Scaling hypertension treatment in 24 low-income and middle-income countries: economic evaluation of treatment decisions at three blood pressure cut-points

OBJECTIVE

Estimate the incremental costs and benefits of scaling up hypertension care in adults in 24 select countries, using three different systolic blood pressure (SBP) treatment cut-off points-≥140, ≥150 and ≥160 mm Hg.

INTERVENTION

Strengthening the hypertension care cascade compared with status quo levels, with pharmacological treatment administered at different cut-points depending on the scenario.

TARGET POPULATION

Adults aged 30+ in 24 low-income and middle-income countries spanning all world regions.

PERSPECTIVE

Societal.

TIME HORIZON

30 years.

DISCOUNT RATE

4%.

COSTING YEAR

2020 USD.

STUDY DESIGN

DATA SOURCES: Institute for Health Metrics and Evaluation's Epi Visualisations database-country-specific cardiovascular disease (CVD) incidence, prevalence and death rates. Mean SBP and prevalence-National surveys and NCD-RisC. Treatment protocols-WHO HEARTS. Treatment impact-academic literature. Costs-national and international databases.

OUTCOME MEASURES

Health outcomes-averted stroke and myocardial infarction events, deaths and disability-adjusted life-years; economic outcomes-averted health expenditures, value of averted mortality and workplace productivity losses.

RESULTS OF ANALYSIS

Across 24 countries, over 30 years, incremental scale-up of hypertension care for adults with SBP≥140 mm Hg led to 2.6 million averted CVD events and 1.2 million averted deaths (7% of expected CVD deaths). 68% of benefits resulted from treating those with very high SBP (≥160 mm Hg). 10 of the 12 highest-income countries projected positive net benefits at one or more treatment cut-points, compared with 3 of the 12 lowest-income countries. Treating hypertension at SBP≥160 mm Hg maximised the net economic benefit in the lowest-income countries.

LIMITATIONS

The model only included a few hypertension-attributable diseases and did not account for comorbid risk factors. Modelled scenarios assumed ambitious progress on strengthening the care cascade.

CONCLUSIONS

In areas where economic considerations might play an outsized role, such as very low-income countries, prioritising treatment to populations with severe hypertension can maximise benefits net of economic costs.

Barriers to accessibility of medicines for hyperlipidemia in low- and middle-income countries

Despite the high burden of hyperlipidemia and the effectiveness of treatment, evidence suggests that the accessibility of hyperlipidemia medicines can be low in many low- and middle-income countries (LMICs). The aim of this study was to identify common barriers to the accessibility of medicines for hyperlipidemia in LMICs. A multimethod analysis and multiple data sources were used to assess the accessibility and barriers of medicines for hyperlipidemia in selected LMICs. The overall median availability of statins for hyperlipidemia in public facilities was 0% and 5.4%, for originators and generics, respectively. In private facilities, median availability was 13.3% and 35.9%, for originators and generics, respectively. Statin availability was lowest in Africa and South-East Asia. Private facilities generally had higher availability than public facilities. Statins are less affordable in lower-income countries, costing around 6 days' wages per month. Originator statins are less affordable than generics in countries of all income-levels. The median cost for statin medications per month ranges from a low of $1 in Kenya to a high of $62 in Mexico, with most countries having a median monthly cost between $3.6 and $17.0. The key informant interviews suggested that accessibility to hyperlipidemia medicines in LMICs faces barriers in multiple dimensions of health systems. The availability and affordability of statins are generally low in LMICs. Several steps could be implemented to improve the accessibility of hyperlipidemia medicines, including private sector engagement, physician education, investment in technology, and enhancement of health systems.

Cost analysis of the WHO-HEARTS program for hypertension control and CVD prevention in primary health facilities in Ethiopia

Background

In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package.

Objective

To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities.

Study design

This study entails a program cost analysis using cross-sectional primary and secondary data.

Methods

Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension.

Results

The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively.

Conclusions

The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia.

Building the health-economic case for scaling up the WHO-HEARTS hypertension control package in low- and middle-income countries

ABSTRACT

Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs.

An analytical model of population level uncontrolled hypertension management: a care cascade approach

Effective control of hypertension at the population level is a global public health challenge. This study shows how improving population coverages at different hypertension care cascade levels could impact population-level hypertension management. We developed an analytical framework and a companion Excel model of multi-level hypertension care cascade entailing awareness, treatment, and control. The model estimates the prevalence of uncontrolled hypertension for different level of population coverages at certain cascade levels. We applied the model to data from Bangladesh and reported prevalence estimates associated with coverage interventions at different cascade levels. The model estimated that if 50% of the unaware hypertensive patients became aware of their hypertensive condition, the prevalence of uncontrolled hypertension would decrease by 1.8 and 1.3 percentage points (8.2% and 5.8% relative reduction), respectively, for constant and variable rates in the status quo setting. When 50% of the aware, but untreated individuals received treatment, the prevalence would decrease by around 0.7 percentage points (3.3% relative reduction). A 50% decrease in the share of treated individuals who did not have hypertension under control, would result in decreasing the prevalence by 2.8 percentage points (12.7% relative reduction). By providing an analytical tool that demonstrates the probable impact of population coverage interventions at certain hypertension care cascade levels, our study endows public health practitioners with vital information to identify gaps and design effective policies for hypertension management.

Cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in Bangladesh: a HEARTS costing tool application

OBJECTIVE

To estimate the costs of scaling up the HEARTS pilot project for hypertension management and risk-based cardiovascular disease (CVD) prevention at the full population level in the four subdistricts (upazilas) in Bangladesh.

SETTINGS

Two intervention scenarios in subdistrict health complexes: hypertension management only, and risk-based integrated hypertension, diabetes, and cholesterol management.

DESIGN

Data obtained during July-August 2020 from subdistrict health complexes on the cost of medications, diagnostic materials, staff salaries and other programme components.

METHODS

Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual costs of implementing the HEARTS programme from the health system perspective.

PRIMARY AND SECONDARY OUTCOME MEASURES

Programme cost, provider time.

RESULTS

The total annual cost for the hypertension control programme was estimated at US$3.2 million, equivalent to US$2.8 per capita or US$8.9 per eligible patient. The largest cost share (US$1.35 million; 43%) was attributed to the cost of medications, followed by the cost of provider time to administer treatment (38%). The total annual cost of the risk-based integrated management programme was projected at US$14.4 million, entailing US$12.9 per capita or US$40.2 per eligible patient. The estimated annual costs per patient treated with medications for hypertension, diabetes and cholesterol were US$18, US$29 and US$37, respectively.

CONCLUSION

Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local community health workers would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh.

The Cost-Effectiveness of Hyperlipidemia Medication in Low- and Middle-Income Countries: A Review

Hyperlipidemia is a risk factor for cardiovascular disease - the leading cause of death globally. Increased understanding of the cost-effectiveness of hyperlipidemia treatment in low- and middle-income countries can guide approaches to hyperlipidemia management in resource-limited environments. We conducted a systematic review of the evidence on the cost-effectiveness of hyperlipidemia medication treatment in low- and middle-income countries using studies published between January 2010 and April 2020. We abstracted study details, including study design, treatment setting, intervention type, health metrics, costs standardized to constant 2019 US dollars, and cost-effectiveness measures including average and incremental cost-effectiveness ratios. Comparisons across studies suggested that treatment via polypill is generally more cost-effective than statin-only therapy, and that primary prevention is more cost-effective than secondary prevention. Treating hyperlipidemia at a threshold of 5.7 mmol/l comes at a higher cost per disability-adjusted life-years averted than at a threshold of 6.2 mmol/l. Most pharmacological treatment strategies for hyperlipidemia were found to be cost-effective in most of the examined low- and middle-income countries.

Cost assessment of a program for laboratory testing of plasma trans-fatty acids in Thailand

Objectives

Intake of trans fatty acids (TFA) increases the risk of cardiovascular disease. Assessment of TFA exposure in the population is key for determining TFA burden and monitoring change over time. One approach for TFA monitoring is measurement of TFA levels in plasma. Understanding costs associated with this approach can facilitate program planning, implementation and scale-up. This report provides an assessment of costs associated with a pilot program to measure plasma TFA levels in Thailand.

Study design

Cost analysis in a laboratory facility in Thailand.

Methods

We defined three broad cost modules: laboratory, personnel, and facility costs, which were further classified into sub-components and into fixed and variable categories. Costs were estimated based on the number of processed plasma samples (100–2700 in increments of 50) per year over a certain number of years (1–5), in both USD and Thai Baht. Total cost and average costs per sample were estimated across a range of samples processed.

Results

The average cost per sample of analyzing 900 samples annually over 5 years was estimated at USD186. Laboratory, personnel, and facility costs constitute 67%, 23%, and 10% of costs, respectively. The breakdown across fixed costs, such as laboratory instruments and personnel, and variable costs, such as chemical supplies, was 60% and 40%, respectively. Average costs decline as more samples are processed: the cost per sample for analyzing 100, 500, 1500, and 2500 samples per year over 5 years is USD1351, USD301, USD195; and USD177, respectively.

Conclusions

Laboratory analysis of plasma TFA levels has high potential for economies of scale, encouraging a long-term approach to TFA monitoring initiatives, particularly in countries that already maintain national biometric repositories.

Disease and demography: a systems-dynamic cohort-component population model to assess the implications of disease-specific mortality targets

INTRODUCTION

The 2015 Sustainable Development Goals include the objective of reducing premature mortality from major non-communicable diseases (NCDs) by one-third by 2030. Accomplishing this objective has demographic implications with relevance for countries' health systems and costs. However, evidence on the system-wide implications of NCD targets is limited.

METHODS

We developed a cohort-component model to estimate demographic change based on user-defined disease-specific mortality trajectories. The model accounts for ageing over 101 annual age cohorts, disaggregated by sex and projects changes in the size and structure of the population. We applied this model to the context of Bangladesh, using the model to simulate demographic outlooks for Bangladesh for 2015-2030 using three mortality scenarios. The 'status quo' scenario entails that the disease-specific mortality profile observed in 2015 applies throughout 2015-2030. The 'trend' scenario adopts age-specific, sex-specific and disease-specific mortality rate trajectories projected by WHO for the region. The 'target' scenario entails a one-third reduction in the mortality rates of cardiovascular disease, cancer, diabetes and chronic respiratory diseases between age 30 and 70 by 2030.

RESULTS

The status quo, trend and target scenarios projected 178.9, 179.7 and 180.2 million population in 2030, respectively. The cumulative number of deaths during 2015-2030 was estimated at 17.4, 16.2 and 15.6 million for each scenario, respectively. During 2015-2030, the target scenario would avert a cumulative 1.73 million and 584 000 all-cause deaths compared with the status quo and trend scenarios, respectively. Male life expectancy was estimated to increase from 71.10 to 73.47 years in the trend scenario and to 74.38 years in the target scenario; female life expectancy was estimated to increase from 73.68 to 75.34 years and 76.39 years in the trend and target scenarios, respectively.

CONCLUSION

The model describes the demographic implications of NCD prevention and control targets, estimating the potential increase in life expectancy associated with achieving key NCD reduction targets. The results can be used to inform future health system needs and to support planning for increased healthcare coverage in countries.

Tobacco control and household tobacco consumption: A tale of two educational groups

Since the ratification of the World Health Organization Framework Convention on Tobacco Control in 2004, Pakistan has made modest but continued progress in implementing various tobacco control measures. By 2014, substantial progress was achieved in areas of monitoring, mass media antitobacco campaigns, and advertising bans. However, the findings from the 2014 Global Adult Tobacco Survey of Pakistan show significant differences in antitobacco campaign exposure among individuals of different educational attainment. Given this large variation in noticing antitobacco information, this paper analyzes how heterogeneity in treatment exposure may differentially impact tobacco-use prevalence across household groups. Household-level tobacco-use prevalence in 2014 was, respectively, 56% and 48% for the low- and high-education households. The gap in tobacco-use prevalence between the two educational groups further widens post 2014. We find that, on average, individuals with higher than primary education are 14 percentage points and 6 percentage points more likely to notice anticigarette and antismokeless tobacco information in 2014, respectively. Subsequently, in 2016, high-education households experienced a 3.6 percentage point higher reduction in tobacco-use prevalence compared to the low-education households. These findings motivate policies to enhance the outreach of tobacco control measures across different educational groups.

Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017

Background

We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups.

Methods

We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER – high prevalence (HM-HP). (2) High MPOWER – low prevalence (HM-LP). (3) Low MPOWER – high prevalence (LM-HP). (4) Low MPOWER – low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects.

Results

A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries.

Conclusion

A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

The cost-effectiveness of hypertension management in low-income and middle-income countries: a review

Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes.

Correction: Introducing the PLOS special collection of economic cases for NCD prevention and control: A global perspective

[This corrects the article DOI: 10.1371/journal.pone.0228564.].

Access to Cardiovascular Disease and Hypertension Medicines in Developing Countries: An Analysis of Essential Medicine Lists, Price, Availability, and Affordability

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

Introducing the PLOS special collection of economic cases for NCD prevention and control: A global perspective

Noncommunicable diseases (NCDs), such as heart disease, cancer, diabetes, and chronic respiratory disease, are responsible for seven out of every 10 deaths worldwide. While NCDs are associated with aging in high-income countries, this representation is often misleading. Over one-third of the 41 million annual deaths from NCDs occur prematurely, defined as under 70 years of age. Most of those deaths occur in low- and middle-income countries (LMICs) where surveillance, treatment, and care of NCDs are often inadequate. In addition to high health and social costs, the economic costs imposed by such high numbers of excess early deaths impede economic development and contribute to global and national inequity. In higher-income countries, NCDs and their risks continue to push health care costs higher. The burden of NCDs is strongly intertwined with economic conditions for good and for harm. Understanding the multiple ways they are connected–through risk factor exposures, access to quality health care, and financial protection among others–will determine which countries are able to improve the healthy longevity of their populations and slow growth in health expenditure particularly in the face of aging populations. The aim of this Special Collection is to provide new evidence to spur those actions.

Assessing costs of a hypertension management program: An application of the HEARTS costing tool in a program planning workshop in Thailand

The HEARTS technical package, a part of the Global Hearts Initiative to improve cardiovascular health globally, is a strategic approach for cardiovascular disease prevention and control at the primary care level. To support the evaluation of costs associated with HEARTS program components, a costing tool was developed to evaluate the incremental cost of program implementation. This report documents an application of the HEARTS costing tool during a costing workshop prior to the initiation of a HEARTS pilot program in Thailand's Phothong District, 2019‐2020. During the workshop, a mock exercise was conducted to estimate the expected costs of the pilot study. The workshop application of the tool underscored its applicability to the HEARTS program planning process by identifying cost drivers associated with individual program elements. It further illustrated that by supporting disaggregation of costs into fixed and variable categories, the tool can inform the scalability of pilot projects to larger populations. Lessons learned during the initial development and application of the costing tool can inform future HEARTS evaluation efforts.

An Intertemporal Analysis of Post-FCTC Era Household Tobacco Consumption in Pakistan

Since the ratification of the WHO Framework Convention on Tobacco Control (FCTC) in 2004, Pakistan has taken various measures of tobacco control. This study examines how these tobacco control measures are associated with change in household-level tobacco consumption patterns in Pakistan over the decade (2005 to 2016) after FCTC ratification. We used multiple waves of the household survey data of Pakistan from 2004-2005 to 2015-2016 for analyzing household-level tobacco use. We find that tobacco consumption remains at a significantly high level (45.5%) in Pakistan despite the recent declining trend in the post-FCTC era. During the preparatory phase of FCTC implementation between 2005 and 2008, the smoking rate was on the rise, and smokeless tobacco use was declining. Over the implementation phase of FCTC policies between 2008 and 2016, the pattern of change in tobacco use reversed-the smoking rate started to decrease while smokeless tobacco use started to rise. However, the decrease in the smoking rate was slower and the increase in smokeless tobacco use at the national level was driven by an increase among the poor and middle-income households. These trends resulted in the growing burden of tobacco expenditure among the poor and middle-income households relative to the wealthier households.

Comparative analysis of diet and tobacco use among households in Bangladesh

INTRODUCTION

While studies from developed countries have reported dietary differences between tobacco users and non-users, less is known about the influence of tobacco on diet in developing countries where malnutrition is a major public health challenge.

METHODS

In this study we used the nationally representative Household Income Expenditure Survey 2010 from Bangladesh. Detailed household-level food consumption data including both ethnic and region-specific foods were collected over 14 days, consisting of 7 visits each collecting two days of dietary recall information.

RESULTS

Out of 12240 households, 2061 consumed smoking tobacco only (16.8%), 3284 consumed smokeless tobacco only (26.8%), and 3348 consumed both (27.4%). Overall, 71% of the households reported expenditure on tobacco (smoking and/or smokeless) and were considered any-tobacco use households. Our results indicate that after controlling for household expenditure, household size, household child to adult ratio, place of residence (urban/rural), and region fixed effects, any-tobacco households consumed significantly lower amounts (g/day) of milk and dairy products (β = -17.11, p<0.01) and oil/fat (β = -10.30, p<0.01) compared to tobacco non-use households (β: adjusted mean difference in food amount g/day/household). Conversely, consumption of cereal grains (β = 152.46, p<0.0001) and sugar (β = 8.16, p<0.0001) were significantly higher among any-tobacco households compared to non-tobacco households. We observed similar patterns for smoking-only, smokeless-only, and dual tobacco product households.

CONCLUSION

Evidence of dietary differences between tobacco-use and non-use households may play an important role in developing strategies to address poor diet and malnutrition among tobacco-use households in a developing country like Bangladesh. This study provides one of the first reports addressing diet in relation to tobacco use from a developing country, particularly using nationally representative data. The finding that tobacco-use households have poorer dietary consumption than non-use households suggests that it is important to address tobacco use in the context of nutrition and development programs in low-income environments.

Assessing the relationship between out-of-pocket spending on blood pressure and diabetes medication and household catastrophic health expenditure: evidence from Pakistan

Background

Treatment of non-communicable diseases (NCDs) in low-and-middle-income countries (LMICs) is costly and could expose households to financial hardship and vulnerability. This paper examines the association between medication costs of two major NCDs – hypertension (blood pressure) and diabetes, and household-level incidences of catastrophic health expenditure (CHE) in a South Asian LMIC, Pakistan.

Methods

The study analyzes self-reported blood pressure and diabetes (BPD) medication expenditure from the latest version (2015–16) of the Household Integrated Economic Survey (HIES) of Pakistan, a nationally representative survey of 24,238 households. The incidence of CHE is defined as households’ out-of-pocket (OOP) medical expenditure exceeding 10% of the total household expenditure. Using a linear probability model, we estimate the adjusted differences in CHE incidence between households that are spending and ‘not’ spending on BPD medication. We also analyze several hypothetical scenarios of BPD medication cost coverage, and compare the estimated CHE incidences of respective scenarios with the status quo.

Results

We find that the average monthly medical expenditure, and average medical expenditure share are significantly higher for households spending on BPD medication, compared to households ‘not’ spending. The incidence of CHE is found 6.7 percentage point higher for the households consuming BPD medication, after controlling for relevant socioeconomic attributes. If 25, 50, and 100% of the BPD medication OOP cost is covered, then the CHE incidence would reduce respectively by 5.9, 12.7, and 21.4% compared to the status quo.

Conclusion

Medication cost for managing two major NCDs and household catastrophic health expenditure have strong associations. The findings inform policies toward ensuring access to necessary healthcare services, and protecting households from NCD treatment related financial hardship.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0906-x) contains supplementary material, which is available to authorized users.

Road map for leadership and management in public health: a case study on noncommunicable diseases program managers' training in Rwanda

Ministries of Health (MoHs) and health organizations are compelled to work across sectors and build coalitions, strengthening health systems to abate the rise of noncommunicable diseases (NCDs). A critical element of NCD prevention and control involves significant and difficult changes in attitudes, policies and protective behavior at the population level. The population-level impact of NCD interventions depends on the strength of the health system that delivers them. In particular, low-resource settings are exploring efficiencies and linkages to existing systems or partnerships in ways that may alleviate redundancies and high delivery costs. These entail complex operational challenges, and can only be spearheaded by a competent and passionate workforce. There is a critical need to develop and strengthen the management and leadership skills of public health professionals so that they can take on the unique challenges of NCD prevention and control. An added component must include a shift from the traditional clinical approach to a community-based effort, focusing heavily on health education and community norm change. Strengthening the work-force capacity of program managers at MoHs and other implementing institutions is key to capturing, analyzing, advocating and communicating information and will, in turn, reinforce the scale-up of interventions fostering a robust health system. This paper summarizes the best practices and lessons learned from the NCD Program Managers short course conducted by the US Centers for Disease Control and Prevention (CDC) in December, 2016 in Rwanda.

Consumption displacement in households with noncommunicable diseases in Bangladesh

The economic burden of noncommunicable diseases (NCDs), including treatment costs and income and productivity losses, is a growing concern in developing countries, where NCD medical expenditure may offset consumption of other essential commodities. This study examines the role of NCDs in household resource allocation in Bangladesh. We use the Bangladesh Household Income and Expenditure Survey (HIES) 2010 to obtain expenditure data on 11 household expenditure categories and 12 food expenditure sub-categories for 12,240 households. Household NCD status was determined through self-report of at least one of the six major NCDs within the household-heart disease, hypertension, diabetes, kidney diseases, asthma, and cancer. We estimated unadjusted and regression-adjusted differences in household expenditure shares between NCD and non-NCD households. We further investigated how consumption of different food sub-categories is related to NCD status, distinguishing between household economic levels. The medical expenditure share was estimated to be 59% higher for NCD households than non-NCD households, and NCD households had lower expenditure shares on food, clothing, hygiene, and energy. Regression results indicated that presence of NCDs was associated with lower relative expenditure on clothing and housing in all economic subgroups, and with lower expenditure on food among marginally poor households. Having an NCD was significantly associated with higher household spending on tobacco and higher-calorie foods such as sugar, beverages, meat, dairy, and fruit, and with lower spending on fish, vegetables, and legumes. The findings indicate a link between NCDs and the possibility of adverse economic effects on the household by highlighting the potential displacement effect on household consumption that might occur through higher medical expenditure and lower spending on essentials. The findings might also point to a need for raising awareness about the link between NCDs and diet in Bangladesh.

Noncommunicable disease-attributable medical expenditures, household financial stress and impoverishment in Bangladesh

BACKGROUND

Treatment of noncommunicable diseases (NCDs) in low-income countries can entail large out-of-pocket (OOP) medical expenditures, which can increase the likelihood of household impoverishment and perpetuate the poverty cycle. This paper studies the implications of NCDs on household medical expenditure, household financial stress (e.g. selling assets or borrowing for treatment financing), catastrophic OOP expenditure, and impoverishment in Bangladesh.

METHODS

We used self-reported health status and household expenditure survey data from 12,240 households in Bangladesh. NCD-afflicted households were defined by presence of at least one of the following conditions within the household - heart disease, hypertension, asthma, diabetes, cancer, or kidney disease. Using linear regression models, we examined whether NCD households incur more medical expenditures, allocate a larger budget share on medical expenditures, and have greater probability of experiencing catastrophic medical expenditure or financial stress from OOP spending than non-NCD households. Finally, using survey weights, we extrapolated how NCD-attributable medical expenditure can result in impoverishment and downward movement in net consumption status at the population level.

RESULTS

NCD-afflicted households allocate a greater share of household expenditures for medical care than households without NCDs, and their probability of incurring catastrophic medical expenditure is higher by 6.7 percentage points compared to the households with no reported conditions. NCD households are 85% more likely to sell assets or borrow from informal sources to finance treatment cost. Household spending on NCD care is estimated to account for the impoverishment of 0.66 million persons in Bangladesh in 2010, and for reducing the net consumption status of 7.63 million persons on both sides of the poverty line after accounting for NCD-related OOP expenditures.

CONCLUSION

NCD-related household medical expenditure is associated with experiencing financial distress and aggravating poverty in Bangladesh.

The crowding-out effect of tobacco expenditure on household spending patterns in Bangladesh

BACKGROUND

Tobacco consumption constitutes a sizable portion of household consumption expenditure, which can lead to reduced expenditures on other basic commodities. This is known as the crowding-out effect. This study analyzes the crowding-out effect of tobacco consumption in Bangladesh, and the research findings have relevance for strengthening the tobacco control for improving health and well-being.

METHODS

We analyzed data from the Bangladesh Household Income and Expenditure Survey 2010 to examine the differences in consumption expenditure pattern between tobacco user and non-user households. We further categorize tobacco user households in three mutually exclusive groups of smoking-only, smokeless-only, and dual (both smoking and smokeless); and investigated the crowding-out effects for these subgroups. We compared the mean expenditure shares of different types of households, and then estimated the conditional Engel curves for various expenditure categories using Seemingly Unrelated Regression (SUR) method. Crowding-out was considered to have occurred if estimated coefficient of the tobacco use indicator was negative and statistically significant.

RESULTS

We find that tobacco user households on average allocated less in clothing, housing, education, energy, and transportation and communication compared to tobacco non-user households. The SUR estimates also confirmed crowding-out in these consumption categories. Mean expenditure share of food and medical expenditure of tobacco user households, however, are greater than those of tobacco non-user households. Albeit similar patterns observed for different tobacco user households, there were differences in magnitudes depending on the type of tobacco-use, rural-urban locations and economic status.

CONCLUSION

Policy measures that reduce tobacco use could reduce displacement of commodities by households with tobacco users, including those commodities that can contribute to human capital investments.

Changes in cigarette prices, affordability, and brand-tier consumption after a tobacco tax increase in Thailand: Evidence from the Global Adult Tobacco Surveys, 2009 and 2011

Despite the 2009 implementation of a tobacco tax increase in Thailand, smoking rates remained unchanged between 2009 and 2011. Prior evidence has linked cigarette tax increases to compensatory behaviours aimed at lowering the cost of smoking, such as switching to lower-priced cigarette brands. Using data from 2009 and 2011 Global Adult Tobacco Surveys in Thailand, we estimated unadjusted changes in cigarette prices paid, cigarette affordability, and consumption of cigarettes in three price categories classified as upper-, middle-, and lower-priced brand tiers (or price tertiles). We used ordered logit regression to analyse the correlates of price-tier choice and to estimate the change in price-tier consumption adjusted for demographic and region characteristics. Between 2009 and 2011, real cigarette prices increased, but the affordability of cigarettes remained unchanged overall. There was a significant reduction in the consumption of cigarette brands in the top price-tier overall, accompanied by increases in the consumption of brands in the bottom and middle price-tiers, depending on the region. Adjusted estimates from the logit models indicate that, on average, the proportion of smokers selecting brands from upper- and middle price-tiers decreased while consumption of lower price-tier brands increased during the study period. The estimated shifts in consumption from more expensive to less expensive cigarette brands and the overall lack of change in cigarette affordability in Thailand between 2009 and 2011 are both factors that may have contributed to the observed lack of change in smoking rates after the 2009 tax increase.

An overview of tobacco control and prevention policy status in Africa

Tobacco smoking prevalence remains low in many African countries. However, growing economies and the increased presence of multinational tobacco companies in the African Region have the potential to contribute to increasing tobacco use rates in the future. This paper used data from the 2014 Global Progress Report on implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), as well as the 2015 WHO report on the global tobacco epidemic, to describe the status of tobacco control and prevention efforts in countries in the WHO African Region relative to the provisions of the WHO FCTC and MPOWER package. Among the 23 countries in the African Region analyzed, there are large variations in the overall WHO FCTC implementation rates, ranging from 9% in Sierra Leone to 78% in Kenya. The analysis of MPOWER implementation status indicates that opportunities exist for the African countries to enhance compliance with WHO recommended best practices for monitoring tobacco use, protecting people from tobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco, enforcing bans on tobacco advertising and promotion, and raising taxes on tobacco products. If tobacco control interventions are successfully implemented, African nations could avert a tobacco-related epidemic, including premature death, disability, and the associated economic, development, and societal costs.

Money Gone Up in Smoke: The Tobacco Use and Malnutrition Nexus in Bangladesh

BACKGROUND

The tobacco epidemic in Bangladesh is pervasive. Expenditures on tobacco may reduce money available for food in a country with a high malnutrition rate.

OBJECTIVES

The aims of the study are to quantify the opportunity costs of tobacco expenditure in terms of nutrition (ie, food energy) forgone and the potential improvements in the household level food-energy status if the money spent on tobacco were diverted for food consumption.

METHOD

We analyzed data from the 2010 Bangladesh Household Income and Expenditure Survey, a nationally representative survey conducted among 12,240 households. We present 2 analytical scenarios: (1) the lower-bound gain scenario entailing money spent on tobacco partially diverted to acquiring food according to households' food consumption share in total expenditures; and (2) the upper-bound gain scenario entailing money spent on tobacco diverted to acquiring food only. Age- and gender-based energy norms were used to identify food-energy deficient households. Data were analyzed by mutually exclusive smoking-only, smokeless-only, and dual-tobacco user households.

FINDINGS

On average, a smoking-only household could gain 269-497 kilocalories (kcal) daily under the lower-bound and upper-bound scenarios, respectively. The potential energy gains for smokeless-only and dual-tobacco user households ranged from 148-268 kcal and 508-924 kcal, respectively. Under these lower- and upper-bound estimates, the percentage of smoking-only user households that are malnourished declined significantly from the baseline rate of 38% to 33% and 29%, respectively. For the smokeless-only and dual-tobacco user households, there were 2-3 and 6-9 percentage point drops in the malnutrition prevalence rates. The tobacco expenditure shift could translate to an additional 4.6-7.7 million food-energy malnourished persons meeting their caloric requirements.

CONCLUSIONS

The findings suggest that tobacco use reduction could facilitate concomitant improvements in population-level nutrition status and may inform the development and refinement of tobacco prevention and control efforts in Bangladesh.

Tobacco-free economy: A SAM-based multiplier model to quantify the impact of changes in tobacco demand in Bangladesh

In Bangladesh, where tobacco use is pervasive, reducing tobacco use is economically beneficial. This paper uses the latest Bangladesh social accounting matrix (SAM) multiplier model to quantify the economy-wide impact of demand-driven changes in tobacco cultivation, bidi industries, and cigarette industries. First, we compute various income multiplier values (i.e. backward linkages) for all production activities in the economy to quantify the impact of changes in demand for the corresponding products on gross output for 86 activities, demand for 86 commodities, returns to four factors of production, and income for eight household groups. Next, we rank tobacco production activities by income multiplier values relative to other sectors. Finally, we present three hypothetical 'tobacco-free economy' scenarios by diverting demand from tobacco products into other sectors of the economy and quantifying the economy-wide impact. The simulation exercises with three different tobacco-free scenarios show that, compared to the baseline values, total sectoral output increases by 0.92%, 1.3%, and 0.75%. The corresponding increases in the total factor returns (i.e. GDP) are 1.57%, 1.75%, and 1.75%. Similarly, total household income increases by 1.40%, 1.58%, and 1.55%.

Approaches for controlling illicit tobacco trade--nine countries and the European Union

An estimated 11.6% of the world cigarette market is illicit, representing more than 650 billion cigarettes a year and $40.5 billion in lost revenue. Illicit tobacco trade refers to any practice related to distributing, selling, or buying tobacco products that is prohibited by law, including tax evasion (sale of tobacco products without payment of applicable taxes), counterfeiting, disguising the origin of products, and smuggling. Illicit trade undermines tobacco prevention and control initiatives by increasing the accessibility and affordability of tobacco products, and reduces government tax revenue streams. The World Health Organization (WHO) Protocol to Eliminate Illicit Trade in Tobacco Products, signed by 54 countries, provides tools for addressing illicit trade through a package of regulatory and governing principles. As of May 2015, only eight countries had ratified or acceded to the illicit trade protocol, with an additional 32 needed for it to become international law (i.e., legally binding). Data from multiple international sources were analyzed to evaluate the 10 most commonly used approaches for addressing illicit trade and to summarize differences in implementation across select countries and the European Union (EU). Although the WHO illicit trade protocol defines shared global standards for addressing illicit trade, countries are guided by their own legal and enforcement frameworks, leading to a diversity of approaches employed across countries. Continued adoption of the methods outlined in the WHO illicit trade protocol might improve the global capacity to reduce illicit trade in tobacco products.

Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS

OBJECTIVE

To estimate the direct healthcare cost of being overweight or obese throughout pregnancy to the National Health Service in Wales.

DESIGN

Retrospective prevalence-based study.

SETTING

Combined linked anonymised electronic datasets gathered on a cohort of women enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Women were categorised into two groups: normal body mass index (BMI; n=260) and overweight/obese (BMI>25; n=224).

PARTICIPANTS

484 singleton pregnancies with available health service records and an antenatal BMI.

PRIMARY OUTCOME MEASURE

Total health service utilisation (comprising all general practitioner visits and prescribed medications, inpatient admissions and outpatient visits) and direct healthcare costs for providing these services in the year 2011-2012. Costs are calculated as cost of mother (no infant costs are included) and are related to health service usage throughout pregnancy and 2 months following delivery.

RESULTS

There was a strong association between healthcare usage cost and BMI (p<0.001). Adjusting for maternal age, parity, ethnicity and comorbidity, mean total costs were 23% higher among overweight women (rate ratios (RR) 1.23, 95% CI 1.230 to 1.233) and 37% higher among obese women (RR 1.39, 95% CI 1.38 to 1.39) compared with women with normal weight. Adjusting for smoking, consumption of alcohol, or the presence of any comorbidities did not materially affect the results. The total mean cost estimates were £3546.3 for normal weight, £4244.4 for overweight and £4717.64 for obese women.

CONCLUSIONS

Increased health service usage and healthcare costs during pregnancy are associated with increasing maternal BMI; this was apparent across all health services considered within this study. Interventions costing less than £1171.34 per person could be cost-effective if they reduce healthcare usage among obese pregnant women to levels equivalent to that of normal weight women.

The information needs of people living with ankylosing spondylitis: a questionnaire survey

BACKGROUND

Today, health care is patient-centred with patients more involved in medical decision making and taking an active role in managing their disease. It is important that patients are appropriately informed about their condition and that their health care needs are met. We examine the information utilisation, sources and needs of people with ankylosing spondylitis (AS).

METHODS

Participants in an existing AS cohort study were asked to complete a postal or online questionnaire containing closed and open-ended questions, regarding their information access and needs. Participants were stratified by age and descriptive statistics were performed using STATA 11, while thematic analysis was performed on open-ended question narratives. Qualitative data was handled in Microsoft Access and explored for emerging themes and patterns of experiences.

RESULTS

Despite 73% of respondents having internet access, only 49% used the internet to access information regarding AS. Even then, this was only infrequently. Only 50% of respondents reported accessing written information about AS, which was obtained mainly in specialist clinics. Women were more likely than men to access information (63% (women) 46% (men)) regardless of the source, while younger patients were more likely to use online sources. The main source of non-written information was the rheumatologist. Overall, the respondents felt there was sufficient information available, but there was a perception that the tone was often too negative. The majority (95%) of people would like to receive a regular newsletter about AS, containing positive practical and local information. Suggestions were also made for more information about AS to be made available to non-specialist medical professionals and the general public.

CONCLUSIONS

There appears to be sufficient information available for people with AS in the UK and this is mostly accessed by younger AS patients. Many patients, particularly men, choose not to access AS information and concerns were raised about its negative tone. Patients still rely on written and verbal information from their specialists. Future initiatives should focus on the delivery of more positive information, targeting younger participants in particular and increasing the awareness in the general population and wider non-specialist medical community.

No increased rate of acute myocardial infarction or stroke among patients with ankylosing spondylitis-a retrospective cohort study using routine data

OBJECTIVES

To examine if people with ankylosing spondylitis (AS) are at higher risk of acute myocardial infarction (MI) or stroke compared to those without AS.

METHODS

Primary care records were linked with all hospital admissions and deaths caused by MI or stroke in Wales for the years 1999-2010. The linked data were then stratified by AS diagnosis and survival analysis was used to obtain the incidence rate of MI and separately cerebrovascular disease (CVD)/stroke. Cox regression was used to adjust for gender and age. Logistic regression was used to examine prevalence of diabetes, hypertension, or hyperlipidemia for those with AS compared to those without.

RESULTS

There were 1686 AS patients (75.9% male, average age 46.1 years) compared to 1,206,621 controls (48.9% male, average age 35.9 years). Age- and gender-adjusted hazard ratios for MI were 1.28 (95% CI: 0.93 to 1.74) P = 0.12, and for CVD/stroke 1.0 (95% CI: 0.73 to 1.39) P = 0.9, in AS compared to controls. The prevalence of diabetes and hypertension, but not hyperlipidemia/hypercholesterolemia, was higher in AS.

CONCLUSIONS

There is no increase in the MI or CVD/stroke rates in patients with AS compared to those without AS, despite higher rates of hypertension, which may be related to nonsteroidal anti-inflammatory drug use.

Performing internal sphincterotomy with other anorectal procedures

PURPOSE

A study was conducted to compare the outcome of combined anorectal procedures involving lateral internal sphincterotomy with lateral internal sphincterotomy alone to determine if the former results in increased complications.

METHODS

Complications and anal function of 57 patients who underwent lateral internal sphincterotomy for chronic anal fissure in conjunction with another anorectal procedure (combined group) between April 1989 and June 1992 were compared with 57 other age- and sex-matched patients who underwent lateral internal sphincterotomy alone (control group).

RESULTS

There was no statistical difference in the incidence of incontinence in the combined group (8.7 percent) and the control group (7 percent). None of the cases in either group had permanent incontinence. There were also no statistical differences in the incidence of postoperative bleeding, pruritus ani, mucus discharge, abscess formation, fistulation, and rates of fissure recurrence.

CONCLUSIONS

Additional anorectal procedures performed at the same time as internal sphincterotomy do not increase the incidence of postoperative complications.