Introduction
To prevent death or morbidity from chronic diseases in an economically sustainable manner, an intervention should meet at least four conditions. First, the intervention must target behaviours or risk factors that have been causally associated with chronic diseases. Second, there should be knowledge that the intervention will probably lead to favourable changes in behaviours or risk factors, which should then lead to reductions in morbid or fatal events. Third, evidence should show that the intervention is cost effective in the settings in which it is implemented. Lastly, there should be evidence that the scaling up of the intervention is fiscally feasible in resource-constrained countries.
Tobacco control measures, salt reduction strategies, and multidrug strategies to treat patients with high-risk cardiovascular disease meet the first three conditions. For these interventions, causality has been proven, intervention effectiveness has been confirmed, and cost-effectiveness has been shown through modelling in resource-strained countries. The third and fourth papers in this Series1, 2 assess the evidence for the fourth condition of fiscal feasibility for the scaling up of these three interventions. However, a range of other potentially effective interventions that are proven in high-income countries but for which evidence on cost-effectiveness has not yet been gathered in countries of low or middle income are also highly plausible candidates for investigation and early adoption.
Such evidence on causation and health benefits of other interventions is usually transferable to the populations of low-income and middle-income countries. However, estimates of population attributable risk for individual risk factors, and of cost-effectiveness for specific interventions could differ substantially across these groups of countries. A further limitation is that such evidence is mostly confined to personal interventions directed at changing the behaviours of individuals, and provides little information on non-personal policy interventions that could potentially alter individual behaviours through economic and environmental effects that operate at the societal level. The absence of such evidence is especially unfortunate, since such policy interventions could be more cost effective and affordable for resource-constrained countries than are resource-intensive interventions focused on behaviour change in individuals.
Key messages
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Interventions to reduce chronic diseases should be both cost effective and financially feasible before scaling up in countries of low or middle income
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Tobacco control, salt reduction, and a multidrug strategy to treat individuals with high-risk cardiovascular disease are three interventions that have strong cost-effectiveness data for scale-up in such countries
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Further studies to assess the best national policies to reduce consumption of saturated and trans fats at a reasonable cost are needed before scaling up such interventions
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Several other interventions do not have sufficient cost-effectiveness data for countries of low or middle income, but their effectiveness data are so compelling that their implementation, along with critical assessment, should be considered in such settings
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There are limited data for structural interventions directed at the social determinants of chronic diseases, including health systems. This is an area that deserves immediate focused attention
In this paper we review the array of proven and potential interventions that can reduce the burdens of chronic diseases in low-income and middle-income countries, using proven causation and ability to intervene as the main criteria. Intervention effectiveness and cost-effectiveness data are reviewed where available (effectiveness data for the interventions in the third and fourth articles of this Series are reviewed within those papers1, 2). In view of the large number of interventions, this paper is not exhaustive, but rather draws attention to several possible interventions for which there are various levels of evidence for scaling up in low-income and middle-income countries.