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
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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.
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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 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?
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'
Condition
Interventions
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 & Reduced salt intake; replacement of trans fat with polyunsaturated
physical inactivity fat; public awareness about diet & physical activity
(3)
CVD & diabetes (2)
Cancer (2)
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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
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
Estimating the cost of scale up: information needed
Parameter
Definition
Data source(s)
Population
Total population of country
UN 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 use
Resources 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
Parameter
2007
2011
(Lancet chronic disease series)
(forthcoming WHO report)
Countries
23 (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 factors
Tobacco use; high BP; CVD
All elements of NCD action plan
(4 risk factors, 4 diseases)
Tobacco 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'
Interventions
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Different implementation time in different contexts, depending
on existing health system and policy environment
Scale up of patient interventions
Scale up of activities for
population interventions
(policy implementation):
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)
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Resource needs matrix for NCD policy instruments
Stage of policy
development
Human
resources
Training
Meetings
Planning
(year 1)
Program
management;
administration
Strategy /
policy analysis
Stakeholders
Development
(year 2)
Advocacy; law
Legislation
Intersectoral
collaboration
Awareness
campaigns
Partial
implementation
(years 3-5)
Inspection
Regulation
Monitoring
Counteradvertising
Full
implementation
(year 6 onwards)
Enforcement
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Evaluation
Mass media
Supplies &
equipment
Other
Office
equipment
Baseline
survey
Opinion poll
Vehicles, fuel
Follow-up
survey
Cost 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)
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Costing primary care services
Ingredient-based costing, specific by level
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Costing primary care services (contd.)
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Modeled costs indicate variability of resource needs
for scaling up NCD interventions
Median annual cost per capita of tobacco control, 2011-2025
$0.50
$0.45
Cost per capita (I$)
$0.40
$0.35
Lower IQR
Min
Median
Max
Upper IQR
$0.30
$0.25
$0.20
$0.15
$0.10
$0.05
$-
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Low-income countries
(N=14)
Lower middle-income
countries (N=13)
Upper middle-income
countries (N=15)
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 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 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)
Low-income
countries
(14)
Afghanistan; Bangladesh; Côte d'Ivoire; DPR Korea; DR
Congo; Ethiopia; Ghana; Kenya; Myanmar; Nepal; Nigeria;
Sudan; Uganda; Tanzania
Lower-middle
China; Egypt; India; Indonesia; Iraq; Morocco; Pakistan;
income countries Philippines; Sri Lanka; Ukraine; Uzbekistan; Viet Nam;
(13)
Yemen
Upper-middle
Algeria; Argentina; Brazil; Colombia; Iran; Kazakhstan;
income countries Malaysia; Mexico; Peru; Romania; Russian Federation;
(15)
South Africa; Thailand; Turkey; Venezuela
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Stenberg- Methods for Costing NCD Prevention and Control