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Non-communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys
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Forewords

The ultimate purpose of the Prince Mahidol Award Foundation under Royal Patronage, according to my interpretation, is to pursue the ideology of Prince Mahidol of Songkla in serving the benefit of mankind. The Foundation has three activities: the Prince Mahidol Award, the PMAC (Prince Mahidol Award Conference) and the Prince Mahidol Award Youth Program. The theme of PMAC 2019 was ‘The Political Economy of NCDs: A Whole of Society Approach’. The idea to publish this book, Non-communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys, was proposed during the PMAC 2019 preparation meeting and has been partially funded by PMAC.

PMAC is proud to have supported the development and dissemination of this book. In fact, it is more than just a book. We hope that it will be a collective learning tool for NCD managers and stakeholders, together with health economists or health intervention and technology assessment specialists. The ultimate goal of the learning process is ‘good health at reasonable cost’ with emphasis on NCDs. Taking a broader perspective, this learning process aims to help strengthen universal health coverage (UHC) schemes.

NCDs and their root causes are very complex; addressing or preventing them is even more complex. A policy or intervention which is thought to be Best Buy can turn out to be Wasted Buy. Even when there is evidence of high cost-effectiveness in one country, when the intervention is transferred directly to another country, it can become a Wasted Buy.

This is a book of evidence management and utilization in NCD prevention, which can be applied to the development of health systems as a whole. The key proposal is the SEED Tool (Systematic thinking for Evidence-based and Efficient Decision-making). To me, it is a framework or conceptualization tool that can handle complex situations. The decision-making process proposed is not linear, but a learning loop to guide deliberation. The book helps the target audience scrutinize evidence, mainly cost-effectiveness analyses, to be applied in local contexts with involvement.

PMAC is proud to present this high-quality commissioned work. We hope it will help to change the paradigm from communicable-disease-oriented health systems to more NCD-oriented systems, which is a much more complex paradigm.

Prof. Vicharn Panich

Chairperson of PMAC International Organizing Committee

Since 2007, the Prince Mahidol Award Conference (PMAC) has been organized as an annual international conference focusing on policy of global significance related to public health. For over a decade, PMAC has provided opportunities for debate, discussion and deliberation on priority global health policy and systems, and it has contributed to the exchange of knowledge and experience on global health between participants from across the world. In 2018, PMAC initiated commissioned work to provide a body of evidence to facilitate the sharing of experience at country level and among country and regional networks, in order to influence the implementation of global health and/or national policies and to enhance PMAC’s capacities to deliver its knowledge and experiences to a wider spectrum of people.

Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys is the first PMAC-commissioned work. This book provides evidence-informed insights to help understand which non-communicable disease (NCD) interventions work and which don’t, so that program managers, policy officers and decision-makers in low- and middle-income countries (LMICs) can assess and implement interventions for the prevention and control of NCDs. It is a gold mine of very informative, easy to read and extremely helpful guidelines for those who wish to implement or reassess their strategies for preventing the NCD burden in their settings.

Non-Communicable Disease Prevention will augment PMAC’s contribution in terms of changing health policy and improving health systems in different settings in relation to NCDs. It will continue the momentum of the PMAC 2019 theme on ‘The Political Economy of NCDs: A Whole of Society Approach’, enable the contributions from PMAC to reach a wider audience and sustain PMAC work into the future. This sharing of real-world case studies, practical guidelines and key learning points will truly benefit all relevant stakeholders and the global health community and help accelerate the global progress in NCD prevention and control.

Prof. Churnrurtai Kanchanachitra

PMAC Secretariat

Demographic change, like climate change, proceeds slowly. National populations — starting from very different positions — exhibit a steady, usually predictable, but always slow increase in the number of individuals at older ages. The risks of stroke, heart disease, cancers and chronic respiratory illness increase sharply with age. Thus demography drives increases in incidence and mortality from these conditions. These changes — like the consequences of climate change — often remain below the threshold of visibility. Until they don’t. Almost all middle-income countries (and many low-income ones) have crossed a threshold where the major non-communicable diseases (NCDs) have become highly salient in public discourse and, more practically, in the budgetary demands on health systems. Yet only recently — in many countries — have the medical, public health and public policy communities begun to assess critically how best to respond to the inexorable rise in NCDs.

Thailand achieved unusually early success in reducing child mortality and infectious disease mortality more generally with one consequence being the aging of its population and concomitant rise in NCDs. Also unusually, Thailand invested early and substantially to create the analytic capacity to identify and develop approaches to NCD prevention and management. The Thai Health Ministry’s Health Intervention and Technology Assessment Programs (HITAP), as well as closely associated efforts at Mahidol University, have provided world leadership in developing and applying techniques of economic evaluation to help ensure that public money spent on health buys the greatest possible reduction in premature mortality and morbidity. This timely volume — Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys — brings to a global audience a distillation of much of HITAP’s experience. An international editorial team was formed to match authors to topics. Then a broadly inclusive and iterative process of chapter development, described in Chapter 1, led to a volume that will become required reading for two important audiences: one concerned with implementation of strategies for NCD control and, significantly, the community of economists and others seeking an up-to-date account of how best to apply economic methods in practice.

Three important characteristics contribute to making this book an unusually informative resource. First, the volume results from an extensive international collaboration of individuals and institutions. This collaboration enriches the book’s content and facilitates communication with diverse audiences. Second and closely related, the volume relies heavily on case studies to convey its main message — a total of fifty-eight case studies from thirty countries. The case studies ground the lessons of the book in operational experience and should prove of particular salience to NCD program managers, an audience the volume particularly tries to reach. Finally, this book develops and present a practical guide to the assessment of intervention attractiveness — the ‘Systemic thinking for Evidence-based and Efficient Decision-making (SEED)’ tool. SEED provides a valuable framework both for the book itself and for its application in practice.

It is not my purpose in this brief forword to overview this rich a volume. Nonetheless, I would like to touch on three points that resonated with my own experience working on the Disease Control Priorities (DCP) Project and, in particular, on issues that various iterations of DCP have had to deal with over many years.1 One concerns the quality and transferability of evidence. A second persistent issue concerns economic evaluation when an intervention has significant non-health consequences (what the volume’s authors call cross-sectoral intervention). Third, the volume’s title points to consideration of Wasted Buys as well as Best Buys, a topic too often neglected in the literature. On each of these issues the authors provide valuable insights.

Two of the volume’s chapters discuss evidence: one focuses on the synthesis of evidence of varying degrees of quality; and another on transferring findings from one setting or population to another and perhaps to very different settings or populations. The volume concurs in the general observation that randomized-controlled trials (RCTs) provide the highest quality evidence, but it is equally insistent in pointing out that an RCT must be supplemented by judgement about transferability if the results are to be applied outside of the original setting. ‘Hard’ evidence can become soft very quickly and the DCP approach has been to acknowledge the ever-present need for informed judgement about the relevance and transferability of evidence. The explicit objective of the DCP’s approach has been to balance concerns about accepting that an intervention is attractive when it is not — unfortunately the dominant concern of the medical community — with apprehension about rejecting an intervention that might be appropriate. The approach advocated in this book provides a welcome, systematic approach to facilitate judgement in this necessary search for balance. This approach can be applied equally to two other areas where judgement is required: evaluating the effect of a combined intervention (multi-drug approaches to secondary prevention of vascular disease, for example, when trials have been undertaken only on single-drug regimens); and deciding whether two different interventions (two health promotion campaigns or two anti-hypertensive drugs, for examples) can be viewed as essentially the same in terms of efficacy.

Reducing behavioral and environmental risk often involves action outside the health sector. Issuing and enforcing controls on air quality, for example, could result in significant reductions in mortality in many cities. Health ministries lack money and mandates to issue such regulations and, even if they did, there are likely to be significant benefits that derive from such investments that are unrelated to health. An economic evaluation of air quality regulation that relies on a standard incremental cost-effectiveness assessment — cost per death averted, say — will fail to capture all relevant benefits. On the other hand, an economic evaluation from the perspective of an energy ministry may simply neglect to consider health benefits. This book includes a thoughtful chapter on how to approach this problem within a cost-effectiveness framework. DCP authors assessing cross-sectoral intervention have tended either to report ‘dashboards’ of outcomes, without aggregation into a single figure of merit, or to use monetary metrics within a benefit-cost analysis (BCA) framework. I don’t see an approach that is obviously best (although I lean toward BCAs). This book very much contributes to the thinking on this topic and national experience with the methods explained here will, over time, provide insight into what is practical and useful.

Separating economic evaluation from advocacy can prove difficult. Groups that work on immunization (or any other interventions you can name) often do so from a laudable commitment to the value of what they are doing. Likewise, because of their interest, these groups often commission or participate in economic evaluations. It requires no conscious bias to have results lean toward the favorable. Thus, this book’s explicit argument for the importance of also considering Wasted Buys is very much to be welcomed. My own experience in DCP was that asking authors to identify interventions of low priority met with little success. Most DCP authors — there were important exceptions — simply avoided doing this. It appears that the authors of this book experienced similar problems. They report that of the fifty-eight case studies received, forty-seven were of Best Buys, seven were Contestable Buys and only four were Wasted Buys. This simply underscores this volume’s contribution to generating sustained and serious consideration of what not to do (or to do only later). The inclusion of Wasted Buys in the title of the book and in the analysis sends a good message.

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Analysts often neglect the political economy of implementation. One could argue that there is a natural division of labor between analysis and the politics of implementation (and in the past I have so argued). This book takes the perspective that considerations of political economy need inclusion from the outset. It is reasonable to predict that this explicit approach will combine with the book’s analytic strength to give it enduring value.

Prof. Dean T. Jamison

Institute for Global Health Sciences University of California, San Francisco


1 Dean T. Jamison et al., Disease Control Priorities: Improving Health and Reducing Poverty (Washington, DC: World Bank, 2017), 3rd edition, IX.