The Chronic Disease Prevention model and its use in the definition of public health policies Jeremy Lauer, PhD Health Systems Financing World Health Organization

Generalized Cost-effectiveness Analysis Acknowledges global budget constraints Allows the comparison of interventions within and outside the health sector Identifies the mix of interventions that generates the largest health gain Improves the transferability of results across similar settings

When is cost-effectiveness analysis useful? Outside health sector: –When the finance minister says, "So what's your plan?" –To support strategies with operationalizable actions Inside health sector: –To assist establishing priorities for action. –To set norms and standards –To plan for health system development Outside health sector Inside health sector

WHO-CHOICE has focused on cancers for which there are both treatment and preventive interventions. In addition, interventions to prevent or reduce tobacco use, responsible for about one-quarter of the total cancer burden. Other high-burden cancers such as stomach (about 11% of cancer burden) and liver (about 9% of cancer burden) lack efficacious treatments options at present.  breast, cervical and colorectal cancer. Background: WHO-CHOICE work on cancer

WHO-CHOICE work on cancer 10-country study financed by the Komen Foundation to use cost-effectiveness analysis to support policy development in breast cancer control; participating are: –Mexico –Costa Rica –Colombia and –Brazil. Our work on the CDP model was motivated by the desire to embed this analysis inside a broader NCD framework.

Scope of previous CDP modelling work Regional analysesCountry analyses

Distal risk factors Intermediate risk factor Proximal risk factors Diseases Causal web concept Ezzati M et al., 2004

Physical activity adequate physical act insuff.physical act Body mass index normal weight pre-obesity obesity Blood pressure normal hypertension Cholesterol normal hypercholesterolemia Glycaemia normal diabetes Cancers Stroke Ischemic heart disease Distal risk factors Intermediate risk factor Proximal risk factors Diseases Fat low fat intake medium fat intake high fat intake Fibre adequate fibre intake low fibre intake Socio-economic status upper lower

Microsimulation approach (StatCan) Starting population (age- and sex-based distribution); prevalences, incidences, etc. At the beginning of the simulation, individuals are : (1) assigned to different risk factor groups; (2) given certain characteristics that determine their evolution over time. The model runs for set period of time allowing for births and deaths; individuals are exposed to the risk of death and disease, and demographic processes. Model inputs can be adjusted so as to create alternative scenarios (e.g. assess impact of interventions). Output tables can include: life expectancies, population healthy years, disease episodes, time spent with disease, disease prevalence and incidence, remission and mortality rates.

Interventions Health education and health promotion Regulation and fiscal measures Primary-care based interventions Mass media campaigns Fiscal measures (fruit and vegetables and foods high in fat) Physician counselling of individuals at risk School-based interventions Government regulation or industry self-regulation of food advertising to children Intensive physician and dietician counselling of individuals at risk Worksite interventions Compulsory food labelling

Health Impact Mass media camp Worksite interv. Physician couns. School-based int. Food labelling Fiscal measures Food advert reg. Disability-adjusted life years (thousands) Life years (thousands)

DALYs Saved as a function of time

Impact on Health Expenditure

Cost and Impact on Health Expenditure

Financial Impact

An Affordable Prevention Package

Cost-Effectiveness after 20 years Brazil India China Russian Federation Mexico South Africa England after 50 years

Cost-effectiveness as a function of time

Impact on Inequalities Worksite interventionsFiscal measures

What matters most for health policy? Does prevention improve health? Does it reduce health expenditure? Does it improve health inequalities? Is it cost-effective?

References Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost- effectiveness Lancet Nov 20;376(9754):