A Systems Approach to Preventing and Controlling Non-communicable Diseases in Low Resource and Emerging Economies:

K.M.Venkat NarayanRuth and O.C. Hubert Professor

Emory University, AtlantaConsortium of Universities of Global Health, Seattle, 20 September, 2010

http://www.nejm.org/doi/full/10.1056/NEJMp1002024

Two types of approaches to combating a problem

Transformational – that aims to achieve large, permanent improvements in broad social and economic indicators

Marginal – that attempts to solve a specific problem for a targeted group of beneficiaries

Bendavid, Miller. JAMA, 2010

Some desirable qualities of a health system for NCD

Data for decision-making & evaluation Decisions should be evidence-based Resource allocation proportional to expected

outcomes Integrated and organized care Low-cost & affordable interventions Scalablity

Setting intervention priorities in developing countries - Challenges

Little direct evidence on the effectiveness or cost-effectiveness of interventions in developed countries

Translating evidence from developed countries to the context of developing countries

Assessing Priorities for ImplementationDisease Control Priorities-2 Chapter 30

http://www.dcp2.org/pubs/DCP

Program Priorities

R&D Priorities

1. Burden

2. Intervention effectiveness & cost-effectiveness

3. Level of implementation or quality of care

Methods for setting intervention priorities in developing countries

Translating the cost-effectiveness evidence from developed countries to the context of developing countries by assuming

• Same effectiveness• Different costs for the intervention and medical care

Feasibility of interventions • Reach• Technical complexity• Capital intensity• Cultural acceptability

Ranking interventions to set implementation priority

Levels of Intervention Priorities

OneCost saving and highly feasible

TwoCost saving or cost <1,500/QALY and pose some

feasibility challenges Three

Cost 1,500-8,550/QALY and pose considerable feasible challenges

Primary Prevention Interventions for Diabetes

Intervention Cost/QALY (2001 $)

Feasibility Priority

Prev (L/S) 130 ++ 1

Prev (Metformin) 3,630 ++ 3

Secondary Prevention - Priority One Interventions

Intervention Cost/QALY (2001 $)

Latin America

Feasibility

Control HbA1c <9% Cost saving ++++

BP <160/95 Cost saving ++++

Foot care Cost saving ++++

Secondary Prevention - Priority Two Interventions

Intervention Cost/QALY (2001 $)

Latin America

Feasibility

Preconp care Cost saving ++

Fluvac 360 ++++

Eye exam 700 ++

Smoking cessation

1,450 ++

ACE-I for all 1,020 +++

Secondary Prevention - Priority Three Interventions

Intervention Cost/QALY (2001 $)

Latin America

Feasibility

TC <200 mg/dl 7,350 +++

HbA1c<8% 4,000 ++

Screening DM 8,550 ++

Microab test 5,510 ++

Need direct evidence from developing countries

Two examples

1. Primary prevention translation trial in Chennai, India

2. Secondary prevention translation trial in eight centers in India/Pakistan

CDCCENTERS FOR DISEASE COTROL

AND PREVENTION

Intervention Studies: 1 Prevention

IDF BRiDGES Translation Trial (D-CLIP)Evaluate effectiveness, cost-effectiveness, sustainability of

culturally-congruent , low-cost 1 prevention strategies

• Screening 12-15,000 people; n=700 Pre-diabetes (IFG, IGT, both) randomized

• Lifestyle delivered by lay educators / community ambassadors + Peer support groups

• Metformin after 4 m, if needed (ADA guidelines)

Program Evaluation

1. Effectiveness

2. Cost-effectiveness

3. Sustainability

4. Scalability under discussion

CDCCENTERS FOR DISEASE COTROL

AND PREVENTION

NHLBI/OvationsNHLBI/Ovations C Centre for Centre for CAArdiometabolic rdiometabolic RRisk isk RReduction eduction in in SSouth Asia - outh Asia - CARRSCARRS

New DelhiNew Delhi

ChennaiChennai

KarachiKarachiAtlantaAtlanta

K.M. Venkat K.M. Venkat NarayanNarayanM.K. AliM.K. Ali

E.W. GreggE.W. Gregg

M. KadirM. Kadir D. D. PrabhakaranPrabhakaranK. Srinath K. Srinath ReddyReddy

N. Tandon N. Tandon V. Mohan V. Mohan

Research Coordinating Centre (RCC) atResearch Coordinating Centre (RCC) atPublic Health Foundation of India (PHFI)Public Health Foundation of India (PHFI)

CDCCENTERS FOR DISEASE COTROL

AND PREVENTION

Intervention Studies: 2 Prevention

Ovations/NHLBI Translation Trial (CARRS)Evaluate effectiveness, cost-effectiveness, sustainability of low-

cost, multi-factorial 2 prevention strategies

• n=1,120 people with diabetes at 8 centers

• Care coordinator

• Decision support software

• Guidelines driven comprehensive diabetes and CVD management

SiteRandomized Individuals Assignment Outcomes

CARRS Translation TrialCARRS Translation Trial

14070

140

14070

70

70

70

70

8 sites Total sample ~ 1,120

ControlUsual care

InterventionSupported

Intensive care

1.Care coordinator2.Decision Support3.Guidelines

1° OutcomeProportion achieving multiple RF control (HbA1c & 1 other)

2° Outcomes•Cost-effectiveness•QOL •Satisfaction

Conclusions By systematically implementing known cost-

effective interventions• Diabetes incidence can be halved

• Diabetes complications can be halved

Better data on effectiveness and cost-effectiveness in developing country settings are needed

Investing in programs of unproven effectiveness or cost-ineffectiveness is a waste of limited resources

Need to invest in system infrastructure

Quantity of Unmet MDG Progress

IMR Child Mortality

TB Mortality HIV Prevalence

10% higher GDP per capita

-0.17% -0.16% -1.80% 1.10%

1% GDP Higher health spending

-2.23% -2.35% -3.57% -2.96%

1 Additional physician/10,000

-0.38% -0.26% -1.47% -0.09%

10% Higher NCD Mortality rate

6.32% 5.78% 7.56% 2.03%

Stuckler et al. PLoS 2010

Why Child Health and Infectious Disease Improvements Depend on Reducing NCD Mortality?