Elsevier

The Lancet

Volume 370, Issue 9603, 8–14 December 2007, Pages 1939-1946
The Lancet

Series
Scaling up interventions for chronic disease prevention: the evidence

https://doi.org/10.1016/S0140-6736(07)61697-3Get rights and content

Summary

Interventions to prevent morbidity and mortality from chronic diseases need to be cost effective and financially feasible in countries of low or middle income before recommendations for their scale-up can be made. We review the cost-effectiveness estimates on policy interventions (both population-based and personal) that are likely to lead to substantial reductions in chronic diseases—in particular, cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We reviewed data from regions of low, middle, and high income, where available, as well as the evidence for making policy interventions where available effectiveness or cost-effectiveness data are lacking. The results confirm that the cost-effectiveness evidence for tobacco control measures, salt reduction, and the use of multidrug regimens for patients with high-risk cardiovascular disease strongly supports the feasibility of the scale-up of these interventions. Further assessment to determine the best national policies to achieve reductions in consumption of saturated and trans fat—chemically hydrogenated plant oils—could eventually lead to substantial reductions in cardiovascular disease. Finally, we review evidence for policy implementation in areas of strong causality or highly probable benefit—eg, changes in personal interventions for diabetes reduction, restructuring of health systems, and wider policy decisions.

Introduction

To prevent death or morbidity from chronic diseases in an economically sustainable manner, an intervention should meet at least four conditions. First, the intervention must target behaviours or risk factors that have been causally associated with chronic diseases. Second, there should be knowledge that the intervention will probably lead to favourable changes in behaviours or risk factors, which should then lead to reductions in morbid or fatal events. Third, evidence should show that the intervention is cost effective in the settings in which it is implemented. Lastly, there should be evidence that the scaling up of the intervention is fiscally feasible in resource-constrained countries.

Tobacco control measures, salt reduction strategies, and multidrug strategies to treat patients with high-risk cardiovascular disease meet the first three conditions. For these interventions, causality has been proven, intervention effectiveness has been confirmed, and cost-effectiveness has been shown through modelling in resource-strained countries. The third and fourth papers in this Series1, 2 assess the evidence for the fourth condition of fiscal feasibility for the scaling up of these three interventions. However, a range of other potentially effective interventions that are proven in high-income countries but for which evidence on cost-effectiveness has not yet been gathered in countries of low or middle income are also highly plausible candidates for investigation and early adoption.

Such evidence on causation and health benefits of other interventions is usually transferable to the populations of low-income and middle-income countries. However, estimates of population attributable risk for individual risk factors, and of cost-effectiveness for specific interventions could differ substantially across these groups of countries. A further limitation is that such evidence is mostly confined to personal interventions directed at changing the behaviours of individuals, and provides little information on non-personal policy interventions that could potentially alter individual behaviours through economic and environmental effects that operate at the societal level. The absence of such evidence is especially unfortunate, since such policy interventions could be more cost effective and affordable for resource-constrained countries than are resource-intensive interventions focused on behaviour change in individuals.

Key messages

  • Interventions to reduce chronic diseases should be both cost effective and financially feasible before scaling up in countries of low or middle income

  • Tobacco control, salt reduction, and a multidrug strategy to treat individuals with high-risk cardiovascular disease are three interventions that have strong cost-effectiveness data for scale-up in such countries

  • Further studies to assess the best national policies to reduce consumption of saturated and trans fats at a reasonable cost are needed before scaling up such interventions

  • Several other interventions do not have sufficient cost-effectiveness data for countries of low or middle income, but their effectiveness data are so compelling that their implementation, along with critical assessment, should be considered in such settings

  • There are limited data for structural interventions directed at the social determinants of chronic diseases, including health systems. This is an area that deserves immediate focused attention

In this paper we review the array of proven and potential interventions that can reduce the burdens of chronic diseases in low-income and middle-income countries, using proven causation and ability to intervene as the main criteria. Intervention effectiveness and cost-effectiveness data are reviewed where available (effectiveness data for the interventions in the third and fourth articles of this Series are reviewed within those papers1, 2). In view of the large number of interventions, this paper is not exhaustive, but rather draws attention to several possible interventions for which there are various levels of evidence for scaling up in low-income and middle-income countries.

Section snippets

Community-based interventions

In the 1970s and 1980s a series of population-based community intervention studies were done in high-income countries to reduce risk factors for chronic disease. These studies focused on either changes in health behaviours or on risk factors such as tobacco use, bodyweight, cholesterol, and blood pressure, as well as a reduction in morbidity and mortality due to cardiovascular disease. In general, they included a combination of community-wide actions as well as those focused on individuals

Cost-effectiveness of interventions

The results of the cost-effectiveness analyses presented below are listed in US$ per either quality-adjusted life-year (QALY) gained or per disability-adjusted life-year (DALY) averted, in keeping with the choice of measure used in the analyses of each article. Results are presented as cost-effectiveness ratios that refer to only direct costs of the intervention and the number of health-care dollars consumed or saved. An intervention that is deemed to be cost saving saves the health-care system

Discussion

Policymakers in countries of lower and middle income are faced with a wide range of possible effective (and cost-effective) interventions, and they are forced to set priorities using a rational approach. They must decide in a context of uncertainty and they are faced with two issues of increasing complexity. First is how to apply evidence on policy: what are the interventions that effectively reduce the risk of chronic disease and alleviate the existing burden? Which of these are cost-effective

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