Methods for costing NCD prevention and control

1. Methods for costing NCD prevention and control Workshop on Country Perspectives on Decision Making for control of chronic diseases Institute of Medicine of the National Academies July 19-21, 2011 Karin Stenberg, Department of Health Systems Financing

2. Acknowledgements 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.

3. Economic evidence for NCD prevention & control – a story with 3 parts – • Economic burden(the size of the problem): • Micro-economic impact (at level of households and firms) • Macro-economic impact (at aggregate level of society) • Priorities for investment(potential solutions): • Synthesis of available cost-effectiveness evidence • Identification of 'best buys' for low- and middle-income countries • Costs of scaled up action (financial 'price tag'): • Resource needs associated with enhanced coverage / implementation • Budgetary gaps and implications

4. Cost of scaling-up for NCDs: immediate and future steps • 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. • Country-level use / contextualization (for national planning; 2011-2012) • Incorporation into OneHealth (for integrated health system planning; 2012) • Modelling of health gains / return on investment (impact analysis; 2012 ?)

5. What to scale up? • Scope (WHO NCD action plan): • Risk factors: tobacco & (harmful) alcohol use; unhealthy diet & physical inactivity • Diseases: CVD and diabetes; cancers; respiratory disorders (asthma, COPD) • '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)

6. Summary of 'best buys' Addressing population risk factors Primary care 2008-2013 Action Plan for the WHO Global Strategy for the Prevention and Control of Noncommunicable Diseases

7. Estimating the cost of scale up: information needed

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

9. 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 policy implementation: • Planning stage (year 1) • Policy development (year 2) • Partial implementation (year 3-5) • Full implementation (year 6 onwards)

10. Resource needs matrix for NCD policy instruments

11. Cost of scaling up : Illustrative example

12. Costing population interventions (example)

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

14. Costing primary care services (contd.)

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

16. 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

17. Strengths 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.

18. Next 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

19. Additional slides

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