The Epidemiology of Non-Communicable Diseases

1
South Asian Cardiovascular Research Methodology
Workshop
Economics and Health
Thomas Songer, PhD
2
Economics and Health
3
Human Development
Income/Economic
Population
Health Nutrition
Education
Political
4
Transitions in Human Development

Epidemiologic
Disease - Infectious to Chronic

Demographic
Younger to Older populations Rural to Urban

Economic
Developing to Developed Economies

5
Transitions in Human Development

Health Care Systems
Centralized to Decentralized, Cost
Containment

Political
Controlled to Free Market Economies


6
Trends in Death in Developing Areas
NCDs
Comm. Dis.
Injuries
40
30
Deaths (millions)
20
10
0
1990
2000
2010
2020
Global Burden of Disease
7
DALYs in Developing Areas
1990 2020
Infectious Disease NCDs Injury
8
Economic Transition
9
Economic Growth

• Many Differing ways of defining growth
• Goods and services produced
• GNP - money value of all goods and services
  produced
• GNP per capita reflects the average income of a
  countrys citizens
• GNP per capita outlines general standard of
  living

10
Gross National Product, per capita
Average Annual
1991
Growth Rate,

1980-91()
Sub-Saharan Africa
350
- 1.2
East Asia Pacific
650
6.1
South Asia
320
3.1
Europe C.Asia
2,670
0.9
Mideast/N.Africa
1,940
- 2.4
Latin America
2,390
- 0.3
OECD members
21,530
2.3
World
4,010
1.2
11
GNP per capita
Monetary value of goods and services
population
12
GNP per capitaImpact of Population Changes

• An increasing population makes it more difficult
  to increase GNP per capita
• With a stable population, increases in GNP will
  increase GNP per capita

13
How does the development level of an economy
relate to health?
14
Economics and Health
15
Higher GNP per capita is associated with .

• Longer life expectancy
• lower infant mortality
• better access to safe water
• better education

16
Income and Health Spending
World Bank Development Report
12
10
8
6
Share of GDP spent on health
4
2
0
5000
10000
15000
20000
25000
GDP per capita (1991 dollars)
17

Economics and Health
malnutrition
poor sanitation
Poverty
poor education
poor housing - crowding
no quality health care
18
Low economic growth
High fertility
Poverty
Poor health
19

• UNDP Poverty Report 2000
• OVERCOMING HUMAN
• POVERTY

20
Increased productivity
Low fertility
Rising incomes
Better health
21
Economic growthEconomic development
22
Economic growthincrease in the amount of goods
and services producedEconomic
developmentcombines economic growth with an
improvement in living standards
23
Economic growth does not always translate to
economic development
24

• In the 1950s and 1960s, a large number of 3rd
  world countries achieved UN growth targets, yet
  the levels of living for most remained unchanged

GNP per capita is a narrow definition of growth
and development
Todaro 1997
25
Health used to be viewed as an end product of the
growth process

• New thinking is that health enhances economic
  growth

26
Economics and Health
27
Economics and Health
28
WHO Commission on Macroeconomics and Health

• Ill-health undermines economic development and
  efforts to reduce poverty. Investments in
  peoples health are vital pre-conditions for
  economic growth and human development.

www.who.int/macrohealth/en
29
The human being is an investment of
capitalHealthy people are productive people
Chadwick
30
Chadwick

The human being is
an investment of capital

Healthy people are productive people
Better sanitation is a good investment
Prevention of disease is a good investment
31
The Commission on Macroeconomics and Health
established in January 2000 Mandate To
examine the links between investment in health,
economic development and poverty reduction CMH
Structure 6 working groups, 18 Commissioners,
hundreds of experts in public health, finance and
economics.
32
Summary of key CMH findings Ill health
undermines economic development and efforts for
poverty reduction A few health conditions
account for most of the avoidable deaths in low /
middle-income countries HIV/AIDS, TB, malaria,
maternal child health, and tobacco-related
illness The HIV/AIDS pandemic is a distinct
and unparalleled catastrophe not only in its
human dimension but in its implications for
economic development
33
HIV/AIDS and Economic Development

• High HIV/AIDS prevalence leads to
• decline in labor force participation
• decline in productivity
• decline in human capital

34
HIV/AIDs in Russia, 2001
World Bank 2002
35
HIV/AIDs in Russia
by 2020

• 5.4 to 14.5 million cases
• -2 to -14 change in effective labor supply
• -5 to -25 decline in GDP

36
Health Economics
37
Why is there an interest in health economics?




Economics and health are related
Rising costs of health care
Limited resources for health care
Variations in health outcomes exist
Economic data influence government
decisions regarding health care
38
Economic Approaches in Health Care

Descriptive
Cost studies
Evaluative
Cost-Benefit Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Explanatory
Demand/Supply issues
Regulation/Taxation
39
Cost Effectiveness Analysis

• Primary form of economic analysis of health care
  interventions
• Very often included in clinical trials that are
  testing new interventions
• A method for evaluating the outcomes and costs of
  interventions designed to improve health.

40
The purpose of economic evaluation, such as
cost effectiveness analysis, is to identify,
measure, value, and compare the costs and
consequences of alternative interventions.
41
Cost Effectiveness CalculationComparison of
interventions examines differences in cost by the
differences in benefits gained
Cost with intervention A - Cost with
intervention B Benefit with A - Benefit with
B
in other words
? Cost ? Benefit
42
Cost Effectiveness Calculation
Intervention
A
B
Costs
4,000
5,000
Effectiveness
3 months
8 months
.
Incremental CE (5,000 4,000)/8-3
200/month
43
Cost-effectiveness analysis Important Steps

1. Define the question to be analyzed
2. Define the audience for the evaluation
3. Specify the perspective of the analysis
4. Define the relevant time frame for the analysis
5. Identify relevant outcomes
6. Identify relevant costs
7. Determine the summary measure to be reported

44
Defining interventions or the question to be
assessed

• Major increase or decrease in an existing
  activity
• Or
• Adding a new activity to replace an existing one
  or adding a new activity when there is no current
  activity

Mulligan/Mills
45
Selected interventions in malaria control
Drug use Early diagnosis and effective treatment Intermittent therapy during pregnancy Chemoprophylaxis for target groups
Personal Community Protection Insecticide treated materials Home repellants and insecticide use
Vector control Indoor residual spraying Larviciding, fogging Civil engineering drainage and filling
Social Action/ Management effectiveness Mobilization of individual, family and communities Health Education Surveillance of infection and disease Monitoring and evaluation of programs
Mulligan/Mills
46
Defining the Audience and Perspective of the study

• Health care payers
• Health care providers
• Patients
• Government health plans
• Society
• among others

47
Identify Time frame

• Short-term
• Within the time period of the trial
• Long-term
• e.g 5 years
• e.g. 10 years
• Lifetime
• Many interventions in chronic disease show
  benefits years later

48
Summary Outcome Measures

• Quality-adjusted Life Years
• Survival weighted by patients value of
  health-related quality of life
• Patients value health states on a 0 (death) to 1
  (optimal health) scale
• Recommended as a gold standard
• Other Clinical Outcomes pain, test results
• Non-Clinical Outcomes health status, patient
  satisfaction

49
Examples of outcome measures

• Logan et al. (1981) Hypertension
  mmHg
• Hypertension 32211-18 treatment blood
  pressure reduction
• Hull et al. (1981) Diagnosis of deep cases of
  DTV
• NEJM 3041561-67 vein
  thrombosis detected
• Sculpher and Buxton (1993) Asthma
  episode-free
• PharmacoEconomics 45345-52 days
• Mark et al. (1995) Thrombolysis years
  of life
• NEJM 332211418-24 gained

50
Cost-Effectiveness Analysis in the TODAY
(Treatment Options for Diabetes in Adolescents
and Youth) Study

• Results expressed as
• Cost per change in HbA1c
• Cost per unit of treatment failure
• e.g. cost per day of treatment failure avoided
• Cost per unit of clinical improvement
• e.g. change in weight, BMI, obesity
• Cost per quality-adjusted life year (QALY)