Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 47 Records) |
Query Trace: Kostova D[original query] |
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Cost analysis of adding hypertension and diabetes management into routine HIV care in Mbarara and Ibanda districts, Uganda
Ninsiima M , Basu S , Husain MJ , Kawungezi PC , Kabami Z , Simbwa BN , Bulage L , Kruse M , Tetlow S , Kadobera D , Ssali M , Migisha R , Ario AR , Kostova D . BMC Health Serv Res 2024 24 (1) 1392 BACKGROUND: In 2016, Uganda introduced services for hypertension and diabetes in selected HIV clinics. We evaluated the costs associated with scaling up these services in HIV clinics in Mbarara and Ibanda districts, Uganda. METHODS: We estimated the annual costs of providing hypertension and diabetes services using an activity-based costing approach from the health system perspective in ten randomly selected HIV clinics in Mbarara and Ibanda districts. Cost inputs included 2023 data on costs of medications, health provider time, salaries, training costs, and monitoring costs. We determined the average annual cost and medication costs for hypertension and diabetes treatment per enrolled adult patient, stratified by type of health facility. RESULTS: The total annual cost of hypertension and diabetes management services in ten selected HIV clinics was estimated to be $413,850 (range: $8,386 - 186,973). The annual average clinic-level cost per enrolled patient was estimated at $14 (range: $7 - 31). Of the total annual cost, the cost of provider time for initial and follow-up visits represented the largest cost component in 5/10 clinics (mean: 37%, range [13-58%]). In 4/10 clinics, the major cost components were the costs of medication, diagnostic tests, and related supplies (mean: 37%, range [10-75%]). The average cost per enrolled adult patient was $11 at public facilities and $21 in private not-for-profit facilities. The average medication cost per patient for hypertension was $24 (range: $7 - 97) annually; $13 at public facilities and $50 at private not-for-profit facilities. For diabetes treatment, the average annual medication cost per patient was estimated at $14 (range: $6 - 35); $11 at public facilities and $22 at private not-for-profit facilities. CONCLUSION: Adding hypertension and diabetes management to routine HIV care might be feasible based on the estimated annual cost per patient. Hypertension and diabetes treatment was more costly in private not-for-profit facility-based clinics than at public facilities. This variation was primarily driven by higher medication procurement prices at private facilities, revealing a potential area for optimizing costs through improved procurement practices. |
Comparing scale up of status quo hypertension care against dual combination therapy as separate pills or single pill combinations: an economic evaluation in 24 low- and middle-income countries
Hutchinson B , Husain MJ , Nugent R , Kostova D . eClinicalMedicine 2024 75 Background: International hypertension treatment guidelines recommend initiating pharmacological treatment with combination therapy and using fixed dose single pill combinations (SPCs) to improve adherence. However, few countries have adopted combination therapy as a form of first-line treatment and SPC uptake in low- and middle-income countries is low due in part to cost and availability. Evidence on costs and cost-effectiveness is needed as health authorities consider incorporating new recommendations into national clinical practice guidelines. Methods: Over a 30-year time horizon, we used an Excel-based Markov cohort state-transition model to assess the financial costs (screening, treatment, program, and supply chain costs) and socio-economic outcomes (health outcomes, value of lives saved, productivity losses averted) of three antihypertensive treatment scenarios. A baseline scenario scaled treatment among adults age 30 plus while assuming continuation of the widespread practice of initiating treatment with monotherapy. Scenarios one and two scaled treatment while initiating patients on two antihypertensive medications, either as separate pills or as a SPC. Analysis inputs are informed by country-specific data, meta-analyses of the blood-pressure lowering of antihypertensive medications, and own-studies of medication costs. We compared costs, cost-effectiveness, and net-benefits across scenarios, and assessed uncertainty in a one-way sensitivity analysis. Findings: Using dual combination therapy (with or without SPCs) as first-line treatment would increase costs relative to current practices that largely use monotherapy. Required additional annual resources averaged as much as 3.6, 0.9, and 0.2 percent of government health expenditures in the analysis’ low-, lower-middle, and upper-middle income countries. However, across 24 countries, over the next 30 years, combination therapy with separate pills could save 430,000 more lives and combination therapy with SPCs could save 564,000 more lives compared to baseline treatment practices. Administration of two or more medications using SPCs generated higher net benefits in most countries (16/24) compared to the baseline scenario. Interpretation: First line treatment employing SPCs is likely to generate higher net benefits compared to status quo treatment practices in countries with relatively higher incomes. To improve population health, national health systems would benefit from reducing structural and other barriers to the use of combination therapy and SPCs. Funding: This journal article was supported by TEPHINET cooperative agreement number 1NU2HGH000044-01-0 funded by the USCenters for Disease Control and Prevention. © 2024 The Author(s) |
Scaling hypertension treatment in 24 low-income and middle-income countries: economic evaluation of treatment decisions at three blood pressure cut-points
Hutchinson B , Walter A , Campbell N , Whelton PK , Varghese C , Husain MJ , Nugent R , Kostova D , Honeycutt A . BMJ Open 2024 14 (4) e071036 OBJECTIVE: Estimate the incremental costs and benefits of scaling up hypertension care in adults in 24 select countries, using three different systolic blood pressure (SBP) treatment cut-off points-≥140, ≥150 and ≥160 mm Hg. INTERVENTION: Strengthening the hypertension care cascade compared with status quo levels, with pharmacological treatment administered at different cut-points depending on the scenario. TARGET POPULATION: Adults aged 30+ in 24 low-income and middle-income countries spanning all world regions. PERSPECTIVE: Societal. TIME HORIZON: 30 years. DISCOUNT RATE: 4%. COSTING YEAR: 2020 USD. STUDY DESIGN: DATA SOURCES: Institute for Health Metrics and Evaluation's Epi Visualisations database-country-specific cardiovascular disease (CVD) incidence, prevalence and death rates. Mean SBP and prevalence-National surveys and NCD-RisC. Treatment protocols-WHO HEARTS. Treatment impact-academic literature. Costs-national and international databases. OUTCOME MEASURES: Health outcomes-averted stroke and myocardial infarction events, deaths and disability-adjusted life-years; economic outcomes-averted health expenditures, value of averted mortality and workplace productivity losses. RESULTS OF ANALYSIS: Across 24 countries, over 30 years, incremental scale-up of hypertension care for adults with SBP≥140 mm Hg led to 2.6 million averted CVD events and 1.2 million averted deaths (7% of expected CVD deaths). 68% of benefits resulted from treating those with very high SBP (≥160 mm Hg). 10 of the 12 highest-income countries projected positive net benefits at one or more treatment cut-points, compared with 3 of the 12 lowest-income countries. Treating hypertension at SBP≥160 mm Hg maximised the net economic benefit in the lowest-income countries. LIMITATIONS: The model only included a few hypertension-attributable diseases and did not account for comorbid risk factors. Modelled scenarios assumed ambitious progress on strengthening the care cascade. CONCLUSIONS: In areas where economic considerations might play an outsized role, such as very low-income countries, prioritising treatment to populations with severe hypertension can maximise benefits net of economic costs. |
Barriers to accessibility of medicines for hyperlipidemia in low- and middle-income countries
Li C , Spencer G , Husain MJ , Nugent R , Auzenne D , Kostova D , Richter P . PLOS Glob Public Health 2024 4 (2) e0002905 Despite the high burden of hyperlipidemia and the effectiveness of treatment, evidence suggests that the accessibility of hyperlipidemia medicines can be low in many low- and middle-income countries (LMICs). The aim of this study was to identify common barriers to the accessibility of medicines for hyperlipidemia in LMICs. A multimethod analysis and multiple data sources were used to assess the accessibility and barriers of medicines for hyperlipidemia in selected LMICs. The overall median availability of statins for hyperlipidemia in public facilities was 0% and 5.4%, for originators and generics, respectively. In private facilities, median availability was 13.3% and 35.9%, for originators and generics, respectively. Statin availability was lowest in Africa and South-East Asia. Private facilities generally had higher availability than public facilities. Statins are less affordable in lower-income countries, costing around 6 days' wages per month. Originator statins are less affordable than generics in countries of all income-levels. The median cost for statin medications per month ranges from a low of $1 in Kenya to a high of $62 in Mexico, with most countries having a median monthly cost between $3.6 and $17.0. The key informant interviews suggested that accessibility to hyperlipidemia medicines in LMICs faces barriers in multiple dimensions of health systems. The availability and affordability of statins are generally low in LMICs. Several steps could be implemented to improve the accessibility of hyperlipidemia medicines, including private sector engagement, physician education, investment in technology, and enhancement of health systems. |
Cost analysis of the WHO-HEARTS program for hypertension control and CVD prevention in primary health facilities in Ethiopia
Beshah SA , Husain MJ , Dessie GA , Worku A , Negeri MG , Banigbe B , Moran AE , Basu S , Kostova D . Public Health Pract (Oxf) 2023 6 100423 BACKGROUND: In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package. OBJECTIVE: To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities. STUDY DESIGN: This study entails a program cost analysis using cross-sectional primary and secondary data. METHODS: Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension. RESULTS: The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively. CONCLUSIONS: The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia. |
The HEARTS partner forum-supporting implementation of HEARTS to treat and control hypertension
Khan T , Moran AE , Perel P , Whelton PK , Brainin M , Feigin V , Kostova D , Richter P , Ordunez P , Hennis A , Lackland DT , Slama S , Pineiro D , Martins S , Williams B , Hofstra L , Garg R , Mikkelsen B . Front Public Health 2023 11 1146441 Cardiovascular diseases (CVD), principally ischemic heart disease (IHD) and stroke, are the leading causes of death (18. 6 million deaths annually) and disability (393 million disability-adjusted life-years lost annually), worldwide. High blood pressure is the most important preventable risk factor for CVD and deaths, worldwide (10.8 million deaths annually). In 2016, the World Health Organization (WHO) and the United States Centers for Disease Control (CDC) launched the Global Hearts initiative to support governments in their quest to prevent and control CVD. HEARTS is the core technical package of the initiative and takes a public health approach to treating hypertension and other CVD risk factors at the primary health care level. The HEARTS Partner Forum, led by WHO, brings together the following 11 partner organizations: American Heart Association (AHA), Center for Chronic Disease Control (CCDC), International Society of Hypertension (ISH), International Society of Nephrology (ISN), Pan American Health Organization (PAHO), Resolve to Save Lives (RTSL), US CDC, World Hypertension League (WHL), World Heart Federation (WHF) and World Stroke Organization (WSO). The partners support countries in their implementation of the HEARTS technical package in various ways, including providing technical expertise, catalytic funding, capacity building and evidence generation and dissemination. HEARTS has demonstrated the feasibility and acceptability of a public health approach, with more than seven million people already on treatment for hypertension using a simple, algorithmic HEARTS approach. Additionally, HEARTS has demonstrated the feasibility of using hypertension as a pathfinder to universal health coverage and should be a key intervention of all basic benefit packages. The partner forum continues to find ways to expand support and reinvigorate enthusiasm and attention on preventing CVD. Proposed future HEARTS Partner Forum activities are related to more concrete information sharing between partners and among countries, expanded areas of partner synergy, support for implementation, capacity building, and advocacy with country ministries of health, professional societies, academy and civil societies organizations. Advancing toward the shared goals of the HEARTS partners will require a more formal, structured approach to the forum and include goals, targets and published reports. In this way, the HEARTS Partner Forum will mirror successful global partnerships on communicable diseases and assist countries in reducing CVD mortality and achieving global sustainable development goals (SDGs). |
Assessing costs of a hypertension program in primary care: evidence from the HEARTS program in Mexico
Chivardi C , Hutchinson B , Molina V , Moreno E , Fajardo I , Giraldo-Arcila GP , Malo HM , Ordunez P , Rodrguez-Franco R , Moran AE , Kostova D . Rev Panam Salud Publica 2022 46 e144 OBJECTIVE: In 2021, Mexico launched the HEARTS program to improve the prevention and control of cardiovascular disease (CVD) risk factors in 20 primary care facilities in the states of Chiapas and Yucatn. This study projects the annual cost of program implementation and discusses budgetary implications for scaling up the program. METHODS: We obtained district-level data on treatment protocols, medication costs, and other resources required to prevent and treat CVD. We used the HEARTS Costing Tool to estimate total and per-patient costs. A "partial implementation" scenario calculated the costs of implementing HEARTS if existing pharmacological treatment protocols are left in place. The second scenario, "full implementation," examined costs if programs use HEARTS pharmacological protocol. RESULTS: Respectively in the partial and full implementation scenarios, total annual costs to implement and operate HEARTS were $260 023 ($32.1 per patient/year) and $255 046 ($31.5 per patient/year) in Chiapas, and $1 000 059 ($41.3 per patient/year) and $1 013 835 ($43.3 per patient/year) in Yucatn. In Chiapas, adopting HEARTS standardized treatment protocols resulted in a 9.7 % reduction in annual medication expenditures relative to maintaining status-quo treatment approaches. In Yucatn, adoption was $12 875 more expensive, in part because HEARTS hypertension treatment regimens were more intensive than status quo regimens. CONCLUSION: HEARTS in the Americas offers a standardized strategy to treating and controlling CVD risk factors. In Mexico, approaches that may lead to improved program affordability include adoption of the recommended HEARTS treatment protocols with preferred medications and task shifting of services from physicians to nurses and other providers. |
Building the health-economic case for scaling up the WHO-HEARTS hypertension control package in low- and middle-income countries
Moran AE , Farrell M , Cazabon D , Sahoo SK , Mugrditchian D , Pidugu A , Chivardi C , Walbaum M , Alemayehu S , Isaranuwatchai W , Ankurawaranon C , Choudhury SR , Pickersgill SJ , Watkins DA , Husain MJ , Rao KD , Matsushita K , Marklund M , Hutchinson B , Nugent R , Kostova D , Garg R . Rev Panam Salud Publica 2022 46 e140 Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs. |
The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia.
Richter P , Aslam M , Kostova D , Lasu AAR , Vliet GV , Courtney LP , Chisenga T . Health Secur 2022 20 (4) 286-297 Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases. |
Cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in Bangladesh: a HEARTS costing tool application
Husain MJ , Haider MS , Tarannum R , Jubayer S , Bhuiyan MR , Kostova D , Moran AE , Choudhury SR . BMJ Open 2022 12 (6) e061467 OBJECTIVE: To estimate the costs of scaling up the HEARTS pilot project for hypertension management and risk-based cardiovascular disease (CVD) prevention at the full population level in the four subdistricts (upazilas) in Bangladesh. SETTINGS: Two intervention scenarios in subdistrict health complexes: hypertension management only, and risk-based integrated hypertension, diabetes, and cholesterol management. DESIGN: Data obtained during July-August 2020 from subdistrict health complexes on the cost of medications, diagnostic materials, staff salaries and other programme components. METHODS: Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual costs of implementing the HEARTS programme from the health system perspective. PRIMARY AND SECONDARY OUTCOME MEASURES: Programme cost, provider time. RESULTS: The total annual cost for the hypertension control programme was estimated at US$3.2million, equivalent to US$2.8 per capita or US$8.9 per eligible patient. The largest cost share (US$1.35million; 43%) was attributed to the cost of medications, followed by the cost of provider time to administer treatment (38%). The total annual cost of the risk-based integrated management programme was projected at US$14.4million, entailing US$12.9 per capita or US$40.2 per eligible patient. The estimated annual costs per patient treated with medications for hypertension, diabetes and cholesterol were US$18, US$29 and US$37, respectively. CONCLUSION: Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local community health workers would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh. |
National health and budget impact of implementing the WHO HEARTS hypertension control program in Bangladesh
Pidugu A , Pickersgill S , Watkins D , Husain J , Kostova D , Farrell M , Haider M , Jubayer S , Tarannum R , Bhuiyan M , Moran AE , Choudhury S . Lancet Glob Health 2022 10 Suppl 1 S23 BACKGROUND: About a fifth of adults in Bangladesh have hypertension; only 13% of Bangladesh adults living with hypertension have their blood pressure controlled (<140/90 mmHg). To address the growing burden of hypertension in low-income and middle-income countries, the WHO recommends implementing the HEARTS technical package. HEARTS outlines a practical approach to cardiovascular disease (CVD) prevention in primary care settings, including risk factor screening, diagnosis, treatment, and patient counseling. The Bangladesh Ministry of Health and Family Welfare and the National Heart Foundation of Bangladesh implemented the HEARTS programme in four district health complexes in Sylhet Division starting in 2019. To inform Bangladesh's health care policies, we translated Bangladesh HEARTS programme effectiveness and cost estimates into projections of national health and budget impact for nationwide programme scale-up. METHODS: We used an interactive, web-based model to project CVD deaths averted based on observed facility-based hypertension control rates and used local costs to obtain budget impact estimates of national HEARTS programme implementation. We also explored three alternative scenarios: reducing medication costs by 50%, increasing team-based care with larger roles for nurses and community health workers, and removing laboratory costs. Relative improvement in hypertension control observed in the HEARTS programme (from 26% to 46% in the four districts over 24 months) was applied to the 13% baseline national control rate resulting in a projected improvement to 33% at national scale. The costs of the hypertension programme were quantified with a standard HEARTS costing tool that was deployed in the four district health complexes. The costing tool recorded and calculated unit costs for hypertension screening, CVD risk assessment, health-care worker time or compensation, and drug prices. FINDINGS: An absolute improvement of 20 percentage points in the national hypertension control rate, from 13% to 33%, would save 9400 lives. Extrapolating local programme costs to the national level resulted in a budget of US$599 million by 2030. Reducing medication costs would lower the budget impact by 42·6%. Increasing team-based care would not substantively affect the cost. Removing laboratory costs would lower the budget by 14%. Combining these innovations would lower the projected cost by 56·9%. INTERPRETATION: Implementing the HEARTS programme in Bangladesh might improve hypertension control and save 9400 lives at a budget impact of $599 million by 2030. Increased task sharing and lower medication prices have potential to reduce costs and make reaching hypertension control goals more affordable and sustainable for Bangladesh. FUNDING: Columbia University Global & Population Health Summer Research Fellowship. |
The cost-effectiveness of hyperlipidemia medication in low- and middle-income countries: A review
Husain MJ , Spencer G , Nugent R , Kostova D , Richter P . Glob Heart 2022 17 (1) 18 Hyperlipidemia is a risk factor for cardiovascular disease - the leading cause of death globally. Increased understanding of the cost-effectiveness of hyperlipidemia treatment in low- and middle-income countries can guide approaches to hyperlipidemia management in resource-limited environments. We conducted a systematic review of the evidence on the cost-effectiveness of hyperlipidemia medication treatment in low- and middle-income countries using studies published between January 2010 and April 2020. We abstracted study details, including study design, treatment setting, intervention type, health metrics, costs standardized to constant 2019 US dollars, and cost-effectiveness measures including average and incremental cost-effectiveness ratios. Comparisons across studies suggested that treatment via polypill is generally more cost-effective than statin-only therapy, and that primary prevention is more cost-effective than secondary prevention. Treating hyperlipidemia at a threshold of 5.7 mmol/l comes at a higher cost per disability-adjusted life-years averted than at a threshold of 6.2 mmol/l. Most pharmacological treatment strategies for hyperlipidemia were found to be cost-effective in most of the examined low- and middle-income countries. |
Cost assessment of a program for laboratory testing of plasma trans-fatty acids in Thailand
Datta BK , Aekplakorn W , Chittamma A , Meemeaw P , Vesper H , Kuiper HC , Steele L , Cobb LK , Li C , Husain MJ , Ketgudee L , Kostova D , Richter P . Public Health Pract (Oxf) 2021 2 100199 Objectives: Intake of trans fatty acids (TFA) increases the risk of cardiovascular disease. Assessment of TFA exposure in the population is key for determining TFA burden and monitoring change over time. One approach for TFA monitoring is measurement of TFA levels in plasma. Understanding costs associated with this approach can facilitate program planning, implementation and scale-up. This report provides an assessment of costs associated with a pilot program to measure plasma TFA levels in Thailand. Study design: Cost analysis in a laboratory facility in Thailand. Methods: We defined three broad cost modules: laboratory, personnel, and facility costs, which were further classified into sub-components and into fixed and variable categories. Costs were estimated based on the number of processed plasma samples (100–2700 in increments of 50) per year over a certain number of years (1–5), in both USD and Thai Baht. Total cost and average costs per sample were estimated across a range of samples processed. Results: The average cost per sample of analyzing 900 samples annually over 5 years was estimated at USD186. Laboratory, personnel, and facility costs constitute 67%, 23%, and 10% of costs, respectively. The breakdown across fixed costs, such as laboratory instruments and personnel, and variable costs, such as chemical supplies, was 60% and 40%, respectively. Average costs decline as more samples are processed: the cost per sample for analyzing 100, 500, 1500, and 2500 samples per year over 5 years is USD1351, USD301, USD195; and USD177, respectively. Conclusions: Laboratory analysis of plasma TFA levels has high potential for economies of scale, encouraging a long-term approach to TFA monitoring initiatives, particularly in countries that already maintain national biometric repositories. © 2021 The Authors |
Strengthening Pandemic Preparedness Through Noncommunicable Disease Strategies
Kostova DA , Moolenaar RL , Van Vliet G , Lasu A , Mahar M , Richter P . Prev Chronic Dis 2021 18 E93 The COVID-19 pandemic has demonstrated the effect of noncommunicable diseases (NCDs) on infectious disease outcomes. This effect can be observed at both the individual and the population level. At the individual level, the presence of preexisting chronic conditions increases a patient’s risk of severe COVID-19 disease (1). At the population level, the aggregate prevalence of chronic conditions could compound the pandemic’s overall burden on health systems and the economy (2). |
Blood from a stone: Funding hypertension prevention, treatment, and care in low- and middle-income countries
Cohn J , Kostova D , Moran AE , Cobb LK , Pathni AK , Bisrat D . J Hum Hypertens 2021 35 (12) 1059-1062 Cardiovascular disease (CVD) is the leading cause of death worldwide, causing ~31% of all deaths [1]. The economic costs of premature death and disability from CVD are enormous: between 2011 and 2025, the estimated financial loss due to CVD in LMICs was $3.7 trillion, representing 2% of GDP of LMICs on average [2]. | | Hypertension, the principal cause of CVD mortality, is common, with an estimated 1.4 billion people living with hypertension globally. Rates of uncontrolled hypertension, defined by blood pressure systolic ≥140 mmHg or diastolic ≥90 mmHg, are high across low- and middle-income countries (LMICs), with LMICs suffering from disproportionate rates of premature mortality [3]. Hypertension is both a preventable and modifiable risk factor for CVD, and low-cost, effective treatments reduce risks of morbidity or mortality [4]. Unfortunately, despite the scale of disease burden from hypertension, and the availability of prevention and treatment solutions, high blood pressure is controlled in <10% of people living with hypertension across LMICs [5]. |
Hypertension in women: The role of adolescent childbearing
Datta BK , Husain MJ , Kostova D . BMC Public Health 2021 21 (1) 1481 BACKGROUND: Adolescent childbearing is associated with various health risks to the mother and child, and potentially with adverse socioeconomic outcomes. However, little is known about the role of adolescent childbearing in maternal health outcomes in adulthood. This study investigates the link between childbirth in adolescence and later-life risk of hypertension among women in India. METHODS: We obtained nationally representative data on demographic and health outcomes for 442,845 women aged 25 to 49 from the India National Family Health Survey (NFHS) 2015-16. We assessed the difference in hypertension prevalence between women who gave birth in adolescence (age 10 to 19) and those who did not, for the full sample and various sub-samples, using linear probability models with controls for individual characteristics, hypertension risk factors, and geographic fixed effects. RESULTS: Nearly 40% of the women in the sample gave birth in adolescence. The adjusted probability of being hypertensive in adulthood was 2.3 percentage points higher for this group compared to women who did not give childbirth in adolescence. This added probability was larger for women who gave birth earlier in adolescence (4.8 percentage points) and for women who gave birth more than once in adolescence (3.4 percentage points). CONCLUSIONS: Adolescent childbearing was strongly associated with a higher probability of adult female hypertension in India. This finding illustrates the intertemporal relationship between health risk factors during the life cycle, informing the importance of addressing adverse early life events (e.g. child marriage and adolescent childbirth) for hypertension outcomes among women in India. |
Disease and demography: a systems-dynamic cohort-component population model to assess the implications of disease-specific mortality targets
Husain MJ , Datta BK , Kostova D . BMJ Open 2021 11 (5) e043313 INTRODUCTION: The 2015 Sustainable Development Goals include the objective of reducing premature mortality from major non-communicable diseases (NCDs) by one-third by 2030. Accomplishing this objective has demographic implications with relevance for countries' health systems and costs. However, evidence on the system-wide implications of NCD targets is limited. METHODS: We developed a cohort-component model to estimate demographic change based on user-defined disease-specific mortality trajectories. The model accounts for ageing over 101 annual age cohorts, disaggregated by sex and projects changes in the size and structure of the population. We applied this model to the context of Bangladesh, using the model to simulate demographic outlooks for Bangladesh for 2015-2030 using three mortality scenarios. The 'status quo' scenario entails that the disease-specific mortality profile observed in 2015 applies throughout 2015-2030. The 'trend' scenario adopts age-specific, sex-specific and disease-specific mortality rate trajectories projected by WHO for the region. The 'target' scenario entails a one-third reduction in the mortality rates of cardiovascular disease, cancer, diabetes and chronic respiratory diseases between age 30 and 70 by 2030. RESULTS: The status quo, trend and target scenarios projected 178.9, 179.7 and 180.2 million population in 2030, respectively. The cumulative number of deaths during 2015-2030 was estimated at 17.4, 16.2 and 15.6 million for each scenario, respectively. During 2015-2030, the target scenario would avert a cumulative 1.73 million and 584 000 all-cause deaths compared with the status quo and trend scenarios, respectively. Male life expectancy was estimated to increase from 71.10 to 73.47 years in the trend scenario and to 74.38 years in the target scenario; female life expectancy was estimated to increase from 73.68 to 75.34 years and 76.39 years in the trend and target scenarios, respectively. CONCLUSION: The model describes the demographic implications of NCD prevention and control targets, estimating the potential increase in life expectancy associated with achieving key NCD reduction targets. The results can be used to inform future health system needs and to support planning for increased healthcare coverage in countries. |
The Role of Noncommunicable Diseases in the Pursuit of Global Health Security
Kostova D , Richter P , Van Vliet G , Mahar M , Moolenaar RL . Health Secur 2021 19 (3) 288-301 Noncommunicable diseases and their risk factors are important for all aspects of outbreak preparedness and response, affecting a range of factors including host susceptibility, pathogen virulence, and health system capacity. This conceptual analysis has 2 objectives. First, we use the Haddon matrix paradigm to formulate a framework for assessing the relevance of noncommunicable diseases to health security efforts throughout all phases of the disaster life cycle: before, during, and after an event. Second, we build upon this framework to identify 6 technical action areas in global health security programs that are opportune integration points for global health security and noncommunicable disease objectives: surveillance, workforce development, laboratory systems, immunization, risk communication, and sustainable financing. We discuss approaches to integration with the goal of maximizing the reach of global health security where infectious disease threats and chronic disease burdens overlap. |
U.S. trade indicators and epidemics: Lessons from the 2003 SARS outbreak
Kostova D , Cherukupalli R , Ochieng W , Redd JT . Econ Bull 2020 40 (4) 2610-2618 We revisited the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS-2003) and its role in two U.S. indicators — U.S. merchandise exports to countries in the East Asia Pacific (EAP) region and domestic U.S. jobs supported by these exports. We employed a quasi-experimental approach where SARS-2003 average treatment effects were derived from comparing before-2003 and after-2003 differences in indicator trends for EAP countries that experienced the bulk of 2003 epidemic transmission (China, T aiwan, Hong Kong and Singapore) and EAP countries that did not, controlling for observed and unobserved country heterogeneity that might concurrently determine trends in trade. The SARS-2003 outbreak was associated with a USD 29 billion relative reduction in U.S. merchandise exports to the group of high-burden SARS countries, with a corresponding relative loss of 61,200 U.S. jobs. These effects were largely explained by a slowdown in exports from the U.S. manufacturing sector (USD 24.9 billion). No significant post-2003 effects were estimated for either exports or jobs, indicating a relatively quick rebound |
Noncommunicable disease outcomes and the effects of vertical and horizontal health aid
Kostova D , Nugent R , Richter P . Econ Hum Biol 2020 41 100935 Foreign health aid forms a substantial portion of health spending in many low- and middle-income countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds used for broad health sector strengthening). Historically, most health aid has been disbursed vertically toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000-2016, and evaluated the relationship between these indicators and vertical and horizontal health aid using country fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319 deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for assessing the role of horizontal assistance. |
The cost-effectiveness of hypertension management in low-income and middle-income countries: a review
Kostova D , Spencer G , Moran AE , Cobb LK , Husain MJ , Datta BK , Matsushita K , Nugent R . BMJ Glob Health 2020 5 (9) Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes. |
Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017
Husain MJ , Datta BK , Nargis N , Iglesias R , Perucic AM , Ahluwalia IB , Tripp A , Fatehin S , Husain MM , Kostova D , Richter P . Tob Control 2020 30 (6) 630-637 BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly. |
Access to cardiovascular disease and hypertension medicines in developing countries: An analysis of essential medicine lists, price, availability, and affordability
Husain MJ , Datta BK , Kostova D , Joseph KT , Asma S , Richter P , Jaffe MG , Kishore SP . J Am Heart Assoc 2020 9 (9) e015302 Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries. |
Introducing the PLOS special collection of economic cases for NCD prevention and control: A global perspective
Nugent RA , Husain MJ , Kostova D , Chaloupka F . PLoS One 2020 15 (2) e0228564 Noncommunicable diseases (NCDs), such as heart disease, cancer, diabetes, and chronic respiratory disease, are responsible for seven out of every 10 deaths worldwide. While NCDs are associated with aging in high-income countries, this representation is often misleading. Over one-third of the 41 million annual deaths from NCDs occur prematurely, defined as under 70 years of age. Most of those deaths occur in low- and middle-income countries (LMICs) where surveillance, treatment, and care of NCDs are often inadequate. In addition to high health and social costs, the economic costs imposed by such high numbers of excess early deaths impede economic development and contribute to global and national inequity. In higher-income countries, NCDs and their risks continue to push health care costs higher. The burden of NCDs is strongly intertwined with economic conditions for good and for harm. Understanding the multiple ways they are connected-through risk factor exposures, access to quality health care, and financial protection among others-will determine which countries are able to improve the healthy longevity of their populations and slow growth in health expenditure particularly in the face of aging populations. The aim of this Special Collection is to provide new evidence to spur those actions. |
Assessing costs of a hypertension management program: An application of the HEARTS costing tool in a program planning workshop in Thailand
Husain MJ , Allaire BT , Hutchinson B , Ketgudee L , Srisuthisak S , Yueayai K , Pisitpayat N , Nugent R , Datta BK , Joseph KT , Kostova D . J Clin Hypertens (Greenwich) 2019 22 (1) 111-117 The HEARTS technical package, a part of the Global Hearts Initiative to improve cardiovascular health globally, is a strategic approach for cardiovascular disease prevention and control at the primary care level. To support the evaluation of costs associated with HEARTS program components, a costing tool was developed to evaluate the incremental cost of program implementation. This report documents an application of the HEARTS costing tool during a costing workshop prior to the initiation of a HEARTS pilot program in Thailand's Phothong District, 2019-2020. During the workshop, a mock exercise was conducted to estimate the expected costs of the pilot study. The workshop application of the tool underscored its applicability to the HEARTS program planning process by identifying cost drivers associated with individual program elements. It further illustrated that by supporting disaggregation of costs into fixed and variable categories, the tool can inform the scalability of pilot projects to larger populations. Lessons learned during the initial development and application of the costing tool can inform future HEARTS evaluation efforts. |
Long-distance effects of epidemics: Assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employment
Kostova D , Cassell CH , Redd JT , Williams DE , Singh T , Martel LD , Bunnell RE . Health Econ 2019 28 (11) 1248-1261 Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports-supported U.S. jobs, 2005-2016. Estimates were obtained using difference-in-differences models where sub-Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time-variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola-affected countries, whereas estimated losses in exports-supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts. |
Consumption displacement in households with noncommunicable diseases in Bangladesh
Datta BK , Husain MJ , Fatehin S , Kostova D . PLoS One 2018 13 (12) e0208504 The economic burden of noncommunicable diseases (NCDs), including treatment costs and income and productivity losses, is a growing concern in developing countries, where NCD medical expenditure may offset consumption of other essential commodities. This study examines the role of NCDs in household resource allocation in Bangladesh. We use the Bangladesh Household Income and Expenditure Survey (HIES) 2010 to obtain expenditure data on 11 household expenditure categories and 12 food expenditure sub-categories for 12,240 households. Household NCD status was determined through self-report of at least one of the six major NCDs within the household-heart disease, hypertension, diabetes, kidney diseases, asthma, and cancer. We estimated unadjusted and regression-adjusted differences in household expenditure shares between NCD and non-NCD households. We further investigated how consumption of different food sub-categories is related to NCD status, distinguishing between household economic levels. The medical expenditure share was estimated to be 59% higher for NCD households than non-NCD households, and NCD households had lower expenditure shares on food, clothing, hygiene, and energy. Regression results indicated that presence of NCDs was associated with lower relative expenditure on clothing and housing in all economic subgroups, and with lower expenditure on food among marginally poor households. Having an NCD was significantly associated with higher household spending on tobacco and higher-calorie foods such as sugar, beverages, meat, dairy, and fruit, and with lower spending on fish, vegetables, and legumes. The findings indicate a link between NCDs and the possibility of adverse economic effects on the household by highlighting the potential displacement effect on household consumption that might occur through higher medical expenditure and lower spending on essentials. The findings might also point to a need for raising awareness about the link between NCDs and diet in Bangladesh. |
Noncommunicable disease-attributable medical expenditures, household financial stress and impoverishment in Bangladesh
Datta BK , Husain MJ , Husain MM , Kostova D . SSM Popul Health 2018 6 252-258 Background: Treatment of noncommunicable diseases (NCDs) in low-income countries can entail large out-of-pocket (OOP) medical expenditures, which can increase the likelihood of household impoverishment and perpetuate the poverty cycle. This paper studies the implications of NCDs on household medical expenditure, household financial stress (e.g. selling assets or borrowing for treatment financing), catastrophic OOP expenditure, and impoverishment in Bangladesh. Methods: We used self-reported health status and household expenditure survey data from 12,240 households in Bangladesh. NCD-afflicted households were defined by presence of at least one of the following conditions within the household - heart disease, hypertension, asthma, diabetes, cancer, or kidney disease. Using linear regression models, we examined whether NCD households incur more medical expenditures, allocate a larger budget share on medical expenditures, and have greater probability of experiencing catastrophic medical expenditure or financial stress from OOP spending than non-NCD households. Finally, using survey weights, we extrapolated how NCD-attributable medical expenditure can result in impoverishment and downward movement in net consumption status at the population level. Results: NCD-afflicted households allocate a greater share of household expenditures for medical care than households without NCDs, and their probability of incurring catastrophic medical expenditure is higher by 6.7 percentage points compared to the households with no reported conditions. NCD households are 85% more likely to sell assets or borrow from informal sources to finance treatment cost. Household spending on NCD care is estimated to account for the impoverishment of 0.66 million persons in Bangladesh in 2010, and for reducing the net consumption status of 7.63 million persons on both sides of the poverty line after accounting for NCD-related OOP expenditures. Conclusion: NCD-related household medical expenditure is associated with experiencing financial distress and aggravating poverty in Bangladesh. |
Does state Medicaid coverage of smoking cessation treatments affect quitting
Kostova D , Xu X , Babb S , McMenamin SB , King BA . Health Serv Res 2018 53 (6) 4725-4746 OBJECTIVE: Cigarette smoking and smoking-related diseases disproportionately affect low-income populations. Health insurance coverage of smoking cessation treatments is increasingly used to encourage quitting. We assess the relationship between state Medicaid coverage of smoking cessation treatments and past-year quitting in adult Medicaid beneficiaries. DATA SOURCES: 2009-2014 National Health Interview Survey (NHIS); 2008-2013 indicators of state Medicaid coverage of smoking cessation treatments. STUDY DESIGN: A triple-differencing specification based on differences in Medicaid cessation coverage policies across states as well as within-state differences between Medicaid beneficiaries and a counterfactual group of low-income adults not covered by Medicaid. DATA COLLECTION/EXTRACTION METHODS: Individual-level NHIS data with restricted geographical identifiers were merged with state-year Medicaid coverage indicators. PRINCIPAL FINDINGS: Combined coverage of both cessation counseling and medications in state Medicaid programs was associated with increased quitting, with an estimated mean increase in past-year quitting of 3.0 percentage points in covered Medicaid beneficiaries relative to persons without coverage. CONCLUSIONS: Combined coverage of both smoking cessation counseling and medication by state Medicaid programs could help reduce cigarette smoking among Medicaid beneficiaries. |
Synergies between communicable and noncommunicable disease programs to enhance global health security
Kostova D , Husain MJ , Sugerman D , Hong Y , Saraiya M , Keltz J , Asma S . Emerg Infect Dis 2017 23 (13) S40-6 Noncommunicable diseases are the leading cause of death and disability worldwide. Initiatives that advance the prevention and control of noncommunicable diseases support the goals of global health security in several ways. First, in addressing health needs that typically require long-term care, these programs can strengthen health delivery and health monitoring systems, which can serve as necessary platforms for emergency preparedness in low-resource environments. Second, by improving population health, the programs might help to reduce susceptibility to infectious outbreaks. Finally, in aiming to reduce the economic burden associated with premature illness and death from noncommunicable diseases, these initiatives contribute to the objectives of international development, thereby helping to improve overall country capacity for emergency response. |
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