The reported impact of non-communicable disease investment cases in 13 countries (2024)

Abstract

Non-communicable diseases (NCDs) are a leading health and development challenge worldwide. Since 2015, WHO and the United Nations Development Programme have provided support to governments to develop national NCD investment cases to describe the socioeconomic dimensions of NCDs. To assess the impact of the investment cases, semistructured interviews and a structured process for gathering written feedback were conducted between July and October 2022 with key informants in 13 countries who had developed a national NCD investment case between 2015 and 2020. Investment cases describe: (1) the social and economic costs of NCDs, including their distribution and projections over time; (2) priority areas for scaled up action; (3) the cost and returns from investing in WHO-recommended measures to prevent and manage NCDs; and (4) the political dimensions of NCD responses. While no country had implemented all the recommendations set out in their investment case reports, actions and policy changes attributable to the investment cases were identified, across (1) governance; (2) financing; and (3) health service access and delivery. The pathways of these changes included: (1) stronger collaboration across government ministries and partners; (2) advocacy for NCD prevention and control; (3) grounding efforts in nationally owned data and evidence; (4) developing mutually embraced ‘language’ across health and finance; and (5) elevating the priority accorded to NCDs, by framing action as an investment rather than a cost. The assessment also identified barriers to progress on the investment case implementation, including the influence of some private sector entities on sectors other than health, the impact of the COVID-19 pandemic, and changes in senior political and technical government officials. The results suggest that national NCD investment cases can significantly contribute to catalysing the prevention and control of NCDs through strengthening governance, financing, and health service access and delivery.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

• Non-communicable diseases (NCDs) are a leading health and development challenge worldwide, with low-income and middle-income countries facing large burdens.

• National NCD investment cases have provided compelling data on the socioeconomic aspects of NCDs and the return on investment (ROI) in priority interventions.

• There has been no systematic assessment of the impact of these investment cases on policymaking.

Introduction

Non-communicable diseases (NCDs)—including cancers, diabetes, cardiovascular disease and chronic respiratory disease—are a leading health and development challenge worldwide. NCDs kill 41 million people each year, comprising 74% of all deaths globally, with 17 million people dying prematurely from an NCD (before age 70 years) each year, of which 86% of these deaths are in low-income and middle-income countries.1 In addition to their health impact, NCDs detract from economies through productivity losses comprised of early workforce dropout, missed work (absenteeism) or reduced performance at work (presenteeism).2 3

The main behavioural and environmental risk factors for NCDs are tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity and air pollution. Cost-effective and evidence-based interventions exist for preventing and controlling NCDs.4 However, governments need to determine the cost-effectiveness of these interventions in their particular context, as well as non-financial considerations such as implementation capacity, feasibility and impact on health equity.5

Since 2015, WHO and the United Nations Development Programme have provided support to governments to develop national NCD investment cases that assess the social and economic costs of NCDs, including their distribution and projections over time; identify priorities for scaled up action; and estimate the cost and returns from investing in WHO-recommended measures to prevent and manage NCDs.6 The cases include an institutional and context analysis (ICA) which explores the political dimensions of NCD responses to inform pathways to implementation.7

The investment cases have provided compelling data on the socioeconomic impact of NCDs and the return on investment (ROI) from implementing interventions to prevent and control NCDs.8 9 They have also provided context-specific governance and financing recommendations, for example, around improving multisectoral planning and coordination and/or strengthening health taxes as a means of sustainable domestic financing. However, there has been no systematic attempt to assess the impact of these investment cases on policymaking. The present study therefore aims to do this.

Methods

16 countries that had undertaken NCD investment cases between 2015 and 2020 were invited to participate in the study. 13 agreed to participate. They were: Armenia, Barbados, Cambodia, Ethiopia, Jamaica, Kyrgyzstan, Russian Federation, Philippines, Thailand, Türkiye, Uganda, Uzbekistan and Zambia.

Results

Discussion

Although the NCD investment case approach has limitations that have been described elsewhere,12 these are unlikely to have affected their impact as a tool to encourage policy change, as all investment case findings were validated and reports cleared by relevant national authorities. However, the methods described in this paper have notable limitations. First, despite the responses from those interviewed and those reviewing the results, it is important to recognise the range of other NCD prevention and control efforts in each of the 13 countries before, during and after the investment cases, making it difficult to determine the precise attribution or contribution from the cases. Second, there is potential for interviewees to have provided overly positive reporting. That may be because they were directly involved in the work and/or wish to maintain good standing with partners and funders. Third, there was no assessment of changes in policy among a comparative set of countries that had not undertaken investment cases. Finally, despite follow-up, 3 of the 16 countries invited to participate did not respond. These may be countries where the impact was less or even negative.

This study suggests that national NCD investment cases are effective at catalysing the prevention and control of NCDs through strengthening governance, financing, and health service access and delivery. Governance impacts spanned new or stronger laws and/or policies, improved plans and coordination mechanisms, and scaled up public communications. Financing impacts included budgetary allocations to NCDs, use of health taxes including mobilising domestic resources and leveraging development assistance funding. Many of the impacts yielded broader health and development benefits, for example, progress towards universal health coverage.

Results also highlighted elements that enabled the changes across governance, financing, and health service access and delivery. These included: (1) strengthening collaboration across government ministries and partners; (2) strengthening advocacy for NCD prevention and control; (3) grounding efforts in nationally owned evidence; (4) developing shared ‘language’ across health and finance; and (5) elevating the priority of NCDs, by framing action as an investment rather than a cost. Informants stressed that the impacts stemmed from not just the investment case report but also from the inclusive and participatory process of developing it. The ICAs were crucial to this.

That tobacco control was the area of greatest impact coheres with it typically having the highest ROI across the investment cases, a consideration reported by key informants. Another explanation for this not explicitly mentioned may be that all participating countries were Parties to the WHO Framework Convention on Tobacco Control, a legally binding international treaty. Armenia and Cambodia were also supported by tobacco control-specific investment cases through another United Nations project.13 14 At the same time, the countries did not just pursue the highest ROIs. For example, clinical interventions received strong attention despite typically projecting lower ROIs. In addition to the reasons provided by key informants, a factor may be that countries are encouraged to implement the investment case recommendations in full, seeing prevention and treatment as mutually reinforcing and both critical to the right to health.

The reported effect of commercial influence on government sectors other than health as a barrier to fuller investment case implementation suggests that technical support on whole-of-government responses, including on policy coherence and prevention of industry interference in policymaking, would be useful complements to investment cases. In addition, it may be useful to develop a more detailed economic analysis on specific issues closely tied with commercial influence, such as nutrition, alcohol and health taxes, just like what has been done with tobacco control, using tobacco control-specific investment cases. That the COVID-19 pandemic diverted attention from NCD action reinforces the urgency of ensuring NCDs are included in global health security and universal health coverage. Chronic and infectious diseases can be mutually exacerbating, for example, NCDs and their risk factors are associated with worse COVID-19 outcomes, and SARS-CoV-2 infection is associated with increases in NCDs.15 Finally, to counter waning commitment to tackle NCDs as a result of changes in ministers and government officials, the investment cases and their recommendations may need refreshing and/or strategic ‘relaunch’ over time.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

Ethics statements

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