Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions

Neil Gupta; Ana Mocumbi; Said H. Arwal; Yogesh Jain; Abraham M. Haileamlak; Solomon T. Memirie; Nancy C. Larco; Gene F. Kwan; Mary Amuyunzu-Nyamongo; Gladwell Gathecha; Fred Amegashie; Vincent Rakotoarison; Jones Masiye; Emily Wroe; Bhagawan Koirala; Biraj Karmacharya; Jeanine Condo; Jean Pierre Nyemazi; Santigie Sesay; Sarah Maogenzi; Mary Mayige; Gerald Mutungi; Isaac Ssinabulya; Ann R. Akiteng; Justice Mudavanhu; Sharon Kapambwe; David Watkins; Ole Norheim; Julie Makani; Gene Bukhman; NCDI Poverty National Commissions Authorship Group; NCDI Poverty Network Secretariat

doi:10.9745/GHSP-D-21-00035

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FIGURE 1
National Noncommunicable Diseases and Injuries Poverty Commission Analytic Framework
Abbreviations: DAH; developmental assistance for health; GDP, gross domestic product; NCDI, noncommunicable diseases and injuries; UHC, universal health coverage.
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FIGURE 2
Frequency of National Noncommunicable Diseases and Injuries Poverty Commissions Reporting Key Outcomes in Evaluation Surveys and Qualitative Interviews, by Thematic Area (n=9)
Abbreviation: NCDI, noncommunicable diseases and injuries.

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TABLE 1.

Key Characteristics of States and Countries With Established National Noncommunicable Diseases and Injuries Poverty Commissions

	Demographics			Finances²⁰			Human Resources²¹		Commission Characteristics
Country	Population (millions)¹	Percent Living in Poorest Billion¹⁶^,c	Population Living in Poorest Billion (millions)¹^,⁵^,¹⁶	Gross Domestic Product per Capita (US$), 2017	Current Health Expenditure per Capita (US$), 2017	General Government Health Expenditure per Capita (US$), 2017	Physicians per 10,000 Population (year)	Nurses/Midwives per 10,000 Population (year)	Month and Year of Commission Establishment^a	Number of Commissioners	Priority Setting Conducted as of July 2020
Afghanistan	32.9	25.1	8.3	569.9	67.1	3.4	2.8 (2016)	1.8 (2017)	April 2018	22	No
Chhattisgarh State,^b India	27.7	15.8	4.4						March 2019	20	No
Ethiopia	102.9	81.5	83.8	721.2	25.3	6.3	0.8 (2018)	7.1 (2018)	Aug 2016	18	Yes
Haiti	11.8	39.0	4.6	776.0	62.4	7.4	2.3 (2018)	6.8 (2018)	Dec 2016	28	Yes
Kenya	48.3	38.9	18.8	1595.2	76.6	32.7	1.6 (2018)	11.7 (2018)	Nov 2016	25	Yes
Liberia	4.7	48.3	2.3	694.0	56.6	9.7	0.4 (2015)	5.3 (2018)	Jan 2017	23	Yes
Madagascar	26.1	65.2	17.0	448.4	24.7	11.6	1.8 (2014)	1.5 (2018)	July 2019		No
Malawi	17.2	48.5	8.3	334.4	32.3	9.9	0.4 (2018)	4.4 (2018)	Nov 2016	23	Yes
Mozambique	30.0	65.1	19.6	426.4	21.1	6.3	0.8 (2018)	6.8 (2018)	June 2017	14	Yes
Nepal	29.9	12.6	3.8	862.8	47.9	10.7	7.5 (2018)	31.1 (2018)	Nov 2016	20	Yes
Rwanda	12.6	49.2	6.2	748.7	49.2	16.9	1.3 (2018)	12.0 (2018)	March 2017	17	No
Sierra Leone	7.8	62.2	4.9	494.8	66.4	9.1	0.3 (2011)	2.2 (2016)	Aug 2018	38	Yes
Tanzania	54.0	56.2	30.4	930.4	33.9	14.7	0.1 (2016)	5.8 (2017)	Sept 2016	7	Yes
Uganda	39.1	58.4	22.8	621.0	38.9	6.0	1.7 (2017)	12.4 (2018)	Jan 2019	26	Yes
Zambia	17.4	46.7	8.1	1513.3	67.6	26.1	11.9 (2018)	13.4 (2018)	Aug 2018	22	Yes
Zimbabwe	14.7	28.6	4.2	1659.9	110.1	56.9	2.1 (2014)	19.3 (2018)	Aug 2018	25	Yes
Total or Averages^c	477.0	51.9	247.4	826.4	52.0	15.2	2.4	9.4		328

↵^a Date of endorsement by formal communication from Ministry of Health or first official commission meeting, whichever came first.
↵^b State-level indicators not available from sources listed.
↵^c Average of “percent living in poorest billion” is weighted average. All other averages are unweighted averages.

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TABLE 2.

Baseline National NCDI Poverty Commission Findings on the Proportion, Severity, Diversity, and Expenditure on NCDIs^a

	Estimated Burden of NCDIs¹			General Government Health Expenditure on NCDIs (2017)²⁰		External Health Expenditure on NCDIs (2017)²⁰
	% DALYs from NCDIs	% NCDI DALYs Occurring Before Age 40 years	% NCD DALYs not due to 5x5 Conditions^b	% General Government Health Expenditure on NCDs	% General Government Health Expenditure on injuries	% External Health Expenditure on NCDs	% External Health Expenditure on injuries
Afghanistan	55.2	61.8	46.3	38.4	2.5	8.8	4.8
Chhattisgarh State, India^c	62.3	37.4	41.9
Ethiopia	40.2	59.7	53.4	19.5	5.3	0.7	0.1
Haiti	63.3	51.8	41.5	20.6	7.7	4.8	5.7
Kenya	43.4	53.1	52.3	4.3	3.2	0.9	0.6
Liberia	37.6	56.4	54.1	17.8	1.3	8.6	0.6
Madagascar	38.9	55.1	45.0
Malawi	36.2	58.0	51.4	11.4	8.9	7.2	5.6
Mozambique	33.5	59.1	50.2
Nepal	68.6	36.4	41.5	50.5	1.1	13.5	1.4
Rwanda	49.5	57.1	53.2
Sierra Leone	33.9	60.2	54.2
Tanzania	43.4	61.9	56.8	12.9	2.1	2.2	0.5
Uganda	36.9	62.9	51.7	26.0	4.0	1.8	0.3
Zambia	37.5	60.6	53.6	12.9	8.6	12.9
Zimbabwe	42.5	50.5	40.1
Average (unweighted)	45.2	55.1	49.2

Abbreviations: DALY, disability adjusted life year; NCDI, noncommunicable disease and injury.
↵^a Gray boxes indicate national health account data is unavailable or not disaggregated for NCDIs.
↵^b ‘5x5 conditions refers to Global Burden of Disease categories of cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, and mental health disorders.
↵^c State-level indicators not available from sources listed.

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TABLE 3.

Results of National NCDI Poverty Commissions Prioritization of NCDI Conditions and NCDI Health-Sector Interventions

	Number Of Prioritized Conditions	Number Of Recommended Interventions	Incremental Intervention Coverage Increase, %	Annual Incremental Expenditure to Provide Target Coverage for Recommended Interventions (mil US$)	Annual Incremental Cost per Capita to Provide Target Coverage Of Recommended Interventions (US$)	Percentage of Current Total Health Expenditure per Capita, %	Percentage of Current Gross Domestic Product per Capita, %
Ethiopia^a	N/A	90	30	550	4.70	16.8	0.6
Haiti	36	36	25	69.1	6.44	9.7	0.8
Kenya	14	34	20-70	520.1	11.97	17.1	0.7
Liberia	19	33	30	29.5	9.21	13.8	2.1
Malawi	38	54	0-50	236.7	13.70	34.2	4.0
Nepal	25	23	30	250.2	8.76	22.0	1.4
Tanzania	48	53	30	702.9	12.26	35.6	1.3

Abbreviation: N/A, not applicable; NCDI, noncommunicable disease and injury.
↵^a In Ethiopia, the commission considered an expanded set of 235 interventions consisting of DCP3-recommended interventions as well as locally customized interventions.

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TABLE 4.

Most Commonly Selected Conditions and Corresponding Prioritized Health Sector Interventions by 6 Commissions Conducting Prioritization Exercises by Both Disease Conditions and Health Sector Interventions (Displaying Conditions and Interventions Selected by >/= 4 Commissions)

Disease Condition Category	Selected Condition (No. of Commissions)	Corresponding Health Sector Intervention (No. of Commissions)
Cardiovascular	Hypertensive heart disease (6) ischemic heart disease (6) ischemic stroke (6) intracerebral hemorrhage (6) subarachnoid hemorrhage (6)	Long term management of ischemic heart disease, stroke, and peripheral vascular disease with aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and statins (as indicated), for secondary prevention (6) Mass media messages concerning healthy eating or physical activity (6) Use of aspirin in case of suspected myocardial infarction (6) Medical management of acute heart failure (6) Medical management of chronic heart failure with diuretics, beta-blockers, ace-inhibitors, and mineralocorticoid antagonists (6) Opportunistic screening for hypertension for all adults, with treatment decisions guided by absolute cardiovascular disease risk (4) Screening and management of hypertensive disorders in pregnancy (4)
	Rheumatic heart disease (6)	Secondary prophylaxis with penicillin for rheumatic fever or established rheumatic heart disease (6) Treatment of acute pharyngitis in children to prevent rheumatic fever (6) Heart failure interventions as above cardiovascular disease
	Congenital heart anomalies (4)	No specific interventions
Diabetes	Diabetes (type 1 and 2) (6)	Prevention of long-term complications of diabetes through blood pressure, lipid, and glucose management as well as consistent foot care (6) Screening for diabetes in pregnant women (6)
Respiratory	Asthma (6) Chronic obstructive pulmonary disease (5)	Mass media messages concerning use of tobacco and alcohol (6) Low-dose inhaled corticosteroids and bronchodilators for asthma and for selected patients with chronic obstructive pulmonary disease (5) Management of acute exacerbations of asthma and chronic obstructive pulmonary disease using systemic steroids, inhaled beta-agonists, and, if indicated, oral antibiotics and oxygen therapy (5) Tobacco cessation counseling and use of nicotine replacement therapy in certain circumstances (4)
	Breast cancer (6)	Treat early stage breast cancer with appropriate multimodal approaches, including generic chemotherapy, with curative intent, for cases that are referred from health centers and first-level hospitals following detection using clinical examination (6) Palliative care and pain control services^a (5)
	Cervical cancer (6)	Treatment of early-stage cervical cancer (6) Opportunistic screening for cervical cancer using visual inspection or human papillomavirus DNA testing and treatment of precancerous lesions with cryotherapy (5) School-based human papillomavirus vaccination for girls (5)
	Non-Hodgkin lymphoma (5)	Treat selected early-stage childhood cancers with curative intent in pediatric cancer units/hospitals (6)
Sickle cell disease	Sickle cell disease (6)	In settings where sickle cell disease is a public health concern, universal newborn screening followed by standard prophylaxis against bacterial infections and malaria^a (6)
Chronic kidney disease	Due to glomerulonephritis (4) Due to hypertension (4)	Treatment of hypertension in kidney disease, with use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in albuminuric kidney disease (5)
Liver cirrhosis	Cirrhosis due to hepatitis B virus (5) Alcoholic cirrhosis (5)	Mass media messages concerning use of tobacco and alcohol (6)
Acute abdominal conditions	Paralytic ileus and intestinal obstruction (4)	Basic first-level hospital surgical services^a (6) Expanded first-level hospital surgical services^a (4)
Epilepsy	Epilepsy (6)	Management of epilepsy using generic anti-epileptics (6)
Mental health	Depression (5) Anxiety (4)	Management of depression and anxiety disorders with psychological and generic antidepressant therapy (6) Management of schizophrenia using generic anti-psychotic medications and psychosocial treatment (5) Management of bipolar disorder using generic mood-stabilizing medications and psychosocial treatment (4)
Injuries	Motor vehicle road injuries (6) Pedestrian road injuries (4) Burns (4)	Basic outpatient surgical services^a (4) Basic first-level hospital surgical services^a (6) Expanded first-level hospital surgical services^a (4) Specialized surgical services^a (6) Basic rehabilitation services^a (5)