The need for cost-effective and affordable responses for the global epidemic of non-communicable diseases
Authors: Barbara McPake
Journal: The Lancet Global Health (2019)

Globally, health systems are struggling to deliver universal health coverage in the context of a global epidemic of non-communicable disease and a paucity of public resources to respond to it. According to the 2010 Global Burden of Disease study, hypertension has become the most important risk factor.1Bromfield S Muntner P High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs.Curr Hypertens Rep. 2013; 15: 134-136Crossref PubMed Scopus (188) Google Scholar Although the areas with the largest burden of non-communicable diseases are still middle-to-high-income countries, the rate of increase is fastest in low-to-middle-income countries.2Forouzanfar MH Liu P Roth GA et al.Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990–2015.JAMA. 2017; 317: 165-182Crossref PubMed Scopus (878) Google Scholar The combination of the prevalence of a condition such as hypertension, the economic situation of a country, and commitment to prioritise public resources for health determines the options that are available to define a health system's response and give meaning to the ambition of universal health coverage for the population that is susceptible to the condition. Countries with high and growing prevalence of such conditions and few available public resources to respond are faced with the greatest challenge. In Nepal, a recent study3Mehata S Srestha N Mehta R et al.Prevalence, awareness, treatment and control of hypertension in Nepal: data from nationally representative population-based cross-sectional study.J Hypertens. 2018; 36: 1680-1688Crossref PubMed Scopus (17) Google Scholar found hypertension prevalence was 18% among the adult population aged 15–69 years, of whom only 38% were aware of their hypertension status and 18% were taking antihypertensive medication. Of those on treatment, only 52% had their blood pressure under control (less than 10% of the total hypertensive population). Nepal's gross national income (GNI) per capita in 2018 was US$960, making it one of the last Asian countries remaining in the World Bank's list of low-income countries (currently numbering 31 countries altogether).4World Bank country and lending groupsThe World Bank.https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groupsDate accessed: August 20, 2019Google Scholar Nepal's health expenditure data for 2016 suggest a relatively strong commitment to its public health system compared with neighbouring countries in south Asia, spending a higher proportion of its GNI on health than Bangladesh, India, Pakistan or Sri Lanka, and with a relatively low share (second lowest after Sri Lanka) of out-of-pocket expenditure compared with these same neighbours, albeit still 55% of the total. Despite this share of GNI allocated to health, health expenditure per capita, including out-of-pocket payments that cannot be easily directed to the most important public health interventions, remains low at US$45. Nevertheless, Nepal is committed to the achievement of universal health coverage.5Mishra SR Khanal P Dhimal M Nepal's quest for universal health coverage.J Pharm Pract Community Med. 2016; 2: 104-106Crossref Google Scholar Hence, Anirudh Krishnan and colleagues' Article in The Lancet Global Health6Krishnan A Finkelstein EA Kallestrup P Karki A Olsen MH Neupane D Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysis.Lancet Glob Health. 2019; 7: e1367-e1374Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar makes a globally important contribution. The authors establish the cost-effectiveness and affordability of scaling up a community-based management programme for hypertension in Nepal that has proven to be effective in reducing blood pressure at the population level. This study provides a model not only for Nepal but for a range of countries in similar circumstances to step-up the response to this important risk factor. The intervention relies on a community health worker-based approach, which is likely to be a major source of innovation to respond to the challenges of non-communicable diseases in low-income and middle-income settings. Beyond establishing that each individual intervention can provide a cost-effective and affordable approach, consideration of how the set of activities that community health workers are tasked with is constructed at the national system level and evolves over time as the burden of disease and the opportunities to respond to it also evolve will be increasingly important. Among the questions that countries will need to address is the distribution of tasks among workers—eg, which is better, to have specialist community health workers who focus on a narrow range of conditions, or generalist multitaskers? This study suggests that the specialist approach would not be more expensive than the generalist approach, because supplying the full workforce with blood pressure monitors and training counterbalances the efficiencies of dealing with multiple conditions in a single visit to a household, such as reduced transport costs. Other elements of community health worker-based approaches, such as relying on volunteers or remuneration, how to select and support community health workers, and the content of curricula for pre-service and in-service training, are important determinants of cost-effectiveness and affordability of the programme. The Health Workforce Department at WHO has produced a set of guidelines related to questions such as these in relation to community health worker programmes.7Cometto G Ford N Pfaffman-Zambruni J et al.Health policy and system support to optimise community health worker programmes: an abridged WHO Guideline.Lancet Glob Health. 2018; 6: e1397-e1404Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar The evidence base in relation to many of the questions raised was found to be severely lacking as part of the WHO assessment. When studies such as this one report their intervention-related findings, documenting what is learned about the operation of the delivery platforms within national health systems will be equally important. I declare no competing interests. Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysisThe programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered. Full-Text PDF Open Access