Post-2015 Consensus: Health Perspective - Non Communicable Diseases, Nugent

Perspective Paper

Summary

The post-2015 target of reducing premature deaths from non-communicable diseases (NCDs) by one-third by 2030 is ambitious, but can come close to being reached with increased coverage – especially in low-and middle-income countries (LMICs) -- of a handful of cost-effective interventions. NCDs are the largest cause of mortality both globally and in the majority of LMICs. NCD mortality exceeds that of communicable, maternal, perinatal and nutritional conditions combined. 80% of these deaths (28 million people) occur in LMICs, making NCDs a major cause of poverty and an urgent development issue. Increasing the urgency, it is projected that the NCD burden will rise by 17% globally in the next decade, and by 27% in Africa.

In 2013, The World Health Assembly agreed on a set of global NCD targets and indicators from which the proposed post-2015 targets are drawn. WHO also created a global monitoring framework (GMF) to track progress in preventing and controlling major NCDs - cardiovascular disease, cancer, chronic lung diseases and diabetes - and their key risk factors. In this paper, we focus on the primary NCD goal of reducing NCD mortality by 25% by 2025 (adapted for the SDG 2030 end date), and the subsidiary GMF targets that reflect high priority diseases and have well-proven, cost-effective interventions available: cardiovascular disease, stroke, chronic obstructive pulmonary disease (COPD), and some cancers. Since most deaths from NCD in high-income countries occur after age 70, the target of a one-third reduction in global premature mortality can only come through dramatic reductions in LMICs, which are therefore our focus.

About 35 million people have an acute coronary or cerebrovascular event every year. An estimated 100 million people in the world are known to have cardiovascular disease, which gives them a five times greater risk of an event compared to people not diagnosed with cardiovascular disease. Multi-drug treatment of those at risk, plus low-cost treatment of acute heart attacks have been identified as cost-effective interventions.

High blood pressure is considered a “silent killer,” that causes fatal or debilitating cerebrovascular events. It is implicated in about half of all deaths from heart disease and stroke. The global population with high blood pressure is estimated at about 1 billion, with a prevalence of 46% among adults in Africa which is even higher than the 35% in HICs. Dietary salt intake is directly linked to high blood pressure, and is over recommended limits in almost all countries. Salt reduction was identified by WHO as a “best buy” for NCD prevention and control, and attention is turning to finding the most effective methods to achieve it.

Tobacco use is a major cause of death via stroke and heart disease, COPD, TB and lung cancer, with at least eight million deaths projected in 2030. Taxation is a particularly effective policy to reduce consumption.

To achieve an estimated 28.5% reduction in premature deaths from NCDs – approaching the one-third target – we consider five actions. These are listed below together with the benefit-cost ratios of achieving them, at a 3% discount rate and using two monetary values for a disability-adjusted life year, DALY ($1,000 and $5,000):

Tobacco tax – Tax tobacco to achieve a 50% relative reduction in user prevalence. In this target, we concentrate on low- and middle-income countries (LMICs) because many high-income countries (HIC) have already implemented significant tax increases. BCRs: 10 (low DALY value); 52 (high DALY)

• Aspirin therapy for AMI: Provide aspirin to 75% of patients at the onset of an acute myocardial infarction (AMI). BCRs: 31; 153
• Salt reduction – 30% reduction in the mean dietary intake of salt through voluntary reformulation of processed foods. BCRs: 19; 95
• Hypertension management – Use of hypertension medicine by 50% of those at medium to high risk. BCRs: 7; 34
• Secondary prevention of cardiovascular disease– 70% coverage and 60% adherence to a multi-pill regimen for those at a high risk of a cardiovascular event. BCRs: 3; 17

The estimated total annual cost of these interventions would be approximately $8.5 billion, and the overall BCR would be 9 (or 44 at the higher DALY valuation).

These opportunities do not explicitly address the need for appropriate strengthening of health system capacity. We advocate developing specific capacity to deliver priority services in volume and with high quality. Overall capacity strengthening would spread out from these high-performing initial nodes. Despite the current weakness of some LMIC healthcare systems, the straightforward interventions covered in this paper can be implemented in developing countries and lead to an overall strengthening of the system.