Prevention of Non-Communicable Disease: Best Buys, Wasted Buys, and Contestable Buys
- WHO’s list of best buy interventions aims to assist the global community’s fight on non-communicable diseases.
- Best buys evaluated in one setting may not be cost effective in other settings.
- Evaluation of context is essential to ensure resources are best deployed towards universal health coverage.
- National or international hubs could help with this evaluation and build evidence to get cross sectoral support towards preventing non-communicable disease.
In this article, Wanrudee Isaranuwatchai and colleagues highlight the importance of local context in making decisions about implementing interventions for preventing non-communicable diseases.
NCD policies have substantial implications for population health and national budgets. Countries therefore need to assess both the health and the financial aspects of these policies before implementation, especially in the context of the aim to achieve universal health coverage. Analysts consider how to distinguish local best buys, wasted buys, and contestable buys among evidence based NCD interventions to improve setting of health priorities and offer suggestions for better decision making processes.
Universal health coverage and prioritisation
The World Health Organization recommends their “best buys” for controlling NCDs. These were selected from following criteria: a demonstrated and quantified effect, cost effectiveness (≤$100 (£80; €90) per disability adjusted life year (DALY) averted in low and middle income countries), and implementability. However, there is an underuse of best buys specially in low and middle income countries.
One reason for this may be because most evidence for best buys do not come from low or middle income countries. Therefore,
- it is not certain whether these global priorities are helpful in these countries;
- there are concerns on transferability of study findings from mostly high income countries to other countries with different characteristics (disease profiles, population characteristics, economic structures, health systems platforms);
- there is also no guideline on how to implement international research findings in these various settings, with varying implementation capacities.
WHO and the Organisation for Economic Cooperation and Development have estimated that a fifth of total health spending in countries is wasted. The waste is far more serious in low and middle income countries, where the overall disease burden is much higher but relatively small expenditures can have enormous impact if spent wisely. To improve priority setting at local level this article distinguish best buys, wasted buys, and contestable buys recognising the importance of context.
How context affects best buys
The analysis present the below figure to follow in finding what are best buys, contestable buys and wasted buys.
In the figure, cost effectiveness plane to show best buys and wasted buys. The broken line denotes the maximum amount the decision maker is willing to spend for additional health benefit. Interventions in quadrant A are clearly not cost effective compared with the current scenario and those in quadrant D are best buys. Decisions about interventions falling in quadrants B and C are less clear cut and will depend on the threshold set. The area of uncertainty indicates ranges of relatively small cost and benefit differentials where uncertainty may be particularly troublesome.
The principal criterion for both best buys and wasted buys is cost effectiveness. Although the methodological principles for cost effectiveness analysis are intended to be universal, their quantitative application often depends on local circumstances (context specificity).
The threshold to separate the cost effective from the cost ineffective will vary according to economic factors such as the budget for public expenditure. For example, evidence on diabetic screening in Indonesia and Thailand shows that screening is a best buy only for high risk groups aged ≥40 rather than from age 15, which had been the standard practice. Screening people aged 15-39 age was a wasted buy, and the savings from focusing on the high risk groups released resources for other priorities.
Local context can also influence cost effectiveness. For example despite increasing tobacco tax (a WHO best buy) in India, tobacco consumption was not reduced substantially as most Indians smoked a local untaxed tobacco.
Analysis of case studies of implementing NCD preventive policies in low and middle income countries highlights important contextual economic and other considerations, including relevance to the community of interest; ethical acceptability; possibility of cross-sectoral collaboration; degree of community and stakeholder engagement; affordability, feasibility, and sustainability; and leadership, governance, compliance, and monitoring.
Beyond cost effectiveness
What is a best or wasted buy does not solely rely on cost or effectiveness but also on other ethical, cultural, political, and practical factors, some of which are modifiable. Several factors which may need consideration include,
- religious taboos or conventions;
- concerns for greater health equality and reduced exposure to financial risk;
- varied capacities of countries to use and implement research on cost effectiveness, which can result in mistaken judgments about effectiveness and cost, and
- interventions that affect NCDs often lie outside the health sector, including in education, transportation, or lifestyle.
NCD programmes need to balance national spending priorities fairly and efficiently against one another, safeguarding rights to health while having due regard for rights to education, security, decent housing, and so on. For instance, seeking only to maximise health benefits can conflict with equity. Achieving equity tends to become costlier as policy reaches out to less accessible, marginalised groups. Exclusion of hard-to-reach populations raises important ethical questions regarding a just distribution of access to healthcare and of health itself.
Interventions that are not cost effective in one context might still be best buys in another, local studies are needed to ascertain in this case. Interventions that are in principle not cost effective might be best buys if they have other attractive attributes. For example, in settings with a commercial alcohol market rather than a tradition of home brewing, implementing a minimum unit price for alcohol could have more effect on health inequalities than simply raising alcohol taxes. A cost ineffective intervention may also be a best buy if it delivers sufficiently strong equity outcomes. Thailand implemented a policy of peritoneal dialysis first for patients with renal failure to ensure that people living in both urban and rural areas throughout the country could access the expensive, lifesaving treatment equally.
Practical ways forward
NCD programme managers face challenges on several fronts, including information and political support. Programme managers have to find ways of identifying relevant information. An expert hub, national or regional, could be used to gather, filter, and review relevant information as well as to support evidence assessment and appraisal processes.
Health technology assessment (HTA) is not just a collection of technical methods, such as cost-effectiveness analysis, but also a way of thinking. Systematic thinking for evidence based and efficient decision making (SEED) is one tool for determining whether an intervention is likely to be worthwhile in a local context.
The tool has two sections: the inner circle aims to assist NCD programme managers in thinking critically about the intervention and the outer boxes provide recommendations for strengthening the evidence base. *Implementation=dosage, frequency. duration, coverage, etc, †Compared with the cost of implementing a similar programme in other settings or the costs in the economic evaluation studies used to decide to implement the intervention.
Deciding whether any prospective intervention for NCDs is likely to be a best buy is tricky. Decision making needs to be credible to ensure policy acceptance and effective implementation. The public will also want to be satisfied that those involved in the process were competent, that they sought to promote the public interest, and that those who were there to represent the public were appointed in a fair way and could be held to account.
Interventions tackling social determinants often require collaborations with other sectors, including government departments such as education, housing, and policing and the corporate sector. High level commitment and support at national and international levels is needed to scale up and accelerate the implementation of cross sectoral policies and interdepartmental collaboration for prevention and control of NCDs.
Interventions to prevent NCDs are often complex, constantly changing, and unique to each jurisdiction. There is no single solution for all policy makers, but there are positive steps that can be taken to further their efforts. Whether an intervention for NCD prevention will be best, wasted, or contestable depends on the context. To understand the context is every bit as important as to understand the technologies of evaluation.