workplaces & public places; health information / warnings; advertising/promotion bans

Alcohol use (3)Tax increases; restrict retail access; advertising bans

Unhealthy diet & physical inactivity

(3)

Reduced salt intake; replacement of trans fat with polyunsaturated fat; public awareness about diet & physical

activity

CVD & diabetes (2)Counselling & multi-drug therapy (including glycaemic control for diabetes) for people with >30% CVD risk (including those with

CVD); treatment of heart attacks with aspirin

Cancer (2)Hepatitis B immunization to prevent liver cancer; screening & treatment of pre-cancerous lesions to prevent cervical cancer

2008-2013 Action Plan for the WHO Global Strategy for the Prevention and Control of Noncommunicable Diseases

Addressing population risk factors

Primary care

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Estimating the cost of scale up: information neededEstimating the cost of scale up: information needed

ParameterDefinitionData source(s)PopulationTotal population of countryUN population division statistics

Prevalence% of population with disease / risk factor exposure (by age & sex)

Global burden of disease estimates: Comparative Risk Assessment study NCD surveillance (e.g. Infobase)

Coverage% of population in need in receipt of intervention

Current coverage: Survey data Target coverage: expert consensus

Resource useResources needed to implement intervention

Treatment protocols, costing studies

Unit cost / price

Cost per unit/item of resource use

Drug prices from MSH; WHO costing data base (CHOICE) – e.g., salaries, media costs, per diems, etc.

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Estimating the global cost of scale up: 2011 study produces a more extensive estimate

Estimating the global cost of scale up: 2011 study produces a more extensive estimate

Parameter2007

(Lancet chronic disease series)

2011

(forthcoming WHO report)

Countries23 (80% of LAMIC burden)42 (90% of LAMIC burden)

Scale-up period (price year)

2006-2015 (in 2005 prices)2011-2025 (in 2008 prices)

NCDs / risk factorsTobacco use; high BP; CVDAll elements of NCD action plan (4 risk factors, 4 diseases)

InterventionsTobacco control measures (4); salt reduction (1); multi-drug

therapy for those at high risk (1)

Core set: all 'best buys' (14) Expanded set: range of 'good buys'

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Different implementation time in different contexts, depending on existing health system and policy environment

Different implementation time in different contexts, depending on existing health system and policy environment

Scale up of activities for population interventions

(policy implementation) :Scale up of patient interventions

Based on available assessment of current enforcement or 'performance' of countries with respect to e.g.,

tobacco control policy ,alcohol control policy.4 stages of policyimplementation:

•Planning stage (year 1) •Policy development (year 2)

•Partial implementation (year 3-5) •Full implementation (year 6 onwards)

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Resource needs matrix for NCD policy instrumentsResource needs matrix for NCD policy instruments

Stage of policy development

Human resources

TrainingMeetingsMass mediaSupplies & equipment

Other

Planning (year 1)

Program management; administration

Strategy / policy analysis

StakeholdersOffice equipment

Baseline survey

Development (year 2)

Advocacy; lawLegislationIntersectoral collaboration

Awareness campaigns

Opinion poll

Partial implementation (years 3-5)

InspectionRegulationMonitoringCounter-advertising

Vehicles, fuel

Full implementation (year 6 onwards)

EnforcementEvaluationFollow-up survey

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Cost of scaling up : Illustrative exampleCost of scaling up : Illustrative example

A 20% rate of prevalence of smoking in a total population of 1 million persons would give a population in need of 200,000 individuals. All these individuals could benefit each year from

a brief intervention in primary care that, say, costs $1 per case to deliver .

• Cost of current coverage: If coverage of the brief intervention was currently only 10%, the total annual cost would be $20,000 (200,000 * 10% * $1).

• Cost of target coverage: If scaled up to a higher desired level of coverage (such as 50%), the total cost in that future year will jump five-fold to $100,000.

• Incremental cost: Difference between the current and target level of coverage ($80,000).

• Cost per capita: Division of total or incremental costs by total number of people in the population (annual cost per person would rise from $0.02 to $0.10, an increment of $0.08).

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Costing population interventions (example)Costing population interventions (example)

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Costing primary care services Ingredient-based costing, specific by level

Costing primary care services Ingredient-based costing, specific by level

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Costing primary care services (contd.)Costing primary care services (contd.)

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Modeled costs indicate variability of resource needs for scaling up NCD interventions

Modeled costs indicate variability of resource needs for scaling up NCD interventions

Median annual cost per capita of tobacco control, 2011-2025

$-

$0.05

$0.10

$0.15

$0.20

$0.25

$0.30

$0.35

$0.40

$0.45

$0.50

Low-income countries(N=14)

Lower middle-incomecountries (N=13)

Upper middle-incomecountries (N=15)

Cost

per

cap

ita (I

$)

Lower IQRMinMedianMaxUpper IQR

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Cost of scaling up NCD prevention: population-based tobacco and salt reduction strategies

(Source: Asaria et al, Lancet 2007)

Cost of scaling up NCD prevention: population-based tobacco and salt reduction strategies

(Source: Asaria et al, Lancet 2007)

Over 10 years (2006–2015), 13·8 million deaths could be averted

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Strengths and limitationsStrengths and limitations

STRENGTHS

Comprehensive assessment of 'best buys' and 'good buys'

Standard methodology used by WHO to derive global 'price tags' and country costing spreadsheets (similar to TB, malaria, child health, etc).

Ingredients based (Quantity x Price ) – easy for countries to review and validate

Assessment of current policies and health system as starting point

LIMITATIONS

Lacks assessment of health gains; does not model changes in epidemiology over time as preventive interventions are scaled up.

May need to be expanded to cover a broader intervention set for country planning.

Does not model health system investment needs.

Financial sustainability assessment needs to be done separately.

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Next stepsNext steps

Report on global price tag launched before UNGASS Sept summit

NCD cost templates available for countries to validate and use

Integration of NCD module into OneHealth tool

will need to consider broader package, including other renal and liver diseases, gastrointestinal diseases, and mental disorders

Develop model for analysis of health impact

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Additional slides

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Estimating the cost of NCD scale up (2011) - 42 countries(each > 20m popn; together, account for 90% NCD LAMIC burden)

Estimating the cost of NCD scale up (2011) - 42 countries(each > 20m popn; together, account for 90% NCD LAMIC burden)

Low-income countries (14)

Afghanistan; Bangladesh; Côte d'Ivoire; DPR Korea; DR Congo; Ethiopia; Ghana; Kenya; Myanmar; Nepal; Nigeria; Sudan; Uganda; Tanzania

Lower-middle income countries (13)

China; Egypt; India; Indonesia; Iraq; Morocco; Pakistan; Philippines; Sri Lanka; Ukraine; Uzbekistan; Viet Nam; Yemen

Upper-middle income countries (15)

Algeria; Argentina; Brazil; Colombia; Iran; Kazakhstan; Malaysia; Mexico; Peru; Romania; Russian Federation; South Africa; Thailand; Turkey; Venezuela