Draft Updated Appendix 3 of the WHO Global NCD Action Plan ...€¦ · 7 October 2016 The Secretariat will submit a final draft of the updated Appendix 3 to WHO’s Governing Bodies

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WHO Discussion Paper (version dated 25 July 2016)

Draft Updated Appendix 3 of the WHO Global NCD Action Plan 2013-2020

MANDATE 1. Resolution WHA69.6 noted “the process to update, in 2016, Appendix 3” and requested DG “to submit an updated Appendix 3 of the global action plan for the prevention and control of noncommunicable diseases 2013–2020, through the Executive Board, to the Seventieth World Health Assembly in 2017, in accordance with the timeline contained in Annex 2 of document A69/10”1. This WHO Discussion paper is prepared pursuant to this resolution.

BACKGROUND 2. In the Director General’s report to the 68th World Health Assembly in May 20152, the WHO Secretariat committed to update Appendix 3 of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCD) 2013-2020 to consider new scientific evidence since the initial list was prepared. 3. Appendix 3 consists of a menu of policy options to support the implementation of the 6 objectives of the Global NCD Action Plan. These 81 recommendations include 14 interventions which are classified as “very cost-effective and affordable interventions for all Member States”3 (previously referred to as the “best buys”), as well as other cost-effective interventions (previously referred to as “good buys”). The purpose is to assist Member States in implementing, as appropriate, for national context, (without prejudice to the sovereign rights of nations to determine taxation among other policies), actions to achieve the nine voluntary global targets for NCD prevention and control. The list of interventions is not exhaustive but is intended to provide information and guidance on effectiveness and cost-effectiveness of population-based and individual interventions based on current evidence, and to act as the basis for future work to develop and expand the evidence base. 4. The main reasons for updating Appendix 3 are firstly, to take into consideration the emergence of new evidence of cost-effectiveness or new WHO recommendations since the adoption of the WHO Global NCD Action Plan 2013-2020, and secondly, to refine the existing formulation of some interventions based on lessons learnt from the use of the first version. The area of Appendix 3 where this is most relevant is under Objective 3 (risk factors) and Objective 4 (health systems). All of

1 http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R6-en.pdf 2 Paragraph 21 in http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_11-en.pdf 3 Generate an extra year of healthy life for a cost that falls below the average annual income or GDP per

person

http://www.who.int/nmh/events/ncd_action_plan/en/

http://www.who.int/nmh/events/ncd_action_plan/en/

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the “very cost-effective and affordable interventions for all Member States” interventions in the original Appendix were listed under Objectives 3 and 4, and this remains the case in the updated version. The Global Action Plan for the prevention and control of noncommunicable diseases ends in 2020, and once the updated Appendix 3 is presented to the World Health Assembly in 2017, any future updates will be considered as part of the development of any subsequent global strategies for noncommunicable diseases.

PROCESS FOLLOWED BY THE SECRETARIAT TO UPDATE APPENDIX 3 5. The Secretariat has convened two technical consultations to seek expert advice on the approach to this work. The first technical consultation was held on 22-23 June 20154, to advise the WHO Secretariat on a suitable methodology for conducting the update of Appendix 3. This methodology was presented to Member States at the Executive Board in January 2016, and endorsed at the World Health Assembly in May 20165. Following the process endorsed by Member States, the Secretariat identified a revised list of 119 potential interventions, including 53 with updated economic data analysed through WHO-CHOICE. 6. A second technical consultation was held in Geneva, 27-28 June 20166, to review the updated economic analyses and discuss the criteria for determining the “very cost-effective & affordable interventions” from the updated list of interventions, and advise on how to structure and present the broad range of policy interventions (some which are suited to economic analysis and some which are not) in a user-friendly way to support implementation of the Global Action Plan in Member States. 7. Through both technical consultations, it was acknowledged that there are inherent challenges in identifying a core list of interventions whilst being comprehensive enough to meet the needs of Member States. The limitations of considering cost-effectiveness in isolation were also recognised, together with the absence of objective criteria for incorporating non-financial considerations into recommendations. Acknowledging these challenges, the Secretariat was urged to be as clear and specific as possible regarding the methodology and source/nature of evidence, while clearly communicating the limitations of economic modelling and not creating false sense of confidence in the precision of any economic values. The Secretariat was also advised to retain familiarity and consistency with the existing Appendix 3 and previously agreed global strategies, to maintain momentum and progress underway in Member States.This update of Appendix 3 is accompanied by a technical annex. This annex provides more detailed information about the methodology used to identify and analyse interventions, and includes the assumptions used in the WHO-CHOICE economic modelling7. The technical annex also presents more detailed economic analyses for each intervention, structured in a variety of ways to provide more information for decision-makers. This includes presenting the results of the economic analysis separately for low and lower-middle income, and upper-middle and high income countries. The Secretariat will also consider the utility of providing this information in an interactive web-tool, to enable users to compare and rank the information according to their own needs once the updated Appendix 3 is finalized.

4 http://www.who.int/nmh/events/meeting-report-consultation-on-appendix-3-final.pdf

5 http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_1Rev1-en.pdf 6 http://www.who.int/nmh/events/en/ 7 http://www.who.int/choice/cost-effectiveness/en/

http://www.who.int/nmh/events/meeting-report-consultation-on-appendix-3-final.pdf

http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_1Rev1-en.pdf

http://www.who.int/nmh/events/en/

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PROPOSED UPDATED APPENDIX 3 8. Annex 1 outlines the proposed structure and content of the updated Appendix 3. This includes: – A proposed preamble text to the Appendix 3 – The updated list of interventions for the main Appendix 3, and – An annotated outline of the proposed technical Annex, which would include more details about

the economic analysis, and methodological information. This would be accompanied at a later stage by an interactive web-based version of the economic analysis, so that users could structure the tables according to their own needs.

TIMELINE AND NEXT STEPS 9. As per the approach shared with Members States, the timeframe and next steps for finalising the updated Appendix 3 is as follows:

Dates Activity

22 July 2016 until 1 September 2016

The Secretariat will hold a web-based consultation on a WHO Discussion Paper which will contain a preliminary updated Appendix 3. The WHO Discussion Paper will be published in English first, and versions in the other five languages will follow shortly. The web-based consultation will be open to Member States, organizations of the UN System, and non-State actors. All contributions received will be published on WHO’s website.

24 August 2016 The Secretariat will convene an informal consultation of Member States in the Executive Board Room on the WHO Discussion Paper. Interpretation will be provided in all six languages.

25 August 2016 The Secretariat will convene informal hearings with non-State actors in the Executive Board Room on the WHO Discussion Paper.

7 October 2016 The Secretariat will submit a final draft of the updated Appendix 3 to WHO’s Governing Bodies for processing and translation, which will enable Member States to access the EB140 report containing the updated Appendix 3 in November 2016 in preparation for EB140 in January 2017.

January 2017 EB140 will consider the draft updated Appendix 3.

May 2017 Pending discussions at EB140, the final draft of the updated Appendix 3 will be submitted to WHA70 for consideration by Member States.

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Annex 1. Proposed updated Appendix 3 of the Global Action Plan for the prevention and control of noncommunicable diseases 2013-2020

What is Appendix 3? Provided at the request of Member States, Appendix 3 is a menu of policy options and cost-effective interventions for prevention and control of major noncommunicable diseases. The purpose is to assist Member States in implementing, as appropriate, for national context, (without prejudice to the sovereign rights of nations to determine taxation among other policies), actions to achieve the nine voluntary global targets for NCD prevention and control through the six objectives of the NCD Global Action Plan 2013-2020. The list of interventions is not exhaustive but is intended to provide information and guidance on effectiveness and cost-effectiveness of population-based and individual interventions based on current evidence, and to act as the basis for future work to develop and expand the evidence base.

Why update Appendix 3? The main reasons for updating Appendix 3 are firstly, to take into consideration the emergence of new evidence of cost-effectiveness or new WHO recommendations since the adoption of the Global Action Plan for the prevention and control of noncommunicable diseases 2013, and secondly, to refine the existing formulation of some interventions based on lessons learnt from the use of the first version. The area of Appendix 3 where this is most relevant is under Objective 3 (risk factors) and Objective 4 (health systems). All of the “very cost-effective and affordable interventions for all Member States” interventions in the original Appendix were listed under Objectives 3 and 4, and this remains the case in the updated version. The Global Action Plan for the prevention and control of noncommunicable diseases ends in 2020, and once the updated Appendix 3 is presented to the World Health Assembly in 2017, any future updates will be considered as part of the development of any subsequent global strategies for noncommunicable diseases.

What has changed? The menu of options listed for Objectives 1 (raising the priority of NCDs), 2 (strengthening leadership & governance), 5 (research) and 6 (monitoring & evaluation) are process-related recommendations and have not changed. Within Objectives 3 (risk factors) and 4 (health systems), in the updated Appendix 3, there are a now a total of 88 interventions and overarching/enabling actions, representing an expansion from the original list of 62. This increase is due to the availability of scientific evidence as proposed by WHO technical units or expert groups, as well as the need to disaggregate some previous interventions into more defined, implementable options. As in the first Appendix, a select number of those interventions which are considered most cost-effective and feasible for implementation are identified in bold. In the updated Appendix, there are now 15 bolded interventions with an average

cost-effectiveness ratio of ≤I$8100/DALY averted in low and lower middle income countries and 19 interventions with a cost-effectiveness ratio >I$100/DALY. In addition 30 interventions without CEA but are part of WHO guidance are also provided.

8 The International dollar is a hypothetical unit of currency that has the same purchasing power parity that the U.S. dollar had in the United States at a given point in time.

https://en.wikipedia.org/wiki/Purchasing_power_parity

https://en.wikipedia.org/wiki/Purchasing_power_parity

https://en.wikipedia.org/wiki/United_States_dollar

https://en.wikipedia.org/wiki/United_States

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Technical annex Based on feedback from experts and Member States, this update of Appendix 3 is accompanied by a technical annex. This annex provides more detailed information about the methodology used to identify and analyse interventions, and includes the assumptions used in the WHO-CHOICE economic modelling. The technical Annex also presents more detailed economic analyses for each intervention, structured in a variety of ways to provide more information for decision-makers. This includes presenting the results of the economic analysis separately for low and lower-middle income, and upper-middle and high income countries. The Secretariat may also provide this information in an interactive web-tool, to enable users to compare and rank the information according to their own needs.

How to use this information The economic analyses in the technical annex, upon which this list is based, give an assessment of cost-effectiveness ratio, health impact and the economic cost of implementation. These economic results present a set of parameters for consideration by Member States, but it must be emphasised that such global analyses should be accompanied by analyses in the local context. Other tools, such as the One Health Tool are available to help individual countries cost specific interventions in their national context. When considering interventions for prevention and control of noncommunicable diseases, emphasis should be given to both economic and non-economic criteria, as both will affect the implementation and impact of interventions. Non-economic implementation considerations such as acceptability, sustainability, scalability, equity, ethics, multisectoral actions and monitoring are essential in preparing to achieve the targets of the global action plan and should be considered before the decision to implement items in Appendix 3.

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Objective 1: To raise the priority accorded to the prevention and control of noncommunicable diseases in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy Overarching/enabling actions

Raise public and political awareness, understanding and practice about prevention and control of NCDs

Integrate NCDs into the social and development agenda and poverty alleviation strategies

Strengthen international cooperation for resource mobilization, capacity-building, health workforce training and exchange of information on lessons learnt and best practices

Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels

Implement other policy options in objective 1

Objective 2: To strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of noncommunicable diseases Overarching/enabling actions

Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs without prejudice to the sovereign right of nations to determine taxation and other policies

Assess national capacity for prevention and control of NCDs

Develop and implement a national multisectoral policy and plan for the prevention of control of NCDs through multi-stakeholder engagement

Implement other policy options in objective 2 to strengthen national capacity including human and institutional capacity, leadership, governance, multisectoral action and partnerships for prevention and control of noncommunicable diseases

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Objective 3: To reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting environments

Tobacco Use Overarching/enabling actions

Strengthen the effective implementation of the WHO Framework Convention on Tobacco Control (FCTC)

Establish and operationalize national mechanisms for coordination of the FCTC implementation as part of national strategy with specific mandate, responsibilities and resources

Specific interventions with WHO-CHOICE analysis9

No Intervention Non-financial considerations

T1 Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products

T2 Comprehensive ban of tobacco advertising, promotion and sponsorship, including cross-border advertising and on modern means of communication

Requires capacity for implementing and enforcing regulations and legislation T3 Implementation of plain/standard packaging and/or large graphic

health warnings on all tobacco packages

T4 Elimination of exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and in all outdoor mass-gathering places

T5 Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services and mCessation) for tobacco cessation to all those who want to quit

Requires sufficient, trained providers and a better functioning health system

Other interventions from WHO Guidance (without WHO-CHOICE analysis)

No Intervention

T6 Implement measures to minimize illicit trade in tobacco products

9 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low and lower middle income countries.

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Harmful Use of Alcohol

Overarching/enabling actions

Implement the WHO global strategy to reduce harmful use of alcohol through actions in the recommended target areas including:

Strengthen awareness of alcohol-attributable burden; leadership and political commitment to reduce the harmful use of alcohol

Provide prevention and treatment interventions for those at risk of or affected by alcohol use disorders and associated conditions

Support communities in adopting effective approaches and interventions to prevent and reduce the harmful use of alcohol

Implement effective drink-driving policies and countermeasures

Regulate commercial and public availability of alcohol

Restrict or ban alcohol advertising and promotion

Use price policies such as excise tax increases on alcoholic beverages

Reduce the negative consequences of drinking and alcohol intoxication, including by regulating the drinking context and providing consumer information

Reduce the public health impact of illicit alcohol and informally produced alcohol by implementing efficient control and enforcement systems

Develop sustainable national monitoring and surveillance systems using indicators, definitions and data collection procedures compatible with WHO’s global and regional information systems on alcohol and health



A1 Increase in excise taxes on alcoholic beverages Levying taxes should be combined with other price measures, such as bans on discounts or promotions

A2 Enforcement of bans or comprehensive restrictions on alcohol advertising (across multiple types of media)

Requires capacity for implementing and enforcing regulations and legislation

A3 Enforcement of restrictions on the physical availability of retailed alcohol (via reduced density of retail outlets and reduced hours of sale)

A4 Enforcement of drink-driving laws and blood alcohol concentration limits via sobriety checkpoints

A5 Provision of brief psychosocial intervention for persons with hazardous and harmful alcohol use

Requires trained providers at all levels of health care


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Unhealthy Diet

Overarching/enabling actions

Implement the WHO Global Strategy on Diet, Physical Activity and Health

Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children



U 1 Reduce salt intake by engaging the industry in a voluntary reformulation process

Requires multisectoral actions with relevant ministries and support by civil society

U 2 Reduce salt intake through establishment of a supportive environment in public institutions such as hospitals, schools and nursing homes to enable low sodium meals to be provided

U 3 Reduce salt intake through a behaviour change communication mass media campaign

U 4 Reduce salt intake through implementation of front-of-pack labelling Regulatory capacity along with multisectoral action is needed

U 5 Complete elimination of industrial trans fats through the development of legislation banning their use in the food chain


No Intervention

U 6 Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breast feeding

U 7 Implement subsidies to increase the intake of fruits and vegetables

U 8 Replace trans fats and saturated fats with unsaturated fats through reformulation, labelling and fiscal and agricultural policies

U 9 Reduce sugar consumption through taxation on sugar sweetened beverages

U 10 Limiting portion size to reduce energy intake and the risk of childhood overweight/obesity

U 11 Implementing nutrition education and counselling in different settings (i.e. schools, workplaces, hospitals etc) to increase the intake of fruits and vegetables

U 12 Nutrition labelling to improve macronutrient intake, and reduce total energy intake (kcal)

U 13 Nutrition labelling in educational settings to improve dietary intake

U 14 Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, fibre and salt, and promote the intake of fruits and vegetables


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Physical Inactivity Overarching/enabling actions

Implement the WHO Global Strategy on Diet, Physical Activity and Health

Specific interventions with WHO-CHOICE analysis


P 1 Provide physical activity counselling as part of routine primary health care services through the use of a brief intervention

Requires sufficient, trained capacity in primary care


No Intervention

P 2 Ensure macro-level urban design incorporates the core elements of residential density, connected street networks, easy access to a diversity of destinations and access to public transport

P 3 Implement public awareness and motivation programmes for physical activity, including mass media campaign for the behavioral change of physical activity levels

P 4 Ensure that adequate facilities are available on school premises to support recreational physical activity for all children

P 5 Provide safe and adequate infrastructure to support walking and cycling

P 6 Implement multi-component workplace physical activity programmes

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Objective 4: To strengthen and orient health systems to address the prevention and control of noncommunicable diseases and the underlying social determinants through people-centred primary health care and universal health coverage Overarching/enabling actions

Integrate very cost-effective noncommunicable disease interventions into the basic primary health care package with referral systems to all levels of care to advance the universal health coverage agenda

Explore viable health financing mechanisms and innovative economic tools supported by evidence

Scale up early detection and coverage, prioritizing very cost-effective high-impact interventions including cost-effective interventions to address behavioural risk factors

Train health workforce and strengthen capacity of health system particularly at primary care level to address the prevention and control of noncommunicable diseases

Improve availability of affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases, in both public and private facilities

Implement other cost-effective interventions and policy options in objective 4 to strengthen and orient health systems to address noncommunicable diseases and risk factors through people-centred health care and universal health coverage

Develop and implement a palliative care policy, including access to opioids analgesics for pain relief, together with training for health workers

Expand the use of digital technologies to increase health service access, efficacy and equity for NCD prevention, and to reduce the costs in health care delivery

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Cardiovascular Disease and Diabetes Specific interventions with WHO-CHOICE analysis12


CV 1a Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling to individuals who have had a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years

Feasible in all resource settings, including by non-physician health workers

CV 1b Drug therapy (including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling to individuals who have had a heart attack or stroke and to persons with moderate to high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years

Applying lower risk threshold increases health gain but also increases implementation cost

CV 2 Treatment of new cases of acute myocardial infarction with either: acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or thrombolysis, or primary percutaneous coronary interventions (PCI)

Selection of option depends on health system capacity

CV 3a Primary prevention of rheumatic fever and rheumatic heart diseases by increasing treatment of pharyngitis at the primary care level

Depending on prevalence in specific countries or sub-populations

CV 3b Secondary prevention of rheumatic fever and rheumatic heart disease (by developing a register of patients who then receive regular prophylactic penicillin)

Depending on prevalence in specific countries or sub-populations


No Intervention

CV 4 Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker and diuretic

CV 5 Cardiac rehabilitation post myocardial infarction

CV 6 Anticoagulation for medium-and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation

CV 7 Low-dose acetylsalicylic acid for ischemic stroke

CV 8 Care of acute stroke and rehabilitation in stroke units


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Diabetes* *Note that diabetes interventions are also covered in the previous section on cardiovascular disease & diabetes

Specific interventions with WHO-CHOICE analysis


D1 Preventive foot care for people with diabetes (including educational programmes, access to appropriate footwear, multidisciplinary clinics)

Requires systems for patient recall

D2 Diabetic retinopathy screening for all diabetes patients and laser photocoagulation for prevention of blindness

D3 Effective glycaemic control for people with diabetes, along with standard home glucose monitoring to reduce diabetes complications


No Intervention

D4 Lifestyle interventions for preventing type 2 diabetes

D5 Influenza vaccination for patients with diabetes

D6 Preconception care among women of reproductive age including patient education and intensive glucose management

D7 Screening of people with diabetes for proteinuria and treatment with ACE-inhibitor for the prevention and delay of renal disease

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Cancer Specific interventions with WHO-CHOICE analysis13


CA 1 HPV vaccination (2 doses) of 9-13 year old girls

CA 2 Prevention of cervical cancer through screening women aged 30-49, either through:

VIA (visual inspection with acetic acid) linked with timely treatment of pre-cancerous lesions

Pap smear (cervical cytology) every 3-5 years linked with timely treatment of pre-cancerous lesions

HPV test every 5 years linked with timely treatment of pre-cancerous lesions

VIA is feasible in low resource settings, including with non-physician health workers. Pap smear requires cytopathology capacity. Requires systems for organised, population-based screening

CA 3 Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy

CA 4 Treatment of breast cancer stages I and II with surgery +/- systemic therapy

CA 5 Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis and treatment of breast cancer

Requires systems for organised, population-based screening

CA 6 Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy

CA 7 Basic palliative care for cancer: home-based and hospital care with multi-disciplinary team and access to opiates and essential supportive medicines

Requires access to controlled medicines for pain relief

Other interventions from WHO Guidance (without WHO-CHOICE analysis) No Intervention

CA 8 Prevention of liver cancer through hepatitis B immunization

CA 9 Oral cancer screening in high-risk groups (eg tobacco users, betel-nut chewers) linked with timely treatment

CA 10 Population-based colorectal cancer screening, including through a faecal occult blood test, as appropriate, at age >50, linked with timely treatment


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Chronic Respiratory Diseases Specific interventions with WHO-CHOICE analysis


CR 1 Treatment of chronic obstructive pulmonary disease with inhaled salbutamol

CR 2a Treatment of asthma with oral prednisolone, theophylline and high dose inhaled beclomethasone

CR 2b Treatment of asthma using low dose inhaled becalmethasone and short acting beta agonist


No Intervention

CR 3 Access to improved stoves and cleaner fuels to reduce indoor air pollution

CR 4 Cost-effective interventions to prevent occupational lung diseases, eg from exposure to

silica, asbestos

CR 5 Influenza vaccination for patients with chronic obstructive pulmonary disease

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Objective 5: To promote and support national capacity for high-quality research and development for the prevention and control of noncommunicable diseases Overarching/enabling actions

Develop and implement a prioritized national research agenda for noncommunicable diseases

Prioritize budgetary allocation for research on noncommunicable disease prevention and control

Strengthen human resources and institutional capacity for research

Strengthen research capacity through cooperation with foreign and domestic research institutes

Implement other policy options in objective 5 to promote and support national capacity for high-quality research, development and innovation

Objective 6: To monitor the trends and determinants of noncommunicable diseases and evaluate progress in their prevention and control Overarching/enabling actions

Develop national targets and indicators based on global monitoring framework and linked with a multisectoral policy and plan

Strengthen human resources and institutional capacity for surveillance and monitoring and evaluation

Establish and or strengthen a comprehensive noncommunicable disease surveillance system, including reliable registration of deaths by cause, cancer registration, periodic data collection on risk factors and monitoring national response

Integrate noncommunicable disease surveillance and monitoring into national health information systems

Implement other policy options in objective 6 to monitor trends and determinants of noncommunicable diseases and evaluate progress in their prevention and control

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Technical annex to Appendix 3: proposed table of contents

This technical annex will be designed to provide further information for those interested in decisions and methods adopted in the development process of the updated Appendix 3. Proposed contents of this Annex include:

1. Detailed methodological information a. This will include more detailed explanation of the methodological approach and

process used to update Appendix 3, including the selection of interventions, and consultation process.

b. Explanation of Generalized Cost Effectiveness and WHO-CHOICE methodology c. References to the evidence source and assumptions used in the economic modelling

for specific interventions

2. The background results of the WHO-CHOICE economic analyses for interventions included in Appendix 3

a. The summary table will be complemented later by an interactive web tool which will enable users to manipulate the data for their own purposes.

Section 1: Detailed methodological information

Identification of interventions

A transparent, unified approach for the identifications was taken after the first consultation on updating Appendix 3, 2015.14 From the consultation, the following effectiveness criteria were used for identifying interventions:

- An intervention must have a demonstrated and quantifiable effect size, from at least one

published study in a peer reviewed journal

- An intervention must have a clear link to one of the global NCD targets

Using the above criteria, additional interventions were considered. The intervention list for the

updated Appendix 3 comprises interventions which have been unchanged from the original version,

interventions which have been re-worded or revised to reflect updates in WHO policy or scientific

evidence and new interventions.

Choice of economic parameters

Economic parameters were identified at the first technical consultation in June 2015 and are listed below: 1. Cost-effectiveness ratio: as analysed using WHO-CHOICE methodology (see below) and

presented as a ratio of international dollars (I$) per disability adjusted life year (DALY). a. Cost-effectiveness ratios are presented in bands, ranging from < I$100/DALY

to >I $10,000/DALY15. The decision to band cost-effectiveness was based on the consensus that the data represent global estimates, therefore banding cost-effectiveness emphasises the relative magnitude of cost-effectiveness rather than a specific amount.

14 http://who.int/nmh/events/meeting-report-consultation-on-appendix-3-final.pdf?ua=1 15 Cost-effectiveness bands (in I$) are: <100, 100-$500, 500-1,000, 1,000-5,000, 5,000-10,000, >10,000

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2. Size of health gain: the expected size of population health impact for each intervention was calculated based on total DALY averted in a standardized16 population of 1 million people. 3. Economic cost of implementation: The total cost required to implement each intervention was estimated, based on cost in I$ millions to implement in a standardized population of 1 million people (i.e. I$ per capita)

Country selection

Economic parameters were assessed for two country income groups: Low and lower middle income countries and upper middle and high income countries were taken as the second group. Recognizing the need for generalizability, applicability and comprehensiveness, countries were selected so that a significant proportion of the total population and health burden would be represented. We also recognized the importance of representation from countries in different regional settings. Resultantly, twenty countries were compiled and listed below. For most interventions, ten countries were analysed from low and lower-middle income settings, and ten from upper-middle and high income settings. Combined, they represent 63% of the total population and 65% of the global burden of disease. For some types of interventions, (eg for cancer) analysis was based on a smaller subset of countries.

Low and Lower-Middle Income Countries Upper-Middle and High Income Countries

Bangladesh China

Ethiopia Germany

Guatemala Iran (Islamic Republic of)

India Japan

Indonesia Mexico

Nigeria Russian Federation

Pakistan South Africa

Philippines Thailand

Ukraine Turkey

Vietnam United States of America

WHO-CHOICE: A brief methodological overview

Value for money and efficiency are fundamental considerations guiding investment in health, and WHO-CHOICE provides a way to measure them. This is true in settings where lack of finance is no longer the greatest barrier to achieving better health outcomes; it is also true in less well-resourced settings, where inefficiency is measured in lives lost and human suffering. Cost-effectiveness analysis supports priority setting by defining areas of action where the greatest health gains can be achieved. Generalized cost-effectiveness analysis (WHO-CHOICE) also allows the definition of an optimal set of interventions, taking into account setting-specific factors such as the burden of disease, health system practice, and economic conditions. Tools to facilitate country-level cost-effectiveness analysis of a wide range of health activities are available. In parallel, WHO-CHOICE publishes and disseminates online a knowledge base of regional-level cost-effectiveness information.

16 Standardized over the total population of the analysed countries per income grouping

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The use of cost-effectiveness analysis within decision making processes in health is increasingly common globally. However, a series of methodological shortcomings may limit the practical application of cost-effectiveness analysis results. Two examples of this are methodological differences between studies that limit comparability, and use of the current practice as a comparator, which implicitly assumes current resource use is efficient. Generalized Cost-Effectiveness Analysis (GCEA) was developed to overcome such shortcomings of traditional cost-effectiveness analysis. The GCEA approach enables both existing and new interventions to be evaluated simultaneously. The comparator used in GCEA is a hypothetical “null” scenario, where the impacts of all currently implemented interventions are removed. Uniquely, this method allows existing and new interventions to be analysed at the same time. Previous cost-effectiveness analyses have been restricted to assessing the efficiency of adding a single new intervention to the existing set, or replacing one existing intervention with an alternative. Using WHO-CHOICE, the analyst is no longer constrained by what is already being done, and policymakers can revisit and revise past choices if necessary and feasible. They will have a rational basis for deciding to reallocate resources between interventions to achieve social objectives. WHO-CHOICE:

• Uses a standardized method for cost-effectiveness analysis that can be applied to all interventions in different settings

• Costs and effectiveness of a wide range of health interventions at the WHO subregional level are calculated to ensure comparability across different interventions

• All interventions are evaluated compared to the “null”, a scenario in which we model the absence of health care interventions

• Impact models are developed using a population based approach, and healthy life years gained due to an intervention are calculated over a 100 year time frame

• Costs for each intervention are developed using an ingredients based economic costing methodology. Costs are calculated over a 100 year time frame and discounted at 3% per year

• All interventions are evaluated at 50%, 80% and 95% coverage. For the appendix 3, 95% coverage results are used

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Section 2. Summary tables of WHO-CHOICE economic analyses for interventions for NCD prevention and control

Notes:

1. The tables below list all interventions for which WHO-CHOICE economic analysis is available. In this example, separate tables are provided for each of the four main risk factors and four main diseases covered by Objectives 3 and 4 of the Global NCD Action Plan. Interventions are listed in descending order of cost-effectiveness in low and lower-middle income countries. The intervention name contains more exact detail about the intervention that was modelled -note that these may differ slightly from the wording of the WHO recommended interventions. This Annex is provided for background scientific information only and should not be used as a specific menu for implementation.

Label Intervention Low and Lower-Middle Income Countries Upper-Middle and High Income Countries

Average cost-effectiveness ratio (I$/DALY averted)

Health Impact (DALY averted per 1 million)

Economic Cost of implementation (I$ in millions per 1 million)




Tobacco Use

T1 Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products (price increase of 25% through excise tax)

<100 11,598 <0.01 <100 1,575 0.01

T2 Comprehensive ban of tobacco advertising, promotion and sponsorship, including cross-border advertising and on modern means of communication at 95% coverage

<100

526

0.01

<100

372

0.01

T3 Implementation of plain/standard packaging and/or large graphic health warnings on all tobacco packages at 95% coverage

<100

210

<0.01 <100

149

0.01

T4 Elimination of exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and in all outdoor mass-gathering places at 95% coverage

<100

210

0.01

100 - 500

149

0.02

T5 Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services and mCessation) for tobacco cessation to all those who want to quit, provided at 95% coverage

500 - 1,000

105

0.09

1,000 - 5,000

74

0.24

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Harmful use of alcohol

A1 Increase in excise taxes on alcoholic beverages (current rate + 50%)

<100 741 0.02 <100 2,588 0.04

A2 Enforcement of bans or comprehensive restrictions on alcohol advertising (across multiple types of media including television, radio, print media and billboards) at 95% coverage

<100 399 0.01 <100 753 0.05

A3 Enforcement of restrictions on the physical availability of retailed alcohol (via reduced density of retail outlets and reduced hours of sale) at 95% coverage.

<100 409 0.03 <100 763 0.08

A3 Enforcement of drink-driving laws and blood alcohol concentration limits via sobriety checkpoints at 95% coverage.

100 - 500 212 0.04 500 - 1,000 224 0.22

A5 Provision of brief psychosocial intervention (3 visits) for persons with hazardous and harmful alcohol use at 50% coverage.

100 - 500 856 0.24 1,000 - 5,000 2,089 4.38

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Unhealthy diet

U1 Reduce salt intake by engaging the industry in a voluntary reformulation process

<100

3,698

<0.01 <100

3,315

<0.01

U2 Reduce salt intake through establishment of a supportive environment in public institutions such as hospitals, schools and nursing homes to enable low sodium meals to be provided

<100

1,086

<0.01 <100

1,164

<0.01

U3 Reduce salt intake through a behaviour change communication mass media campaign

<100

760

0.03

<100

819

0.02

U4 Reduce salt intake through implementation of front-of-pack labelling

<100

2,200

0.01

<100

2,011

0.02

U5 Complete elimination of industrial trans fats through the development of legislation banning their use in the food chain

100 - 500

30

0.01

1,000 - 5,000

21

0.02

Physical Inactivity

P1 Provide physical activity counselling as part of routine primary health care services through the use of a brief intervention consisting of 2 minutes of physician time

1,000 - 5,000 282 0.32 5,000 - 10,000 294 2.41

Page 23 of 26








Cardiovascular Disease & Diabetes

CV1a

Drug therapy including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling

to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years, carried out through primary health care facilities at a 95% coverage rate

<100

19,004

0.29

<100

20,075

1.51

CV1b

Drug therapy including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling

to persons with high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years, carried out through primary health care facilities at a 95% coverage rate

<100

29,103

0.57

<100

30,092

3.01

CV2a

Treatment of new cases of acute myocardial infarction with aspirin and clopidogrel, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate

100 - 500

223

0.05

1,000 - 5,000

148

0.29

CV2b

Treatment new cases of acute myocardial infarction with aspirin, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate

100 - 500

208

0.05

1,000 - 5,000

138

0.29

CV2c

Treatment of new cases of acute myocardial infarction with aspirin and thrombolysis, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate

100 - 500

133

0.06

1,000 - 5,000

88

0.30

CV2d

Treatment of new cases of myocardial infarction with primary percutaneous coronary interventions (PCI), aspirin and clopidogrel, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate

1,000 - 5,000

184

0.19

1,000 - 5,000

122

0.46

CV3a

Primary prevention of rheumatic fever and rheumatic heart diseases by increasing treatment of pharyngitis at the primary care level to 95%

100 - 500

380

0.15

500 - 1,000

123

0.09

CV3b

Secondary prevention of rheumatic fever and rheumatic heart disease by developing a register of ARF or RHD patients who then receive regular prophylactic penicillin

1,000 - 5,000

155

0.51

1,000 - 5,000

95

0.22

Page 24 of 26








Diabetes

D1

Neuropathy screening for all diabetes patients each year and preventive foot care through wound debridement and protective insoles

500 - 1,000

105

0.07

1,000 - 5,000

258

0.32

D2

Diabetic retinopathy screening for all diabetes patients each year and laser photocoagulation for prevention of blindness

1,000 - 5,000

59

0.27

1,000 - 5,000

146

0.51

D3

Standard glycaemic control at 95% coverage using glibenclamide, metformin and insulin for type 1 diabetes, along with standard home glucose monitoring to reduce diabetes complications

5,000 - 10,000

172

1.76

5,000 - 10,000

393

2.70

D4

Intensive glycaemic control at 95% coverage using glibenclamide, metformin and insulin and intensive home glucose monitoring to reduce diabetes complications

>10,000

90

1.42

>10,000

211

2.14

Page 25 of 26








Cancer17

CA 1 HPV vaccination (2 doses) of 9 – 13 year old girls with coverage rate of 95%

<100 7132 0.21

CA 2 Prevention of cervical cancer through screening women aged 30-49 years, either through:

VIA (visual inspection with acetic acid) linked with timely treatment of pre-cancerous lesions with cryotherapy at coverage rate of 95%

<100 6181 0.44

Pap smear (cervical cytology) every 3-5 years linked with timely treatment of pre-cancerous lesions with cryotherapy or LEEP at coverage rate of 95%

<100 6107 0.59

HPV test every 5 years followed by VIA then linked with timely treatment of pre-cancerous lesions with cryotherapy or LEEP at coverage rate of 95%

<100 5900 0.41

CA 3 Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy, including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95%

1,000 - 5,000 463 0.67

CA 4 Treatment of breast cancer stages I and II with surgery +/- systemic therapy (endocrine therapy or chemotherapy), including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95%

500 - 1,000 573 0.46

CA 5 Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment related toxicities

1,000 - 5,000 1570 1.73

17 Economic data for upper middle and high income countries are not available.

Page 26 of 26








CA 6 Treatment of colorectal cancer stages I and II with surgery in select high risk patients, +/- radiotherapy in select rectal cancer patients, including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95%

500 - 1,000 507 0.40

CA 7 Basic palliative care for cancer: home-based and hospital care with multi-disciplinary team and access to opiates and essential supportive medicines at coverage rate of 95%18

0.17

Chronic Respiratory Diseases

CR1

Treatment of COPD with inhaled salbutamol at 95% coverage

100 - 500

1,731

0.32

1,000 - 5,000

1,245

1.43

CR2

Asthma: Oral prednisolone + Theophylline and high dose inhaled beclomethasone at 95% coverage

5,000 - 10,000

59

0.35

>10,000

21

0.48

CR3

Treatment of asthma using low dose inhaled beclomethasone and short acting beta agonist at 95% coverage

>10,000

19

0.19

>10,000

7

0.39

18 Impact model not available for palliative care

Documents

Draft Updated Appendix 3 of the WHO Global NCD Action Plan ...€¦ · 7 October 2016 The Secretariat will submit a final draft of the updated Appendix 3 to WHO’s Governing Bodies