The role of the Basic Public Health Service program in the control of hypertension in China: Results from a cross-sectional health service interview survey.

OBJECTIVES: Non-communicable diseases (NCDs) have become the main cause of mortality in China. In 2009, the Chinese government introduced the Basic Public Health Service (BPHS) program to relieve the rising burden of NCDs through public health measures and delivery of essential medical care. The primary aim of this study was to evaluate the impact of the BPHS program on hypertension control. METHODS: The China National Health Development Research Center (CNHDRC) undertook a Cross-sectional Health Service Interview Survey (CHSIS) of 62,097 people from primary healthcare reform pilot areas across 17 provinces from eastern, central, and western parts of China in 2014. The current study is based on responses to the CHSIS survey from 7,867 participants, who had been diagnosed with hypertension. Multi-variable mixed logit regression analysis was used to estimate the association between BPHS management and uncontrolled hypertension. In a follow-up analysis, generalized structural equation modelling (GSEM) was used to test for mediation of the BPHS program effect through patient compliance with medication. FINDINGS: The estimated proportion of patients with uncontrolled hypertension was 30% lower (23.2% vs 31.5%) in those participants who were adequately managed under the BPHS program. Other predictors of hypertension control included compliance with medication, self-reported wellbeing, income, educational attainment and exercise; smoking was associated with reduced hypertension control. The significant inverse association between uncontrolled hypertension and age indicates poor outcomes for younger patients. Additional testing suggested that nearly 40% of the effect of BPHS management (95% CI: 28.2 to 51.7) could be mediated by improved compliance with medication; there was also an indication that the effect of management was 30% stronger in districts/counties with established digital information management systems (IMS). CONCLUSION: Hypertension control improved markedly following active management through the BPHS program. Some of that improvement could be explained by greater compliance with medication among program participants. This study also identified the need to tailor the BPHS program to the needs of younger patients to achieve higher levels of control in this population. Future investigations should explore ways in which existing healthcare management influences the success of the BPHS program.

Protocol for an economic evaluation alongside a cluster randomised controlled trial: cost-effectiveness of Learning Clubs, a multicomponent intervention to improve women's health and infant's health and development in Vietnam.

INTRODUCTION: Economic evaluations of complex interventions in early child development are required to guide policy and programme development, but a few are yet available. METHODS AND ANALYSIS: Although significant gains have been made in maternal and child health in resource-constrained environments, this has mainly been concentrated on improving physical health. The Learning Clubs programme addresses both physical and mental child and maternal health. This study is an economic evaluation of a cluster randomised controlled trial of the impact of the Learning Clubs programme in Vietnam. It will be conducted from a societal perspective and aims to identify the cost-effectiveness and the economic and social returns of the intervention. A total of 1008 pregnant women recruited from 84 communes in a rural province in Vietnam will be included in the evaluation. Health and cost data will be gathered at three stages of the trial and used to calculate incremental cost-effectiveness ratios per percentage point improvement of infant's development, infant's health and maternal common mental disorders expressed in quality-adjusted life years gained. The return on investment will be calculated based on improvements in productivity, the results being expressed as benefit-cost ratios. ETHICS AND DISSEMINATION: The trial was approved by Monash University Human Research Ethics Committee (Certificate Number 2016-0683), Australia, and approval was extended to include the economic evaluation (Amendment Review Number 2018-0683-23806); and the Institutional Review Board of the Hanoi School of Public Health (Certificate Number 017-377IDD- YTCC), Vietnam. Results will be disseminated through academic journals and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12617000442303.

Reduced Road Traffic Injuries for Young People: A Preliminary Investment Analysis.

PURPOSE: Deaths and serious injuries from road accidents remain a serious issue in developing countries, including for young people, for whom they are the largest cause of death. This article provides an assessment of interventions to reduce these deaths and injuries for adolescents in 75 developing countries. METHODS: We draw on new data on deaths and injuries by age, gender, and accident type for the 75 countries and on the road safety experience of developed and, more recently, developing countries. Critical tasks are to identify key interventions in road safety and estimate their impact and cost. We incorporate these impact and cost estimates in a modeling framework to calculate the reduction in deaths and serious injuries achieved out to 2030, relative to the base case. Finally, established methods are used to value the economic and social benefits arising from these reductions, and hence to calculate benefit-cost ratios. RESULTS: For the unchanged policy case, we estimate that there will be about 3 million deaths and 7.4 million serious injuries from road accidents for persons aged 10-24 years in the 75 countries to 2030. The preferred interventions avert one million of these deaths and 3 million serious injuries, at a cost of $6.5 billion per annum over 2016-2030, or $1.2 per capita across the total population of these countries. After valuing the benefits of the deaths and serious injuries averted, we find a benefit-cost ratio of 7.6 for 2016-2030, but of 9.9 if the interventions continue to 2050. CONCLUSIONS: Proven methods, suitably adjusted to local conditions, are available to reduce the tragic toll of road accidents in developing countries. These initiatives are likely to have strong economic and social returns, and should be given high priority.

A Health System-Based Investment Case for Adolescent Health.

PURPOSE: This study argues that investments in the health of the world's 1.2 billion adolescents is a critical component of the overall investment case for adolescents and is vital for achieving the United Nation's Sustainable Development Agenda. We undertake a benefit cost analysis of a range of interventions to improve adolescent health. METHODS: We examined investments in intervention-specific costs, program costs, and health systems costs at a country level for 40 low- and middle-income countries that account for about 90% of adolescents in low- and middle-income countries. Intervention-specific costs and impacts were computed using the OneHealth Tool, whereas other published resources were used for the program and health systems costs. Interventions modeled include those addressing physical, sexual, and reproductive health; maternal and newborn health; and some noncommunicable diseases. Two coverage scenarios were simulated: an unchanged coverage scenario and one in which the coverage increases to achieve a high coverage by 2030. RESULTS: Key outcomes included estimates of the costs, health-related impacts, and benefit-cost ratios (BCRs). For the 66 adolescent health interventions modeled for 40 countries, the total cost for the period of 2015-2030 was $358.4 billion or an average of $4.5 per capita each year. From 2015 to 2030, there were 7.0 million deaths averted, and 1.5 million serious disabilities averted. At a 3% discount rate, the average BCR were 12.6, 9.9, and 6.4 for low-income, lower middle-income, and upper middle-income countries, respectively. Countries with adolescent mortality rates ≥200 per 100,000 had an average BCR of 14.8 compared with countries with adolescent mortality rates <100 per 100,000 had an average BCR of 5.7. CONCLUSIONS: The results show that there are substantial benefits from a program of interventions to improve adolescent health.

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.

Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents.

Investment in the capabilities of the world's 1·2 billion adolescents is vital to the UN's Sustainable Development Agenda. We examined investments in countries of low income, lower-middle income, and upper-middle income covering the majority of these adolescents globally to derive estimates of investment returns given existing knowledge. The costs and effects of the interventions were estimated by adapting existing models and by extending methods to create new modelling tools. Benefits were valued in terms of increased gross domestic product and averted social costs. The initial analysis showed high returns for the modelled interventions, with substantial variation between countries and with returns generally higher in low-income countries than in countries of lower-middle and upper-middle income. For interventions targeting physical, mental, and sexual health (including a human papilloma virus programme), an investment of US$4·6 per capita each year from 2015 to 2030 had an unweighted mean benefit to cost ratio (BCR) of more than 10·0, whereas, for interventions targeting road traffic injuries, a BCR of 5·9 (95% CI 5·8-6·0) was achieved on investment of $0·6 per capita each year. Interventions to reduce child marriage ($3·8 per capita each year) had a mean BCR of 5·7 (95% CI 5·3-6·1), with the effect high in low-income countries. Investment to increase the extent and quality of secondary schooling is vital but will be more expensive than other interventions-investment of $22·6 per capita each year from 2015 to 2030 generated a mean BCR of 11·8 (95% CI 11·6-12·0). Investments in health and education will not only transform the lives of adolescents in resource-poor settings, but will also generate high economic and social returns. These returns were robust to substantial variation in assumptions. Although the knowledge base on the impacts of interventions is limited in many areas, and a major research effort is needed to build a more complete investment framework, these analyses suggest that comprehensive investments in adolescent health and wellbeing should be given high priority in national and international policy.

Scaling-up treatment of depression and anxiety: a global return on investment analysis.

BACKGROUND: Depression and anxiety disorders are highly prevalent and disabling disorders, which result not only in an enormous amount of human misery and lost health, but also lost economic output. Here we propose a global investment case for a scaled-up response to the public health and economic burden of depression and anxiety disorders. METHODS: In this global return on investment analysis, we used the mental health module of the OneHealth tool to calculate treatment costs and health outcomes in 36 countries between 2016 and 2030. We assumed a linear increase in treatment coverage. We factored in a modest improvement of 5% in both the ability to work and productivity at work as a result of treatment, subsequently mapped to the prevailing rates of labour participation and gross domestic product (GDP) per worker in each country. FINDINGS: The net present value of investment needed over the period 2016-30 to substantially scale up effective treatment coverage for depression and anxiety disorders is estimated to be US$147 billion. The expected returns to this investment are also substantial. In terms of health impact, scaled-up treatment leads to 43 million extra years of healthy life over the scale-up period. Placing an economic value on these healthy life-years produces a net present value of $310 billion. As well as these intrinsic benefits associated with improved health, scaled-up treatment of common mental disorders also leads to large economic productivity gains (a net present value of $230 billion for scaled-up depression treatment and $169 billion for anxiety disorders). Across country income groups, resulting benefit to cost ratios amount to 2·3-3·0 to 1 when economic benefits only are considered, and 3·3-5·7 to 1 when the value of health returns is also included. INTERPRETATION: Return on investment analysis of the kind reported here can contribute strongly to a balanced investment case for enhanced action to address the large and growing burden of common mental disorders worldwide. FUNDING: Grand Challenges Canada.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

The impact of copayments and safety nets on PBS expenditure.

This article discusses the impact on patients of changes in copayments and safety net thresholds (SNT) within the Pharmaceutical Benefits Scheme (PBS). Trends in the nominal and real values of copayments and SNTs are examined, as are changes in the numbers of types of patients. The relationship between the number of safety net cardholders and copayments and SNTs is estimated. Increases in the number of copayments necessary to reach the safety net threshold restrict the number of patients able to benefit from this provision. Policy for determining the levels of copayments and safety net thresholds needs to be put on a rationale basis in a way similar to the determination of prices for PBS medicines.