Saving lives, spending less: the case for investing in noncommunicable diseases: methods supplement

1Saving lives, spending less: the case for investing in noncommunicable diseases Saving lives, spending less: the case for investing in noncommunicable diseases. Methods supplement ISBN 978-92-4-004123-3 (electronic version) ISBN 978-92-4-004124-0 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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In no event shall WHO be liable for damages arising from its use. iii CONTENTS Analytic scope 1 Use of the OneHealth Tool 2 Estimating impact 2 Coverage and scale up patterns 4 Tobacco 4 Alcohol 6 Unhealthy diets 6 Physical inactivity 7 Clinical interventions 7 Estimating intervention costs 7 Health benefits from scaling up interventions 10 Estimating the economic and social returns on investment 11 Avoided deaths 11 Averted incident cases 12 Social benefits of increased years of healthy life 12 Calculating the return on investment 12 Limitations of analytical framework 13 References 14 1 Analytic scope The analytic scope for this report closely follows that of the original NCD Global Business Plan, published in 20181, including the interventions analyzed, the country inclusion criteria, and the overall methodological structure. This report focuses on the 16 “best buys” for NCDs as described in the Appendix 3 of the Global Action Plan for NCDs, updated in 20172 (Table 1). The NCD Best Buys are a set of evidence-based priority interventions for NCD prevention and control, which include considerations of cost-effectiveness, feasibility, affordability, acceptability and potential for successful implementation. While some recent studies may support the cost-effectiveness of other interventions for NCDs, this analysis currently only includes the 16 most cost-effective interventions as endorsed by the World Health Assembly. Table 1. The WHO NCD Best Buys Tobacco 1. Increase excise taxes and prices on tobacco products 2. Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages 3. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship 4. Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public places and public transport 5. Implement effective mass-media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke Alcohol 6. Increase excise taxes on alcoholic beverages 7. Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising (across multiple types of media) 8. Enact and enforce restrictions on the physical availability of alcohol in sales outlets (via reduced hours of sale) Unhealthy Diets 9. Reduce salt intake through the reformulation of food products to contain less salt, and the setting of maximum permitted levels for the amount of salt in food 10. Reduce salt intake through establishing a supportive environment in public institutions such as hospitals, schools, workplaces and nursing homes, to enable low-salt options to be provided 11. Reduce salt intake through behavior change communication and mass media campaigns 12. Reduce salt intake through the implementation of front-of-pack labelling Physical Inactivity 13. Implement community-wide public education and awareness campaigns for physical activity, including mass-media campaigns combined with other community-based education, motivational and environmental programmes aimed at supporting behavioral change around physical activity levels Management Cardiovascular Disease and Diabetes 14. Provide drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counselling for individuals who have had a heart attack or stroke and for persons with high risk (≥ 30%) of a fatal or non-fatal cardiovascular event in the next 10 years Cervical Cancer 15. Vaccination against human papillomavirus (2 doses) of girls aged 9 to 13 years 16. Prevention of cervical cancer by screening women aged 30 to 49 years, either through: visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions; pap smear (cervical cytology) every 3–5 years, linked with timely treatment of pre- cancerous lesions; human papillomavirus tests every 5 years, linked with timely treatment of precancerous lesions. 2 The inclusion criteria for countries was also maintained – the analysis is limited to low- and lower-middle income countries, according to the World Bank Country Income Classification for 2020. Relative to the original report published in 2018, there have been changes to the list of countries due to shifts in their income classification thus 76 low- and lower-middle income countries are now included. Algeria, Belize, Iran, and Samoa have been added, while Armenia, Georgia, Guatemala, Jordan, and Moldova have been dropped. The list also excludes the West Bank and Gaza, which is not a WHO Member State. Furthermore, the Democratic People’s Republic of Korea, Eritrea, South Sudan, and the Syrian Arab Republic were excluded due to a lack of GDP data available to project prices. Kiribati has been excluded as insufficient baseline epidemiology was available. Annex A lists the WHO Member States included in the analysis. Use of the OneHealth Tool Similar to the analysis performed for the original report, the NCD impact module of the inter-UN agency OneHealth Tool (OHT) was used to estimate the health benefits of scaling up the NCD Best Buys. It is primarily designed to inform the development of national strategic health plans, by assessing parameters related to cost, impact and financing projections related to strengthening health systems and delivering costed and quantifiable strategic plans in low- and middle-income countries. Given its incorporation of epidemiological models that allow for prediction of health outcomes and costs in an integrated way across programmes and interventions, OHT has been used for previous global and national investment cases, including cardiovascular disease3, reproductive, maternal, newborn and child (RMNCH) health4 and mental health5, as well as for the cost and impact analysis for the SDG Health Price Tag6. The software and supporting documentation are available for download at https://www.avenirhealth.org/software-onehealth.php. Estimating impact The interventions were configured in several ways to show the benefits of implementation using different options. The first configuration was an ambitious scenario to implement and scale up all 16 NCD Best Buy interventions simultaneously. Succeeding configurations dealt with implementing all interventions within a specific risk factor or disease area (i.e. for tobacco, for alcohol, etc.). For each of these configurations, two alternative scenarios were measured using the OneHealth Tool impact module – the first in which the policies are applied or the target coverage levels are reached in a linear fashion from 2021-2030, and the counterfactual in which the coverage of the policies or services remains at the baseline level until 2030, assuming no additional investment is made to NCD prevention and treatment. The difference in number of fatal and non-fatal cardiovascular events between the two scenarios represents the health gain attributed to additional investment in the interventions. 3 Table 2. Impact sizes used Intervention Effect Size Comments on evidence Increase excise taxes and prices on tobacco products Elasticity is -0.2 to- 0.57 Based on an assumed tax increase that increases the retail price of cigarettes by 25%. Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship Reduction in prevalence of 10% if implemented at the highest intensity level8 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages Reduction in prevalence of 4% if graphic health warnings implemented at the highest intensity level8 Eliminate exposure to second- hand tobacco smoke in all indoor workplaces, public places, public transport Reduction in prevalence of 4% if implemented at the highest intensity level8 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke Reduction in prevalence of 3.8% if implemented at the highest intensity level8 Reduce salt intake by engaging the industry in a voluntary reformulation process 2.2 g/day salt reduction9 Based on Argentina experience Reduce salt intake through implementation of front-of- pack labelling 1.8g/day salt reduction men 1.0 g/day salt reduction women10 The experience in Finland indicated that salt intake reduced by 15% following implementation of a labelling system10. This translates to the gram per day reductions indicated.11 Reduce salt intake through a behaviour change communication mass media campaign 5% reduction in salt intake per day12 Movement from 8.48 to 8.05 g/day via urinary excretion in Vietnam following BCC campaign12.The same campaign in Australia saw a 10% reduction in sodium intake13. We have taken the conservative option. 4 Reduce salt intake through establishment of a supportive environment in public institutions such as hospitals, schools and nursing homes to enable low sodium meals to be provided 7% reduction in salt intake per day A British study on implementing standards for school meals shows a 30% reduction in sodium intake.14 An Australian study shows a 20% reduction in sodium intake.15 We take the more conservative Australian study as the base, along with the assumption that with one out of three daily meals eaten in public places, the overall impact on daily sodium intake would be one third of that observed in the school lunches Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach and counselling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years -1.05 mmol/L change in cholesterol16 5.9mmHg reduction in systolic blood pressure11 Intervention impact is mediated via the risk prediction equation17 Additional supportive evidence suggests a reduction in stroke incidence of 80% and IHD incidence of 88% predicted in use of fixed dose polypill18 Coverage and scale up patterns For the purposes of this analysis, ambitious implementation and coverage scale up patterns were modelled, in order to demonstrate the impact that an increased commitment to NCDs could yield. For all interventions, the quickest possible time in which interventions were believed to be reasonably implementable was applied. This was based on expert consultation with WHO technical teams as utilized in the original NCD Business Plan, where the coverage and scale up summary can be found20. Tobacco The intensity of the MPOWER interventions are graded from 1 to 4, with 1 being the lowest and 4 being the highest level of implementation. These grades correspond to the scores in the most recent WHO Report on the Global Tobacco Epidemic (GTCR)21, with the exception of R (expressed in total tax share), and W-graphic warnings/plain packaging (modified scale that includes plain/standardized packaging at level 5). The assumption is that scale-up happens ambitiously, and at the soonest possible time for all countries. However, care was taken to consider what was historically possible, meaning that these immediate scale-ups or jumps to the highest level of implementation have been observed before. The baseline figures for these interventions were sourced from GTCR 2021 (2020 data), while scale up was assumed to begin in 2022. 5 For P – Smoke-free policies & E – Tobacco Advertising, Promotion and Sponsorship bans: The consensus was that these are interventions with no specific pattern of scaling up (i.e. a country at level 1 or 2 can just as easily jump to level 4 as those countries in level 3). Also, there is no set time-frame by which these interventions occur. Since these are legislative processes in most countries, the team considered it best to allocate 1 full year for these processes (drafting the law, debates, approval, etc.), before its full implementation can begin. Hence for the ambitious scenario, we assume that 2022 is when the process of changing the policy will begin, with 2023 as the first full year of implementation for all countries at the highest level. For W – Mass Media: Since this is usually an executive function that mainly requires budgetary allocation to be implemented, the consensus of the team was that it could be scaled up immediately given that funds are available. Because of this, all countries scale up by 2022. For W – Graphic Warnings / Plain Packaging: Appendix 3 lists these interventions together, however plain packaging is not included in the GTCR score. To resolve this, it was decided that plain packaging be added as an additional level of implementation (level 5). This makes sense because all countries that have implemented plain packaging are already scored at the highest level in GTCR. In addition, the effect size for plain packaging, although separate, can be added into the projection in the OneHealth Tool. Regarding the scale up pattern for smoke-free policies and TAPS bans, this usually requires some form of legislative approval which means having at least one year allocated for that process. Looking at historical data, countries could also jump from having the lowest level of implementation to the highest level. However, the team’s expert opinion is that this particular intervention would need a longer time frame to be implemented, considering that the highest level of implementation (for this simulation) is plain packaging. Hence the earliest time for full implementation would be 2023 among countries that aren’t already at the highest level. For R – Taxation: The team considered the data from GTCR and observed that countries below the highest level of implementation (with less than 75% total tax share of retail price) increased their taxes from 2% to 2.5% per year on average. However, once a country has had a significant increase, it would take at least another 3 years before the next significant increase is implemented. This is the main rationale for the 3-year stepwise scale-up pattern, and the corresponding magnitude of 7.5% for each step (2.5% each year). The scenario is built so that all countries reach a 75% tax rate by 2028-2030. In order to reach this level and following the determined scale up pattern of 7.5% every three years, all countries needed to have a tax rate of at least 52.5% by the first step of scaling-up in 2021. This is the reason why countries that had lower tax shares (below 52.5%) have a slightly different pattern. In keeping with the aggressive scale-up, it was decided that the first jump would be to 52.5% for countries below that threshold. Though certainly very ambitious for some countries, the team considered this as a possible scenario given that historical GTCR data shows the maximum tax share jump to be an increase of 48 percentage points, which happened with a country that initially had a 2% tax share. This is also consistent with the observation that a jump of this magnitude is more feasible if coming from a very low starting point, compared to having the same jump from ~30% to 75%. After this first scale-up, it would then revert to the 7.5% increase every three years until it reaches 75% in 2028. 6 For countries already at the highest level of implementation (above 75%), it was observed that taxes still increased by approximately 1% per year. In keeping with the 3-year pattern, these countries would then increase their tax rates 3% at a time, until their rates have surpassed 80%, after which no additional increases are projected. Alcohol A baseline of coverage was constructed based on the NCD Progress Monitor22. The following exclusions and clarifications were made to the NCD Progress Monitor data: ‘Dry’ countries (i.e. those in which alcohol is prohibited) were included, and the policy recorded as in place. This applied to: Afghanistan, Somalia, Sudan and Yemen. As with the approach taken for the above tobacco control policies, expert input was sought on the quickest feasible scale-up for countries, based on historical precedent. For legislation-based alcohol reduction interventions, i.e. reducing the availability of alcoholic products through reduced hours of sale, and restricting advertising, the following approach was taken: Based on historical precedent, it was assumed that the fastest a country could implement a policy from not having a policy in place through development of the legislation to the point of implementation would be two years. The same approach has been used for legislation-based tobacco control interventions. This was then ‘scored’, by creating a dual scenario from the baseline data; i.e. an enforcement score of 1 was given for countries that did not have a policy in place, and an enforcement score of 2 was given for those that did. For those countries with an enforcement of 1, costing for the planning, development and then full implementation of the policy was applied, with full implementation costs being reached in 2022. For those countries with an enforcement score of 2, the costs of full implementation of the policy were applied from 2021. For taxation on alcoholic products, the following approach was taken: Baseline data was constructed from the OneHealth Tool, with taxation as a percentage of retail price recorded separately for beer, wine and spirits. A scale-up scenario was then applied, following the tobacco taxation model, in which the tax on all products increases every 3 years, reaching 50% (or above) in 2030. For those countries currently below a level 10% tax of retail price, the first increase was to 20%, and then 10% every three years thereafter, thereby reaching 50% by 2030. For those countries that that already have a taxation level above 50%, the same increase every 3 years was applied. These levels of taxation are in keeping with the very wide range of taxation levels for alcoholic beverages seen across the world. Unhealthy diets The first assumption made was that a minimum of 3 years is required in order to create the political economy within which sodium reduction policies can be implemented. The fastest scale up is likely to be in mass media campaigns incorporating behavior change communication techniques which aim to change population behavior around adding salt at the table. The other interventions, particularly 7 reformulation processes will require some time not only due to the political economy but also due to the time it will take companies to complete reformulation processes. Current country implementation was taken from the NCD progress monitor22. An assessment was then made by about the readiness of countries to implement new policies, and an implementation year ranging from immediate to 2023 was proposed. In 12 high income countries where packages of salt reduction policies have been implemented over a period, the average rate of change seen in salt intake is a decrease between 1 to 2% per year23. The maximum change seen is in Finland where a reduction in intake of 38% has been observed over a period of 28 years. From this, it can be derived that the combination of 4 salt reduction best buy policies can have an impact of approximately 40% reduction in salt intake. Considering the real world 28-year time frame to attain the full impact of these interventions, this modelling exercise with ambitious scale up patterns assumes that 40% of the full possible health benefit could be seen within the 10-year period by 2030. Physical inactivity All countries were assumed to need a lead time of 1 year to develop a mass media campaign, followed by an implementation year during which health benefits begin to be seen. Countries existing policies were taken from the NCD Progress Monitor22. Based on the previous assessment made by WHO technical teams about the readiness of countries to implement new policies, an implementation year ranging from immediate to 2022 was assumed. Clinical interventions For the clinical interventions – treatment of those at high risk of cardiovascular disease or post event with multidrug therapy and cervical cancer screening and treatment in the absence of country level data collection systems to monitor coverage, and based on expert knowledge, it was assumed that current coverage in low- and lower middle-income countries is no higher than 5%. In order to reach the SDG target of meeting 50% of current unmet need by 2030, we assumed a linear scale up from the current value to 50% coverage in 2030. The assumption that the health system will strengthen and increase capacity in the appropriate way to meet this target is implicit within the analysis, however as the health system must strengthen as a whole, this has not been costed. For understanding of resource needs for health system strengthening, readers should review the SDG health price tag analysis6. Estimating intervention costs The costing analysis uses an ingredients approach which multiplies needs-based quantities by country- specific unit costs for intervention delivery. For the policy interventions, the investment costs build from the NCD costing tool and approach and are grouped into two major categories: supporting and programme management costs and intervention costs. The prices used to develop unit costs come from the International Drug Price Indicator Guide, combined with the WHO-CHOICE price databases24,25. These prices have been adjusted to reflect 2021 costs, from whichever baseline year of the most recent 8 update of the databases. The quantity assumptions used reflect current guidelines for intervention delivery and not necessarily delivery practices in countries. For the clinical interventions, using the OneHealth Tool enabled an integrated approach to costs and benefits. Numbers of health services required are dynamically estimated over time, and are affected by population growth, mortality and disease incidence as interventions are scaled up. Estimates of the number of health services delivered by country and year enable calculation of the additional health systems capacity to deliver the interventions at scale. For the non-commodity intervention specific costs, the number of inpatient and outpatient visits is calculated in the OHT and then multiplied by the WHO-CHOICE unit prices for inpatient and outpatient visits26. Table 6 and 7 outline costing assumptions for policy/population wide interventions and individual pharmaceutical interventions, respectively. Table 3. Costing inputs for policy / population-based Interventions Intervention Major costing assumptions Increase excise taxes and prices on tobacco products Taxation is considered a legislative intervention. Assumptions on human resource requirements are previously published27 Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship This is considered a legislative intervention. Assumptions on human resource requirements are previously published27 Implement plain/standardized packaging and/or large graphic health warnings on all tobacco packages This is considered a legislative intervention. Assumptions on human resource requirements are previously published27 It is assumed that plain packaging would require additional legislation to large graphic health warnings. Eliminate exposure to second- hand tobacco smoke in all indoor workplaces, public places, public transport This is considered a legislative intervention. Assumptions on human resource requirements are previously published27 Implement effective mass media campaigns that educate the public about the harms of smoking/tobacco use and second-hand smoke Generic advocacy/awareness campaigns are included as part of all health care interventions, with assumptions relying on information from the marketing literature. We estimated that 10 times the intensity would be required to enact behavior change in line with previous costing estimates27 Reduce salt intake by engaging the industry in a voluntary reformulation process Voluntary intervention assumptions are published in previous work on the costs of scaling up NCD action27 Reduce salt intake through implementation of front-of-pack labelling Legislative intervention assumptions are published in previous work on the costs of scaling up NCD action27 Reduce salt intake through a behavior change communication mass media campaign Behavior Change Communication is considered as an intensive mass media campaign. Costs have been developed based on literature reviews across public health and marketing to ensure adequate viewership is reached 9 Reduce salt intake through establishment of a supportive environment in public institutions such as hospitals, schools and nursing homes to enable low sodium meals to be provided Legislative intervention assumptions are published in previous work on the costs of scaling up NCD action27 Increase in excise taxes on alcoholic beverages Key categories of resource include human resources (e.g. administrators, lawyers), training (e.g. enforcement), meetings, mass media. Assumptions follow previous work on the costs of scaling up NCD action27 Enforcement of bans or comprehensive restrictions on exposure to alcohol advertising, promotion and sponsorship (across multiple types of media) Key categories of resource include human resources (e.g. administrators, lawyers), training, meetings, mass media. Assumptions follow previous work on the costs of scaling up NCD action27 Enforcement of restrictions on the physical availability of retailed alcohol (via reduced density of retail outlets and reduced hours of sale Key categories of resource include human resources (e.g. administrators, lawyers), training, meetings, mass media. Assumptions follow previous work on the costs of scaling up NCD action27 Implement community wide public education and awareness campaign for physical activity which includes a mass media campaign combined with other community-based education, motivational and environmental programs aimed at supporting behavioural change of physical activity levels. Behaviour Change communication is considered as an intensive mass media campaign. Costs have been developed based on literature reviews across public health and marketing to ensure adequate viewership is reached. The price was benchmarked against a successful BCC campaign for physical activity in Australia28 Table 4. Costing assumptions for pharmaceutical interventions Percent receiving Number of units per day Days per case Unit cost (USD, 2018) Cost per case (USD, 2018) Combination drug therapy for those post event or at 20% or greater risk. Drugs and supplies required per patient Hydrochlorothiazide, tablet, 25 mg 95 1 365 0.0043 1.49 Enalapril, tablet, 20 mg 40 1 365 0.01 1.46 Atenolol, tablets, 50 mg 25 1.5 365 0.01 1.37 Amlodipine, tablet, 10 mg 40 0.5 365 0.08 5.84 Simvastatin, 15 mg 100 1 365 0.04 14.60 Laboratory tests per patient Blood glucose level test 30 1 1 2 0.60 Cholesterol test 30 1 1 2 0.60 10 Urine analysis 30 1 1 1.83 0.55 Urine sugar analysis 100 1 1 0.67 0.67 Facility visits per patient Outpatient 3 per year 7 per year 97% of patients 3% of patients The model calculates total costs for intervention implementation for each country. The sum of country level costs was then divided by the sum of the population from the countries in each income level to provide an average per capita cost for each income level. Costs are stratified by low income, lower- middle income and total costs. Health benefits from scaling up interventions The impact modules developed for cardiovascular disease, diabetes, asthma, COPD and cancers follow the structural format of the population models previously used in WHO’s cost-effectiveness programme, WHO CHOICE29,30. These are multi-state dynamic population life tables, taking account of competing risks amongst diseases, causes of death and interventions. The impact modules are populated at the regional level using the 21 Global Burden of Disease (GBD) regions, further analyzed to develop complete epidemiological models. Data to populate the modules is derived from the 2010 GBD study along with the WHO Global Health Estimates database and supplemented by literature reviews where data were missing. Risk factor modules impact the incidence of associated diseases using relative risks from the Global Burden of Disease Comparative Risk Assessment analysis31. Country-specific current risk factor prevalence was drawn from WHO Global Health Database, except for salt intake which was taken from the Global Burden of Disease estimates.32 A full list of epidemiological parameters used to populate the modules is available online at http://www.avenirhealth.org/software-onehealth.php, and is summarized in table 5. Table 5. Parameters of the OneHealth Tool Data input Measured as Source Tobacco smoking Yes/No WHO GHDx (Country specific data for ages 20+ M/F)33 Alcohol intake Hazardous and harmful use WHO GHDx (Country specific data for ages 20+ M/F) 33 Physical activity Insufficient vs sufficient WHO GHDx (Country specific data for ages 20+ M/F) 33 Salt intake Grams per day Global Burden of Disease estimates 32 BMI BMI (kg/m2) WHO GHDx (Country specific data for ages 20+ M/F) 33 Systolic Blood Pressure mmHg (population mean and SD) WHO GHDx (Country specific data for ages 25+ M/F) 33 Cholesterol mmol/L (population mean and SD) WHO GHDx (Country specific data for ages 25+ M/F) 33 11 Stroke epidemiology Prevalence IHME GBD data34 Mortality RR mortality post stroke, adjusted by regional variations in stroke deaths35,36 Incidence DisMod 2 calculation using prevalence and mortality inputs37 IHD epidemiology Prevalence IHME GBD data34 Mortality RR mortality post IHD, adjusted by regional variations in IHD deaths 38,39 Incidence DisMod 2 calculation using prevalence and mortality inputs37 Diabetes epidemiology Prevalence IHME GBD data34 Mortality Incidence DisMod 2 calculation using prevalence and mortality inputs37 Asthma epidemiology Prevalence IHME GBD data34 Mortality Incidence DisMod 2 calculation using prevalence and mortality inputs37 COPD epidemiology Prevalence IHME GBD data34 Mortality Incidence DisMod 2 calculation using prevalence and mortality inputs37 Cervical Cancer epidemiology Prevalence Globocan database40 Mortality Incidence DisMod 2 calculation using prevalence and mortality inputs37 The impact modules are used to project two scenarios, one in which current intervention coverage is continued, and an alternative in which the intervention is scaled up at the rate as previously described, and with the health impact previously described. The difference between incidence and mortality rates, and healthy life years lived; between the two populations is the impact of the intervention. Estimating the economic and social returns on investment Avoided deaths The economic modelling of mortality follows the cohort of avoided deaths for each of the years 2021 to 2030. Each cohort is classified by age and sex. The effect of avoided mortality on the labor force is calculated by taking the numbers of deaths avoided by age and sex and applying a corresponding labor 12 force participation rate for this age, sex and year sourced from country specific International Labor Organization projections of labor force participation rates41. The contribution that each of these labor force cohorts makes to economic output is calculated by multiplying the number in each age and sex category who participate in the workforce by a value of the GDP contribution per worker. To do this the average productivity is first calculated for 2021 by dividing the World Bank estimate of GDP in current US dollars by the labor force in that year. The total GDP generated is calculated by summing the GDP produced by each cohort for each year of the period in which they are in the labor force. Averted incident cases The contribution to GDP of each cohort of healthy persons is calculated in a similar way as for mortality using the same assumptions about participation rates and productivity in the cohort of avoided incident cases of CVD. Firstly, 11% of people who have a heart attack or stroke will leave the work force entirely. Those who avoid having an event will continue to participate in the workforce, contributing the GDP per worker value each year. It is assumed that there is reduction in productivity of 0.5% due to absenteeism42 (those who miss work days) and 3.7% due to presenteeism43 (those who attend work but are less productive than expected) for those with CVD who continue to work. These values are similar to those reported by Alsono et al44 and Bruffaerts et al45 based on analysis of the World Mental Health Surveys. Again, the differential contribution to GDP from each cohort is summed to give a total contribution to GDP for each year. Social benefits of increased years of healthy life It is common when estimating the benefits of improved health to put a value on being alive. The common term employed for this kind of statistic is the value of statistical life (VSL), but a more accurate term would be the value of (a small) risk reduction (VRR). Building on the results of Viscusi et al46, Jamison et al47, estimated the value of a life year as between 1.4 and 4.2 times GDP per capita, averaging 1.6 globally. Stenberg et al4 modified this approach by assuming that the value of a life year was 1.5 times GDP per capita and that the economic benefit was equal to GDP per capita, leaving a residual value of 0.5 times GDP per capita as the social benefit. Following this approach, we apply a value of 0.5 times GDP per capita to each healthy life year gained from the interventions to estimate the intrinsic value of longevity. An exception to this within our methodology is for cervical cancer where we were not able to capture incident cases avoided, and instead used a VSL of 1.5 times GDP per capita for each life year saved due to premature mortality avoided. Calculating the return on investment While the returns to an investment in health can be expressed using different but related metrics such as the internal rate of return, this paper uses benefit-cost ratios (BCR) to compare net present values of benefits and costs. These ratios were calculated by dividing the net present value (NPV) of the economic and social benefits from mortality and morbidity avoided by the net present value of the costs of the intervention. NPVs were calculated at a discount rate of 3% as is usual for analysis of health programs. 13 Limitations of analytical framework This modelling exercise should necessarily be considered normative and indicative at the global level. In order to fully grasp the costs and health benefits of scaling up action in countries, a country contextualization process should be undertaken. The model used to underlie this analysis, the OneHealth Tool, is available free to download and use for countries to undertake this process. A contextualization process involves reviewing the epidemiology taken from global databases (WHO, GBD) and comparing to local sources, identifying how interventions are delivered in countries and if these match the quantity assumptions used in this model, identifying how much is paid for different inputs into the interventions in the local setting – this may differ from global modelled databases – and using the countries’ realistic implementation plans. There are two main limitations which impact ROI values calculated within this analysis. Firstly, we are limited in the number of diseases for which we can prospectively model health impacts. This affects in particular tobacco, where cancers have not been modelled, however given the lag time between smoking cessation and reduction in cancer incidence this is unlikely to influence the ROI greatly over the 12-year period. This brings us to the second limitation which is the time frame through to 2030, the SDG target year. For many of the preventive interventions the full health benefit will not yet be realized. An excellent example of this is physical activity mass media campaigns. If extending the analysis through even 10 additional years, the health benefits increase by 2.5 times, which strongly influences the ROI. Further limitations related to the ROI calculation are associated with the use of the labor force participation rates from the ILO, which capture only the formal workforce. At the country level more may be known about the informal labor market in order to incorporate this into the analysis. Secondly, relying on GDP per capita and GDP per worker estimates necessarily produces lower economic benefits in countries of lower income. This leads to a correlation between income level and ROI in this type of analysis. This should not be interpreted as indicating that only higher income counties should invest in NCDs. As countries’ GDP increases over the coming years, higher productivity values will be seen in those countries currently classified as low-income countries. Finally, the use of non-country-specific values for absenteeism and presenteeism has an unknown impact; however, the values used are quite low and we would thus anticipate represent a conservative approach. 14 References 1. Saving lives, spending less: a strategic response to noncommunicable diseases. Geneva, Switzerland. World Health Organization; 2018 (WHO/NMH/NVI/18.8). Licence: CC BY-NC-SA 3.0 IGO. 2. World Health Organization. ‘Best Buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Updated (2017) Appendix 3 of the Global Action Plan for the prevention and control of noncommunicable diseases 2013-2020; 2017. 3. Bertram MY, Sweeny K, Lauer JA, Chisholm D, Sheehan P, Rasmussen B, Upreti SR, Dixit LP, George K, Deane S. 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