Costs, Benefits, and Effectiveness of Interventions for the Prevention, Treatment, and Control of Cardiovascular Diseases and Diabetes in Africa

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Available online at www.sciencedirect.com

ScienceDirect www.onlinepcd.com

Costs, Benefits, and Effectiveness of Interventions for the Prevention, Treatment, and Control of Cardiovascular Diseases and Diabetes in Africa Shanthi Mendisa,⁎, Oleg Chestnovb a

Management of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland Noncommunicable Diseases and Mental Health, World Health Organization, Geneva, Switzerland

b

A R T I C LE I N FO

AB S T R A C T

Keywords:

If a combination of cost-effective health-care interventions and population-wide preven-

Cardiovascular disease

tion interventions is implemented in a sustainable manner, a significant impact can be

Diabetes

made on the cardiovascular disease and diabetes burden. Given the limited resources, weak

Cost effectiveness

health systems and competing health issues in Africa, the focus should be on interventions

Cost

prioritized on the basis not only of cost effectiveness but also of affordability, feasibility and high impact. The Global Action Plan for prevention and control of noncommunicable diseases 2013–2020 identifies such a core set. Financing the effective delivery of this core set as part of the basic health care package through a strengthened health system is a pragmatic approach to address cardiovascular disease and diabetes in Africa. Cost of implementation of this core set of interventions represents an annual investment of under US$ 1 in low income countries, US$ 1.50 in lower middle income countries and US$ 3 in upper middle income countries. © 2013 Published by Elsevier Inc.

Background Cardiovascular diseases, diabetes and other noncommunicable diseases are major threats to public health in the 21st century. An estimated 36 million deaths, or 63% of the 57 million deaths that occurred globally in 2008, were due to noncommunicable diseases (NCD), comprising mainly cardiovascular diseases (48%), cancers (21%), chronic respiratory diseases (12%) and diabetes (3.5%).1–3 The African Region has the highest age standardized death rate from noncommunicable diseases (779 per 100, 000).4 The probability of dying from NCDs between 30 and 70 years is also very high in sub Saharan Africa.

Behavioral risk factors, including tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol, are estimated to be responsible for about 80% of coronary heart disease and cerebrovascular disease.3 Diabetes also increases the risk of cardiovascular deaths, and is estimated to cause 22% of coronary heart disease deaths and 16% of stroke deaths.4 In order to effectively respond to the complex social, cultural and behavioral issues associated with cardiovascular disease, diabetes and other NCDs, national health systems should be oriented towards health promotion, prevention and delivery of cost effective interventions through a primary health care approach.5–8

Disclaimer. Dr. Shanthi Mendis and Dr. Oleg Chestnov of the World Health Organization contributed this paper in their personal capacity. The contents of the paper do not necessarily represent the decisions or the policies of the World Health Organization. Statement of Conflict of Interest: see page 320. ⁎ Address reprint requests to Dr. Shanthi Mendis Director a.i., Department of Management of Noncommunicable Diseases, World Health Organization, Geneva 1211, Switzerland. E-mail address: [email protected] (S. Mendis). 0033-0620/$ – see front matter © 2013 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.pcad.2013.09.001

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Abbreviation and Acronym NCD = noncommunicable disease

Public health strategies to address cardiovascular diseases and diabetes

The likelihood of cardiovascular disease increases continuously as the level of risk factors such as blood pressure or blood glucose increase. Although cutoff points are used to define hypertension and diabetes the risk of cardiovascular disease remains even below these thresholds. Most cardiovascular disease in the population occurs in people with an average risk level, because they constitute the largest proportion of the population. The high risk segment of the population which is smaller contributes less to the cardiovascular disease burden of a population. Cost effective prevention and control of cardiovascular disease and diabetes require a combination of complimentary strategies. These include strategies to reduce exposure of the population to risk factors and to treat individuals at high risk and with established disease. Both strategies have the potential to shift the cardiovascular risk profile of the population to a healthy distribution reducing heart attacks, strokes, cardiac failure and complications of diabetes.9–14

Effective population-wide interventions to reduce exposure to behavioral risk factors Effective interventions to reduce tobacco use include tobacco tax increases, dissemination of information about the health risks of smoking, restrictions on smoking in public places and workplaces, and comprehensive bans on advertising and promotion.15,16 Increases in taxes on and prices of tobacco products are effective in significantly reducing the prevalence of tobacco use.17 Smoke-free work sites and public places reduce second-hand smoke18 and help smokers to cut down or quit smoking. Providing information on tobacco-dependence and health impacts of tobacco has been demonstrated to reduce consumption. Mass media campaigns and graphic health warnings on tobacco packages reduce demand.19,20 A comprehensive set of tobacco advertising and promotion bans has been demonstrated to reduce tobacco consumption by 6.3%.21 A combination of behavioral and pharmacological therapies is effective in achieving tobacco cessation.22 There are many effective interventions to reduce the harmful use of alcohol.23–25 They include: increasing excise taxes on alcoholic beverages; regulating availability of alcoholic beverages, including minimum legal purchase age, restrictions on outlet density and on time of sale; restricting exposure to marketing of alcoholic beverages through effective marketing regulations or comprehensive advertising bans; drink-driving countermeasures including random breath testing; treatment of alcohol use disorders and brief interventions for hazardous and harmful drinking and educational and information campaigns to support these measures. There is evidence that a diet with certain features can prevent cardiovascular diseases and diabetes.9,10,26,27 These features are: balanced energy intake and expenditure to

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maintain a healthy weight; energy intake from total fats less than 30% of total energy intake, shift of fat consumption away from saturated fats to unsaturated fats and towards elimination of trans-fatty acids; limited intake of free sugars; limited sodium consumption from all sources; increased consumption of fruits, legumes, whole grains and nuts. Epidemiological data define the likely magnitude of the blood pressure reductions and cardiovascular risk reductions that could be achieved from reducing sodium consumption.28,29 It has been estimated that if salt consumption is reduced to the recommended level of less than 5 g per day, up to 2.5 million cardiovascular deaths could be prevented each year.26,30 Both legislative and voluntary salt reduction strategies have been shown to be effective for reducing dietary sodium. There are national salt reduction initiatives in several countries including in Africa and a few in developed countries have already demonstrated an impact on consumer awareness or salt levels in food or population salt consumption.31 The elimination of trans-fatty acids from the diet reduces cardiovascular risk. Effective interventions to eliminate transfatty acids include mandatory regulation of food standards, raising awareness about adverse effects of trans-fatty acids, nutrition recommendations, voluntary or mandatory labeling of trans-fatty acid content of foods, and voluntary reformulation by industry.32–34 The reduction in marketing of foods and non-alcoholic beverages high in salt, fats and sugar to children is also an effective action to reduce cardiovascular diseases.35–37 Economic tools such as increased taxation on less healthy foods and decreased taxation, price subsidies or production incentives of healthy foods also have been demonstrated to be effective in promoting a healthy diet.33–35 However, for some of these interventions, the evidence base remains weak and/or the time to effect is relatively long (e.g. food taxes and subsidies, or the regulation of food advertising). There are a number of effective interventions to promote physical activity.33–35 They include; media campaigns to promote physical activity; public policies to encourage physical activity, across sectors including transport, education, youth affairs, sport and urban design; school-based interventions to improve knowledge, attitudes, and behaviour related to physical activity; workplace health promotion programs and community initiatives to promote healthy behavior including physical activity. In addition, community interventions that provide advice on lifestyle modifications that include moderate physical activity and dietary guidance have been shown to prevent diabetes in people who have impaired glucose tolerance.37 It must be noted that, evidence for interventions to promote physical activity comes from small-scale studies conducted in selected settings.38

Benefits and cost effectiveness of population-wide prevention interventions Cost-effectiveness refers to the efficiency with which an intervention produces health outcomes. A “very costeffective” intervention is defined as one that generates an extra year of healthy life (equivalent to averting one disabilityadjusted life year) for a cost that falls below the average annual

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Table 1 – Cost, benefit and cost effectiveness of population-wide interventions to reduce exposure to behavioral risk factors.13 Risk Factor (DALYs, in Millions; % Global Burden) a

Tobacco use (> 50 m DALYs; 3.7% global burden)

Alcohol use (> 50 m DALYs; 4.5% global burden)

Unhealthy diet (> 15 m DALYs; >1% global burden) c

Physical inactivity (> 30 m DALYs; 2.1% global burden)

Interventions/Actions

Protect people from tobacco smoke e Warn about the dangers of tobacco e Enforce bans on tobacco advertising e Raise taxes on tobacco e Offer counseling to smokers Restrict access to retailed alcohol e Enforce bans on alcohol advertising e Raise taxes on alcohol e Enforce drink driving laws (breath-testing) Offer counseling to drinkers Reduce salt intake in food e Restrict food marketing Promote public awareness about diet d Introduce food taxes and subsidies Offer counseling in primary care d Provide health education in worksites d Promote healthy eating in schools d Enforce ban on trans-fat in prepared foods Promote physical activity (mass media) d Promote physical activity (communities) Support active transport strategies Offer counseling in primary care d Promote physical activity in worksites d Promote physical activity in schools d

Avoidable Burden Cost-Effectiveness Implementation Cost (DALYs Averted, Millions) (US$ Per DALY Prevented) (US$ Per Capita) [Very = < GDP Per Person; [Very Low = < US$0.50; Quite = < 3 GDP Per Person Quite Low = < US$ 1 Less = >3 GDP Per Person] Higher = > US$ 1] Combined effect: 25–30 m DALYs averted (> 50% tobacco burden)

Combined effect: 5–10 m DALYs averted (10%–20% alcohol burden)

Effect of salt reduction:5 m DALYs averted Other interventions: Not yet established globally

Not yet established globally

Very cost-effective

Very low cost

Quite cost-effective Very cost-effective

Quite low cost Very low cost

Quite cost-effective

Quite low cost

Very cost-effective Very cost-effective (but more studies needed)

Very low cost Very low cost

Quite cost-effective

Higher cost

Not cost-effective

Low cost

Not established

Very low cost

Very cost-effective (but more studies needed) Not established

Very low cost

Quite cost-effective

Higher cost

Not established

Not cost-effective

a

disability-adjusted life years (DALYs). Low fruit and vegetable intake only. d Combined interventions covering both diet and physical activity (counseling in primary care; school-based intervention; work site intervention); the independent effect of these interventions – on diet or physical activity alone – has not yet been established at the global level. e Very cost effective interventions. c

income or gross domestic product [GDP] per person. Table 1 shows a summary of costs, benefits and cost effectiveness of population-wide interventions to reduce exposure to behavioral risk factors. Among them there are interventions that are very cost effective for all countries including Africa. For tobacco control very cost effective interventions include tax increases, comprehensive legislation creating smoke-free indoor workplaces and public places, health information and warnings about the effects of tobacco, and

bans on advertising, promotion and sponsorship.14 Enhanced taxation of alcoholic beverages and comprehensive bans on their advertising/marketing are very cost effective interventions to reduce harmful use of alcohol.23 Reducing salt content in processed foods and through mass media campaigns is a very cost effective intervention which has the potential to prevent millions of deaths.30 Partial or complete substitution of partially hydrogenated trans-fat with polyunsaturated fats is another highly cost

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effective measure that has been successfully implemented at the point of manufacture of food in several developed countries. A number of other low-cost and feasible interventions that tackle unhealthy diet and physical activity, for example by promoting public awareness, have also been found to be highly cost-effective.13,14,34

Costs of implementation of population-based interventions The cost of implementing four population-based demand reduction measures for tobacco control (smoke-free policies, raise tobacco taxes, package warnings, advertising bans) is low. Total financial resources required to implement them in all low- and middle-income countries is projected to be 0.6 billion per year or US$ 0.11 per head of population.13 Costs include media campaigns and overall program management. Implementation costs vary by income level of countries; the median cost per capita ranges from as little as US$ 0.05 in low-income countries to US$ 0.15 in upper-middle income countries.13

Table 2 – Cost effective individual interventions for prevention and treatment of cardiovascular disease and diabetes.6 •Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years a •Acetylsalicylic acid for acute myocardial infarction a •Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals who have had a heart attack or stroke, and to persons with moderate risk (≥ 20%) of a fatal and nonfatal cardiovascular event in the next 10 years •Secondary prevention of rheumatic fever and rheumatic heart disease •Acetylsalicylic acid, atenolol and thrombolytic therapy (streptokinase) for acute myocardial infarction •Treatment of congestive cardiac failure with ACE inhibitor, betablocker and diuretic •Cardiac rehabilitation post myocardial infarction •Anticoagulation for medium- and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation •Low-dose acetylsalicylic acid for ischemic stroke •Care of acute stroke and rehabilitation in stroke units •Lifestyle interventions for preventing type 2 diabetes •Influenza vaccination for patients with diabetes •Preconception care among women of reproductive age including patient education and intensive glucose management •Detection of diabetic retinopathy by dilated eye examination followed by appropriate laser photocoagulation therapy to prevent blindness •Effective angiotensin-converting enzyme inhibitor drug therapy to prevent progression of renal disease •Interventions for foot care: educational programmes, access to appropriate footwear; multidisciplinary clinics a

Very cost-effective i.e. generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person.

Table 3 – The benefit of individual interventions for prevention and treatment of diabetes.11 Interventions With Evidence of Efficacy Lifestyle interventions for preventing type 2 diabetes in people at high risk Metformin for preventing type 2 diabetes for people at high risk Glycemic control in people with HbA1c greater than 9% Blood pressure control in people whose pressure is higher than 130/80 mmHg

Annual eye examinations Foot care in people with high risk of ulcers ACE inhibitor use in all people with diabetes

Benefit Reduction of 35%–58% in incidence Reduction of 25%–31% in incidence Reduction of 30% in microvascular disease per 1 percent drop in HbA1c Reduction of 35% in macrovascular and microvascular disease per 10 mmHg drop in blood pressure Reduction of 60% to 70% in serious vision loss Reduction of 50% to 60% in serious foot disease Reduction of 42% in nephropathy; 22% drop in cardiovascular disease

The three very cost effective interventions for reducing harmful use of alcohol are restriction of access to retailed alcohol, enforcement of bans on alcohol advertising and raising taxes on alcohol. The cost of implementing them in Africa is US$ 0.14 per person. Core drivers of these costs are media related expenses and human resource costs involved in program management and enforcement of alcohol-related laws and policies. Three interventions for promoting healthy diet and physical activity that can be categorized as very cost effective include: promoting public awareness about diet and physical activity, reducing salt intake, and replacing trans-fat with polyunsaturated fat. The costs of implementing them are low (less than US$ 0.10 per person in Africa). The largest public health expenditure involved in implementing these interventions is in relation to health promotion and awareness campaigns using mass media.

Cost effective individual interventions for prevention and treatment of cardiovascular disease and diabetes Table 2 summarizes some of the cost effective individual interventions for prevention and treatment of cardiovascular disease and diabetes. There are three categories of individual interventions based on the complexity of service delivery.2,9–12,39,40 They are: interventions that pertain to acute events which need to be delivered in special units dealing with coronary care, stroke care or intensive care; health service interventions dealing with complications and advanced stages of disease and; primary health-care interventions for proactive early detection and treatment of cardiovascular risk including diabetes. The last category of primary care interventions reduces the demand for the first

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Table 4 – Cost, benefit and cost effectiveness of individual interventions for prevention and treatment of cardiovascular disease and diabetes.13 Disease (% Global Burden; DALYs a)

Cardiovascular disease (CVD) & diabetes (170 m DALYs; 11.3% global burden)

a b

Interventions/Actions

Avoidable Burden (DALYs Averted, Millions)

Cost-Effectiveness (US$ Per DALY Prevented) [Very = < GDP Per Person; Quite = < 3 GDP Per Person Less = > 3 GDP Per Person]

Implementation Cost (US$ Per Capita) [Very Low = < US$ 0.50; Quite Low = < US$ 1 Higher = > US$ 1]

Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals (≥ 30 years), who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years b Aspirin therapy for acute myocardial infarction Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals (≥ 30 years), who have had a heart attack or stroke and to persons with medium risk (≥ 20%) of a fatal and nonfatal cardiovascular event in the next 10 years b

60 m DALYS averted (35% CVD burden)

Very cost-effective

Quite low cost

4 m DALYs averted (2% CVD burden) 70 m DALYS averted (40% CVD burden)

Very cost-effective

Quite low cost

Quite cost-effective

Higher cost

DALYs (disability-adjusted life years). Includes prevention of recurrent vascular events in people with established coronary heart disease and cerebrovascular disease.

two categories of interventions which are labour intensive, costly and require health workers with specific skills, high technology equipment, and tertiary hospital infrastructure. Counseling and drug treatment in primary care to reduce cardiovascular risk in high risk people, are cost effective for primary prevention of coronary heart disease and stroke if targeted to those at high total cardiovascular risk. Interventions targeting single risk factor levels above traditional thresholds through vertical programs to control hypertension or hypercholesterolemia are less cost effective.41 It is feasible to deliver cardiovascular risk reduction interventions in primary care, even in low-resource settings with non-physician health workers.42,43 Currently, there are major gaps in access to these essential primary care interventions44 in developing countries including in those in sub-Saharan Africa. There are cost effective interventions available for treating established cardiovascular disease and prevention of recurrences. Aspirin, atenolol and streptokinase significantly reduce the relative risk of dying from acute myocardial infarction.45,46 Aspirin, beta-blockers, angiotensin converting enzyme inhibitors and lipid-lowering therapies lower the risk of recurrent vascular events by about a quarter each.2,10,11 When these interventions are used together with smoking cessation, about three-quarters of recurrent vascular events

could be prevented. The incremental cost for aspirin and atenolol is less than US$ 25 per DALY averted worldwide.11 Secondary prophylaxis for rheumatic fever using benzathine penicillin is a cost-saving intervention. These interventions can be delivered in primary care settings with basic technologies and essential medicines.40,47 There are several evidence-based individual interventions for addressing diabetes (Table 3). Three of them reduce cost while improving health.2,11,48 These are blood pressure control (when blood pressure is above 130/80), glycemic control (in people with HbA1c >9%) and foot care for people with a high risk of ulcers. Blood pressure control in people with diabetes has been demonstrated to be highly effective in reducing cardiovascular complications as well as retinopathy and nephropathy.

Cost of implementing individual interventions for prevention and treatment of cardiovascular disease and diabetes Table 4 shows cost, benefit and cost effectiveness of individual interventions for prevention and treatment of cardiovascular disease and diabetes. Improved access to effective interventions at the primary health-care level offers the

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greatest potential for reducing complications, hospitalizations, health-care costs and out-of-pocket expenditures. As alluded to above, there are two very cost effective interventions for prevention and treatment of cardiovascular disease and diabetes that can be implemented in primary care settings.2,6,13,14 These include drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years and aspirin for acute myocardial infarction. The estimated annual average cost of scaling these two interventions in all low and middle income countries is a little over US$ 8 billion. This includes the cost of screening to detect people at high cardiovascular risk, at a cost of US$ 3–5 per person screened. The annual cost per treated case ranges from US$ 70 in low income countries to US$ 105 in upper-middle income countries. The annual cost per person falls below US$ 1 in low income countries and less than US$ 1.50 in lower middle income countries and US$ 2.50 in upper middle income countries.

Table 5 – The nine voluntary global targets for prevention and control of noncommunicable diseases to be achieved by 2025.6 Framework Element Premature mortality from noncommunicable disease

Behavioral risk factors Harmful use of alcohol

Physical inactivity

Salt/sodium intake Tobacco use

Biological risk factors Raised blood pressure

Target (1) A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases (2) At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context (3) A 10% relative reduction in prevalence of insufficient physical activity (4) A 30% relative reduction in mean population intake of salt/sodium (5) A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years

(6) A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances Diabetes and obesity (7) Halt the rise in diabetes and obesity Drug therapy to prevent (8) At least 50% of eligible people heart attacks and strokes receive drug therapy and counseling (including glycemic control) to prevent heart attacks and strokes Essential noncommunicable (9) An 80% availability of the disease medicines and basic affordable basic technologies and technologies to treat major essential medicines, including noncommunicable diseases generics, required to treat major NCD in both public and private facilities

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Table 6 – Very cost effective a policy measures and interventions for cardiovascular disease and diabetes.13 Tobacco use •Reduce affordability of tobacco products by increasing tobacco excise taxes •Create by law completely smoke-free environments in all indoor workplaces, public places and public transport •Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns •Ban all forms of tobacco advertising, promotion and sponsorship Harmful use of alcohol •Regulating commercial and public availability of alcohol •Restricting or banning alcohol advertising and promotions •Using pricing policies such as excise tax increases on alcoholic beverages Unhealthy diet and physical inactivity •Reduce salt intake •Replace trans fats with unsaturated fats •Implement public awareness programmes on diet and physical activity Cardiovascular disease and diabetes •Drug therapy (including glycemic control for diabetes mellitus and control of hypertension using a total risk approach) and counseling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and nonfatal cardiovascular event in the next 10 years •Acetylsalicylic acid for acute myocardial infarction a

Very cost-effective i.e. generate an extra year of healthy life for a cost that falls below the average annual income or gross domestic product per person.

Implementation of cost effective interventions for addressing cardiovascular disease and diabetes in the African region On the 27th of May 2013, the Global Plan for the prevention and control of NCD for the period 2013–2020, including a comprehensive monitoring framework was adopted by 194 Member States of the World Health Organization.6 The Action Plan is built on six interconnected and mutually reinforcing objectives and proposes multilevel actions for Member States, international partners, United Nations Funds, Agencies and programs and WHO. The six objectives focus on international cooperation and advocacy, country led multisectoral response, risk factors and determinants, health systems and universal health coverage, research development and innovation and surveillance and monitoring. The global monitoring framework has nine voluntary global targets (Table 5). The nine targets focus on premature mortality from major NCD, tobacco use, harmful use of alcohol, physical inactivity, salt intake, hypertension, diabetes, obesity, heart attacks and strokes and essential medicines and technologies. Countries in Africa face many barriers to address prevention and control of noncommunicable diseases including the unfinished agenda of communicable diseases, the growing burden of neuropsychiatric disorders, severe resource constraints and weak health systems.49 In this context, interventions to address cardiovascular disease and diabetes need to be prioritized taking into consideration cost effectiveness as well as other factors such as affordability, implementation capacity, feasibility, and

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impact on health equity. Based on applicability and feasibility of implementation in all countries, a core set of very cost effective interventions has been highlighted in the global NCD action plan (Table 6). All of them together contribute to prevention, treatment and control of cardiovascular disease and diabetes. The implementation cost per head of this core set of interventions is low. It represents an annual investment of under US$ 1 in low income countries, US$ 1.50 in lower middle income countries and US$ 3 in upper middle income countries. Expressed as a proportion of current health spending, implementation costs amount to 4% in lower income countries 2% in lower middle income countries and less than 1% in upper middle income countries. Global voluntary targets cannot be achieved, without prevention, treatment and control of cardiovascular disease and diabetes in Africa. At least a modest increase in investment in health care is needed to expand coverage of very cost effective interventions. In many parts of Africa the high out of pocket expenditure on health results in financial hardship. Out of pocket payment is also a deterrent to early detection and treatment. Appropriate health financing policies are urgently needed to shift from reliance on user fees levied on ill people to the protection provided by pooling and prepayment, with inclusion of a core set of cost effective NCD services. Long-term aim should be to make progress towards universal health coverage through a combination of domestic revenues and traditional and innovative financing.9,11,12

State of Conflict of Interest All authors declare that there are no conflicts of interest. REFERENCES

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