Cost-Effectiveness of Population Level and Individual Level Interventions to Combat Non-communicable Disease in Eastern Sub-Saharan Africa and South East Asia: A WHO-CHOICE Analysis.

BACKGROUND: To determine the health system costs and health-related benefits of interventions for the prevention and control of non-communicable diseases (NCDs), including mental health disorders, for the purpose of identifying the most cost-effective intervention options in support of global normative guidance on the best-buy interventions for NCDs. In addition, tools are developed to allow country contextualisation of the analyses to support local priority setting exercises. METHODS: This analysis follows the standard WHO-CHOICE (World Health Organization-Choosing Interventions that are Cost-Effective) approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and South-East Asia. The scope of the analysis is all NCD and mental health interventions included in WHO guidelines or guidance documents for which the health impact of the intervention is able to be identified and attributed. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, both for a period of 100 years. RESULTS: There are many interventions for NCD prevention and management that are highly cost-effective, generating one year of healthy life for less than Int. $100. These interventions include tobacco and alcohol control policies such as taxation, voluntary and legislative actions to reduce sodium intake, mass media campaigns for reducing physical activity, and treatment options for cardiovascular disease (CVD), cervical cancer and epilepsy. In addition a number of interventions fall just outside this range, including breast cancer, depression and chronic lung disease treatment. CONCLUSION: Interventions that represent good value for money, are technically feasible and are delivered for a low per-capita cost, are available to address the rapid rise in NCDs in low- and middle-income countries. This paper also describes a tool to support countries in developing NCD action plans.

Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services.

The global burden of non-communicable diseases (NCDs) is growing, and there is an urgent need to estimate the costs and benefits of an investment strategy to prevent and control NCDs. Results from an investment-case analysis can provide important new evidence to inform decision making by governments and donors. We propose a methodology for calculating the economic benefits of investing in NCDs during the Sustainable Development Goals (SDGs) era, and we applied this methodology to cardiovascular disease prevention in 20 countries with the highest NCD burden. For a limited set of prevention interventions, we estimated that US$120 billion must be invested in these countries between 2015 and 2030. This investment represents an additional $1·50 per capita per year and would avert 15 million deaths, 8 million incidents of ischaemic heart disease, and 13 million incidents of stroke in the 20 countries. Benefit-cost ratios varied between interventions and country-income levels, with an average ratio of 5·6 for economic returns but a ratio of 10·9 if social returns are included. Investing in cardiovascular disease prevention is integral to achieving SDG target 3.4 (reducing premature mortality from NCDs by a third) and to progress towards SDG target 3.8 (the realisation of universal health coverage). Many countries have implemented cost-effective interventions at low levels, so the potential to achieve these targets and strengthen national income by scaling up these interventions is enormous.

Economic evaluation of a task-shifting intervention for common mental disorders in India.

OBJECTIVE: To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary-care settings in Goa, India. METHODS: Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary-care facilities. Subjects were randomly assigned to an intervention or a control arm. Eligible subjects in the intervention arm were given psycho-education, case management, interpersonal psychotherapy and/or antidepressants by lay health workers. Subjects in the control arm were treated by physicians. The use of health-care resources, the disability of each subject and degree of psychiatric morbidity, as measured by the Revised Clinical Interview Schedule, were determined at 2, 6 and 12 months. FINDINGS: Complete data, from all three follow-ups, were collected from 1243 (75.4%) and 938 (81.7%) of the subjects enrolled in the study facilities from the public and private sectors, respectively. Within the public facilities, subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm. Time costs were also significantly lower in the intervention arm than in the control arm, whereas health system costs in the two arms were similar. Within the private facilities, however, the effectiveness and costs recorded in the two arms were similar. CONCLUSION: Within public primary-care facilities in Goa, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving.

Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.

The obesity epidemic is spreading to low-income and middle-income countries as a result of new dietary habits and sedentary ways of life, fuelling chronic diseases and premature mortality. In this report we present an assessment of public health strategies designed to tackle behavioural risk factors for chronic diseases that are closely linked with obesity, including aspects of diet and physical inactivity, in Brazil, China, India, Mexico, Russia, and South Africa. England was included for comparative purposes. Several population-based prevention policies can be expected to generate substantial health gains while entirely or largely paying for themselves through future reductions of health-care expenditures. These strategies include health information and communication strategies that improve population awareness about the benefits of healthy eating and physical activity; fiscal measures that increase the price of unhealthy food content or reduce the cost of healthy foods rich in fibre; and regulatory measures that improve nutritional information or restrict the marketing of unhealthy foods to children. A package of measures for the prevention of chronic diseases would deliver substantial health gains, with a very favourable cost-effectiveness profile.

Cross-country measures for monitoring epilepsy care.

PURPOSE: The International League Against Epilepsy (ILAE) Commission on Healthcare Policy in consultation with the World Health Organization (WHO) examined the applicability and usefulness of various measures for monitoring epilepsy healthcare services and systems across countries. The goal is to provide planners and policymakers with tools to analyze the impact of healthcare services and systems and evaluate efforts to improve performance. METHODS: Commission members conducted a systematic literature review and consulted with experts to assess the nature, strengths, and limitations of the treatment gap and resource availability measures that are currently used to assess the adequacy of epilepsy care. We also conducted a pilot study to determine the feasibility and applicability of using new measures to assess epilepsy care developed by the WHO including Disability-Adjusted Life Years (DALYs), responsiveness, and financial fairness. RESULTS: The existing measures that are frequently used to assess the adequacy of epilepsy care focus on structural or process factors whose relationship to outcomes are indirect and may vary across regions. The WHO measures are conceptually superior because of their breadth and connection to articulated and agreed upon outcomes for health systems. However, the WHO measures require data that are not readily available in developing countries and most developed countries as well. CONCLUSION: The epilepsy field should consider adopting the WHO measures in country assessments of epilepsy burden and healthcare performance whenever data permit. Efforts should be made to develop the data elements to estimate the measures.

Prioritizing health problems in women in developing countries: comparing the financial burden of reproductive tract infections, anaemia and depressive disorders in a community survey in India.

OBJECTIVES: To compare the health care and opportunity costs of three common health problems [depressive disorders, reproductive tract infections (RTIs) and anaemia] affecting women and their associated risks of catastrophic health expenditure (defined a priori as out-of-pocket expenditure on health care exceeding 10% of the total monthly household income). METHODS: Cross-sectional survey of 2494 women who consented to participate, from a randomly selected sample of 3000 women aged 18-50, living in the catchment area of a primary health centre in Goa, India. Depressive disorders were diagnosed with the Revised Clinical Interview Schedule; anaemia on the basis of a fingerprick sample of blood using the Haemocue system; and RTI using PCR, culture and microscopy with vaginal or urine specimens. Economic consequences were measured using the Costs of Illness Schedule and the WHO Disability Assessment Schedule. Health provision costs were calculated using previously derived unit costs for services for the main types of health care provider. RESULTS: Catastrophic health expenditure, defined a priori as >10% of total household income spent out of pocket on health in the previous month, was reported by 138 women (5.5%; CI: 4.7-6.5%); they were more likely to report economic difficulties, such as having gone hungry in the past 3 months because of lack of money (OR 1.99, CI 1.1-3.6, P = 0.02). Only depressive disorder was associated with significantly higher health care costs, lost time costs and risk of catastrophic health expenditure (OR 2.66, CI 1.6-4.4, P < 0.001, after adjustment for possible sociodemographic confounders and other physical health problems). There was a linear association between the psychological morbidity score (arranged into quintile groups) and the risk of catastrophic health expenditure (adjusted). CONCLUSIONS: If economic arguments were considered a key driver for global health policy, then depressive disorder should be considered a major health priority for women in developing countries.

Cost-utility analysis of intravenous immunoglobulin and prednisolone for chronic inflammatory demyelinating polyradiculoneuropathy.

The aim of this study was to provide an incremental cost-effectiveness analysis comparing intravenous immunoglobulin (IVIg) and prednisolone treatment for chronic inflammatory demyelinating polyradiculoneuropathy. Patients were recruited to a double-blind randomized crossover trial from nine European centres and received either prednisolone or IVIg during the first 6-week treatment period on which the economic evaluation was based. A societal perspective was adopted in measuring service use and costs, although the costs of lost employment were not included. The main outcome measure in the economic evaluation was the number of quality adjusted life years (QALYs) gained, with change in a 11-point disability scale used to measure clinical outcomes. Service use and quality of life data were available for 25 patients. Baseline costs were controlled for using a bootstrapped multiple regression model. The cost difference between the two treatments was estimated to be euro 3754 over the 6-week period. Health-related quality of life, as measured by the EuroQol EQ-5D instrument, increased more in the IVIg group but the difference was not statistically significant. Using a net-benefit approach it was shown that the probability of IVIg being cost-effective in comparison with prednisolone was 0.5 or above (i.e. was more likely to be cost-effective than cost-ineffective) only if one QALY was valued at over euro 250 000. The cost-effectiveness of IVIg is greatly affected by the price of IVIg and the amount administered. The impact of later side-effects of prednisolone on long-term costs and quality of life are likely to reduce the cost per QALY of IVIg treatment.

Variations in the costs of child and adolescent psychiatric in-patient units.

BACKGROUND: Child and adolescent in-patient care is a highly specialised service, ideally requiring planning at a national level, but there are no routine data collections specifically for these services. AIMS: To estimate unit costs for child and adolescent psychiatric in-patient units and to analyse the variations in costs between units. METHOD: Data collection alongside a national survey with cost estimations guided by principles drawn from economic theory. Bivariate and multivariate analyses are employed to identify cost influences. RESULTS: Fifty-eight units could provide sufficient data to allow calculation of the cost per in-patient day; mean= pound 197 (s.d.=71.6; 1999-2000 prices). The management sector, type of provision, number of rooms, capacity and location explained nearly half of the cost variation. CONCLUSIONS: Child and adolescent psychiatric in-patient units are an expensive resource, with personnel absorbing two-thirds of the total costs. Costs per in-patient day vary fourfold and the exploration of cost variations can inform commissioning strategies.

Depression status, medical comorbidity and resource costs. Evidence from an international study of major depression in primary care (LIDO).

BACKGROUND: Despite the burden of depression, there remain few data on its economic consequences in an international context. AIMS: To explore the relationship between depression status (with and without medical comorbidity), work loss and health care costs, using cross-sectional data from a multi-national study of depression in primary care. METHOD: Primary care attendees were screened for depression. Those meeting eligibility criteria were categorised according to DSM-IV criteria for major depressive disorder and comorbid status. Unit costs were attached to self-reported days absent from work and uptake of health care services. RESULTS: Medical comorbidity was associated with a 17-46% increase in health care costs in five of the six sites, but a clear positive association between costs and clinical depression status was identified in only one site. CONCLUSIONS: The economic consequences of depression are influenced to a greater (and considerable) extent by the presence of medical comorbidity than by symptom severity alone.

The cost-effectiveness of policies for the safe and appropriate use of injection in healthcare settings.

OBJECTIVE: Poor injection practices transmit potentially life-threatening pathogens. We modelled the cost-effectiveness of policies for the safe and appropriate use of injections in ten epidemiological subregions of the world in terms of cost per disability-adjusted life year (DALY) averted. METHODS: The incidence of injection-associated hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections was modelled for a year 2000 cohort over a 30-year time horizon. The consequences of a "do nothing" scenario were compared with a set of hypothetical scenarios that incorporated the health gains of effective interventions. Resources needed to implement effective interventions were costed for each subregion and expressed in international dollars (I dollars). FINDINGS: Worldwide, the reuse of injection equipment in the year 2000 accounted for 32%, 40%, and 5% of new HBV, HCV and HIV infections, respectively, leading to a burden of 9.18 million DALYs between 2000 and 2030. Interventions implemented in the year 2000 for the safe (provision of single-use syringes, assumed effectiveness 95%) and appropriate (patients-providers interactional group discussions, assumed effectiveness 30%) use of injections could reduce the burden of injection-associated infections by as much as 96.5% (8.86 million DALYs) for an average yearly cost of 905 million I dollars (average cost per DALY averted, 102; range by region, 14-2293). Attributable fractions and the number of syringes and needles required represented the key sources of uncertainty. CONCLUSION: In all subregions studied, each DALY averted through policies for the safe and appropriate use of injections costs considerably less than one year of average per capita income, which makes such policies a sound investment for health care.

Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health care in Goa, India: a randomised, controlled trial.

BACKGROUND: Common mental disorders are associated with substantial morbidity and disability in developing countries, but there are no data for efficacy of treatment. We aimed to assess the efficacy and cost-effectiveness of antidepressant and psychological treatment for common mental disorders in general health-care settings. METHOD: We did a randomised, placebo-controlled trial (double-blind for the antidepressant group) in general outpatient clinics in two district hospitals in Goa, India. Consecutive eligible adults who scored more than 15 on the Revised Clinical Interview Schedule (n=450) were randomly assigned to antidepressant (fluoxetine), placebo, or psychological treatment. Antidepressant or placebo was provided for up to 6 months. Up to six sessions of psychological treatment were provided by trained therapists. The primary outcome was psychiatric morbidity; secondary outcomes were disability and costs. Outcome measurements were done at 2, 6, and 12 months. Intention-to-treat analyses were done with linear regression. FINDINGS: 80% of patients were reviewed; the number of drop-outs was similar in all three groups. Psychiatric outcome was significantly better with antidepressant than with placebo at 2 months (p=0.02; standardised effect size 0.3), but not over the 2-12 month period (p=0.10); antidepressants were significantly more cost effective than placebo in the short term and long term (p<0.05). Psychological treatment was not more effective than placebo for any outcome during either period. INTERPRETATION: Affordable antidepressants such as fluoxetine should be the treatment of choice for common mental disorders in general health-care settings in India, since they are associated with improved clinical and economic outcomes, especially in the short term.

Demand for, access to and use of community mental health care: lessons from a demonstration project in India and Pakistan.

BACKGROUND: A widely promoted model of mental health care and prevention appropriate to many low-income countries is one that is integrated into the local primary health care system. AIMS: To examine the influence of health-seeking behaviours (demand-side factors) and the access to/availability of services (supply-side factors) on local service utilisation patterns for people with common mental disorders. METHOD: Two rural catchment populations outside Bangalore (India) and Rawalpindi (Pakistan), one with the standard primary health care system, the other with additional mental health care training and support, were screened for common mental disorders. Diagnosed cases were interviewed about their use of and perceptions of local health care services (repeated three months later). RESULTS: Individuals' use of integrated mental health and other care was modest. Principal (self-rated) supply-side factors were the cost of care, distance from treatment centre, a perception that care would not be effective, and concerns regarding stigma. Perceptions improved over three months, accompanied by an increased preference for public over private providers, but this was not restricted to the integrated care localities. CONCLUSION: The use (and therefore effectiveness) of mental health services integrated into primary care is influenced by the health-seeking behaviours and perceptions of the local population. Efforts to integrate mental health into primary care need to be accompanied by educational activities in order to increase awareness, reduce stigma and draw attention to the availability of effective treatment.

Course of depression, health services costs, and work productivity in an international primary care study.

The Longitudinal Investigation of Depression Outcomes (LIDO) Study examined the outcomes and economic correlates of previously untreated depression among primary care patients in Barcelona, Spain; Be'er Sheva, Israel; Melbourne, Australia; Porto Alegre, Brazil; St. Petersburg, Russia; and Seattle, USA. Across all sites, 968 patients with current depressive disorder completed assessments of depression severity (Composite International Diagnostic Interview and Center for Epidemiologic Studies Depression Scale) at baseline and 9 months, and assessments of health services utilization and work days missed at baseline, 9 months, and 12 months. Follow-up depression status was characterized as persistent depression (n=345), partial remission (n=283), or full remission (n=340). At each site, patients with more favorable depression outcomes had fewer days missed from work; however, this relationship did not reach the 5% level of statistical significance at any site, and reached the 10% significance level only at Porto Alegre. Patients with more favorable depression outcomes also had lower health services costs, but this relationship reached the 5% significance level only in St. Petersburg. While the lack of statistical precision does not permit definitive conclusions, our findings are consistent with recent studies showing that recovery from depression is associated with lower health services costs and less time missed from work due to illness.

Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs.

OBJECTIVE: To compare service utilization and cost profiles of people with schizophrenia living in Europe in order to understand differences in treatment and care costs. METHOD: Cross-sectional samples were taken of people with schizophrenia in five European locations. Sociodemographic, clinical and service use data were collected via interviewer-administered questionnaires. Site-specific unit costs were obtained, transformed subsequently into a single currency (UK pound). Multiple regression analyses were conducted. RESULTS: There were widespread and considerable differences between sites in service utilization patterns and associated costs. Higher needs, greater symptom severity and longer psychiatric history are associated with higher costs: quality of life and service satisfaction are not. Few differences were found between sites in patterns of association with cost. CONCLUSION: Comparative analyses of the use and cost of mental health services can highlight existing variations helpfully in service provision and uptake. Methodological consistency is required if meaningful conclusions are to be drawn from such comparative data.

Willingness to pay as a measure of the benefits of mental health care.

BACKGROUND: Decision-makers would benefit from being able to plan and evaluate mental health care interventions or programmes on the basis of costs and consequences that are measured in the same unit of measurement (money being the most convenient). Monetized quantification of the consequences of alternative interventions could be subsequently incorporated into cost-benefit allocation decisions. AIM: This paper provides an overview of the policy and research context within which willingness-to-pay survey techniques are located, together with a review of the main approaches used to date. We also highlight key issues in the application of these techniques and indicate areas of mental health research and policy that could benefit from their introduction. METHOD: Willingness-to-pay survey techniques are reviewed, and issues concerning their validity and application in the context of cost-benefit analyses of mental health policies are discussed. DISCUSSION: Different survey methods are available for generating willingness-to-pay data, the most common being the contingent valuation approach. An assessment of the validity of data generated by these alternative techniques is vital in order to ensure that they are consistent with the notion of economic preferences and values. IMPLICATIONS: The generation of valid and meaningful data on the monetized value of mental health outcomes would provide decision-makers with an improved evidence-based framework for resource allocation.

Economics and ethics in mental health care: traditions and trade-offs.

BACKGROUND: Both economic and ethical perspectives are exerting increasing influence at all levels of mental health policy and practice; yet there is little consensus on how these two different perspectives are to be reconciled or explicitly incorporated into decision-making. AIM: This review article is directed towards a fuller understanding of the complex trade-offs and compromises that are or may be made by clinicians, managers and policy-makers alike in the context of mental health care planning and delivery. METHOD: We briefly outline a number of key principles of health care economics and ethics, and then focus on the particular incentives and trade-offs that are raised by these principles at three levels of the mental health system: government and society; purchasers and providers; and users and carers. RESULTS: At the level of government and society, we find (economically influenced) attempts to reform mental health care offset by concerns revolving around access to care: whether society is prepared to forgo economic benefits in exchange for improved equity depends to a considerable extent on the prevailing ethical paradigm. The implementation of these reforms at the level of purchasers and providers has helped to focus attention on evaluation and prioritization, but has also introduced "perverse incentives" such as cost-shifting and cream-skimming, which can impede access to or continuity of appropriate care for mentally ill people. Finally, we detect opportunities for moral hazard and other forms of strategic behaviour that are thrown up by the nature of the carer:user relationship in mental health care. CONCLUSION: We conclude by highlighting the need to move towards a more open, accountable and evidence-based mental health care system. Acknowledgement of and progress towards these three requirements will not deliver ideal levels of efficiency or equity, but will foster a greater understanding of the relevance of ethical considerations to mental health policies and strategies that are often influenced strongly or solely by economic arguments, whilst also demonstrating that equity must come at a price.