Elsevier

The Lancet

Volume 391, Issue 10134, 19–25 May 2018, Pages 2071-2078
The Lancet

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

https://doi.org/10.1016/S0140-6736(18)30665-2Get rights and content

Summary

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.

Introduction

The Sustainable Development Goals (SDGs) have increased global attention on the neglected non-communicable disease (NCD) pandemic. SDG 3, to ensure healthy lives and promote wellbeing for everyone at all ages, includes a specific subtarget on NCDs (target 3.4), to reduce premature mortality from NCDs by a third. As the burden of NCDs continues to increase worldwide, estimating the costs and benefits of an investment strategy to prevent and control NCDs and understanding the resources needed to progress towards SDG 3.4, have become matters of urgency.

In 2015, WHO1 estimated that 40 million deaths worldwide had been caused by NCDs. In the 2016 Global Burden of Disease study,2 NCDs were estimated to account for more than 70% of mortality worldwide. Cardiovascular diseases account for 17·7 million of these deaths, and about 80% of all deaths from NCDs are in low-income and middle-income countries (LMICs). The attainment of SDG 3.4 therefore necessitates a rapid scale-up of prevention and control interventions for cardiovascular disease. Treatment advances in recent decades have sharply reduced cardiovascular disease mortality in many high-income countries. By contrast, cardiovascular disease risk factors have worsened in many LMICs during the same period, and age-standardised cardiovascular disease mortality is high and, in some cases, still increasing.

The large and growing burden of NCDs has raised concerns about the economic consequences of this burden. NCDs are common in people of working age, so these consequences extend beyond the costs of treating the diseases. Reduced employment and productivity, for example, contribute to the loss of income at the household level and to the loss of economic output at a national level.3 In a systematic review4 of 126 studies about the economic effects of NCDs in a variety of country settings, labour force participation was lower in people with NCDs than in people without. Estimates from the USA have indicated that 4·7 working days are lost each year because of cardiovascular disease. In a Danish study, only 37% of people with a primary cardiovascular disease event had returned to work 30 days after the event, although long-term workforce participation returned to the pre-event level.4 More strikingly, in a Nigerian study,4 only 55% of patients who had a stroke returned to work 19·5 months after their stroke. In a UK study, 47% of patients had not returned to the workforce 1 year after their stroke.

Key messages

  • Investing in cardiovascular disease prevention and treatment is integral to achieving the SDG target 3.4 of reducing premature mortality from non-communicable diseases by a third and the SDG 3.8 target to achieve universal health coverage

  • Effective and low-cost interventions are available but implemented at very low levels in most low-income and middle-income countries

  • The investment to scale up this set of investments analysed here is likely to be large, but in addition to the intrinsic health benefits of this package, we would also expect economic benefits in terms of employment and productivity to increase national wealth

In preparation for the 2011 UN high-level meeting on prevention and control of NCDs, the WHO Secretariat identified a core set of evidence-based, so-called Best Buy interventions for NCDs that met the criteria of being cost-effective, affordable, acceptable, and feasible.5 Rolling out these interventions to global scale is estimated to cost US$170 billion for all LMICs during the period 2011–2025, which is equivalent to $1 per capita in low-income countries and $3 per capita in middle-income countries.6 However, the value of the benefits to health or the economy that is associated with the costs of intervention scale-up was not analysed, thereby precluding the possibility of determining the expected returns to investment from comprehensive prevention and treatment of NCDs. The Best Buy interventions were updated at the World Health Assembly in 2017 and were incorporated into an updated package of NCD interventions and and updated list of policy options for NCD prevention and control supported by the WHO member states.7

Broadly understood, the economic, health, and social benefits of NCD prevention and control include both the intrinsic (or social) value of improved health to individuals, households, and society at large and its instrumental (or economic) value in terms of being able to lead a fulfilling life, form and maintain relationships, study, work, pursue leisure interests, and make day-to-day decisions about education, employment, and housing. Estimating the magnitude of these benefits relative to the costs incurred to establish the return to investment can be done by estimating the existing and future levels of NCD burden and the effective current intervention coverage in a population and then determining the value of both the social and economic effects of improved health outcomes resulting from increased levels of intervention coverage.

The investment case for health, as a concept, is gaining traction in the public health literature, as is the notion that investment-case analyses provide important evidence that can inform decision making by governments and donors, particularly in a multisectoral context.8, 9 This thinking flows from a wider appreciation of the shortcomings of gross domestic product (GDP) as a measure of human wellbeing and a search for broader measures that include health and other goals of sustainable development.10, 11 Investment case for health is a term we use to refer to a method of policy analysis to justify the use of resources primarily intended to increase the stock of health (panel 1). A description of the theoretical underpinning of investment case for health is provided in the appendix.

Achieving SDG target 3.4 will have a variety of outcomes beyond the health sector that would contribute to the attainment of other SDG targets. These include contributions to SDG 8 (promoting sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all), SDG 10 (reducing inequality within and amoung countries), and SDG 1 (ending poverty in all its forms everywhere). Here we propose a framework for undertaking investment-case analyses for NCDs, which links SDG 3 to SDG 8. Our proposed framework develops an investment case for NCDs, and we use cardiovascular disease as an example because of its high contribution to the total NCD burden. We present the health-sector costs of scaling up cardiovascular disease prevention interventions, in line with the SDG targets, and estimate the economic and social benefits of improved health.

Section snippets

What will it take to reach SDG targets?

Meeting the SDG goal of a 30% reduction in premature mortality from NCDs by 2030 requires strong action against a background of increasing NCD mortality in many countries. Emphasis is needed to prevent the onset of NCDs and prevent mortality in people with NCDs. The Global Action Plan for Non-Communicable Diseases (appendix) outlines a list of Best Buy interventions to guide policy makers towards the greatest value for money for their investments in NCDs. These interventions are considered

Estimating resource needs to scale up prevention and treatment of cardiovascular disease

We used the OneHealth Tool to estimate the costs of scaling up this set of interventions to control the increasing burden of cardiovascular disease and reduce premature mortality from cardiovascular disease. With cardiovascular disease causing 50% of the NCD mortality burden worldwide, understanding the health system, human resources, and financial needs to scale up action against cardiovascular disease is a key step in understanding the full magnitude of the challenge that health systems musts

Understanding the economic and social returns on investment

In addition to the health benefits, investments for implementing or scaling up these interventions would bring a broader benefit to the economy. For the total sample, at a 3% discount rate and including social benefits, the benefit–cost ratio for cash flows until 2030 is 10·9. At a 7% discount rate, the benefit–cost ratio is about 7·5. A benefit–cost ratio of 5 implies that the discounted social return is five times the discounted value of the investment, which is widely considered high, so

Considerations and recommendations

With this analysis, we present a framework to evaluate the global investment case for scaling up the response to cardiovascular disease. Previous work at the international level has addressed different aspects of this work, such as the mortality-attributable GDP benefits of eliminating disease,19 the economic consequences of NCDs, the costs of scaling up a package of essential interventions for NCDs,6 and the cost-effectiveness of interventions for NCD prevention and control.20 This attempt to

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