INSIGHT

Evidence-Based, Cost-Effective Health Interventions Are Key to Preventing Chronic Diseases

India has expanded health programs over the last 2 decades. Photo credit: ADB.
India has expanded health programs over the last 2 decades. Photo credit: ADB.

Published: 17 June 2021

A study from India shows low- and middle-income countries must improve economic evaluations of health interventions to reduce chronic disease burden.

Introduction

As part of its bid to achieve universal health coverage, India has expanded government health programs over the last 2 decades, most notably by establishing the National Health Mission and implementing public health insurance programs targeting poor households. Now that the government is increasingly becoming a purchaser as well as provider of healthcare and public programs that aim to address the growing chronic disease burden, it is imperative to base decisions about the allocation of scarce resources for health on evidence and find ways to integrate curative hospital services with the most cost-effective preventive and primary interventions.

Analysis

In India, decisions about which healthcare services to cover are typically made by expert committees rather than through systematic assessments of efficacy and cost-effectiveness. This, in part, is because the evidence base on economic evaluations of health interventions in the country remains sparse and of low quality.

In recent years, however, the government has taken several steps toward establishing the infrastructure for evidence-based priority setting and resource allocation, including the establishment of a body for Health Technology Assessment in India within the Department of Health Research to collate and generate evidence on the clinical efficacy and cost-effectiveness of new and existing health technologies and programs. Research evidence on the cost-effectiveness of both preventive and curative health interventions in the Indian context will be a critical input to the evaluation of technologies.

Evidence of cost-effective prevention of diabetes and noncommunicable disease

India is facing a mounting burden of noncommunicable diseases, such as diabetes, cancers, and cardiovascular diseases. These types of diseases affect more than 20% of the population, with incidence and prevalence projected to rise substantially as the population aged 60 and over increases. Levels of several critical risk behaviors, such as alcohol and tobacco use, low physical activity, and unhealthy diet, are increasing in socioeconomic status and will require explicit intervention beyond economic development or access to curative care alone. The risk factors for chronic diseases are overlapping, and therefore the benefits of preventive interventions targeting them are likely to extend beyond preventing any noncommunicable disease.

Numerous reviews find that population-based interventions, such as advertising bans, food industry regulations, mass media campaigns, and tobacco and alcohol taxation, are cost-effective due to their low marginal costs and high coverage. These interventions, however, require concerted public and political effort and have not scaled up in India to date. Targeted individual- or community-level preventive interventions that can be implemented at a more local level may be a promising and feasible complement to population interventions. There is evidence that lifestyle modification to reduce weight, increase activity, and improve diets and medication to prevent diabetes are highly cost-effective in the Indian context, although other approaches, such as universal diabetes screening, may not be.

One recent study that adds evidence on how to prevent diabetes cost-effectively in India and other low- and middle-income countries examines the Kerala Diabetes Prevention Program. The study’s authors present a cost-effectiveness analysis of 1,007 participants in the program, showing potential cost-effectiveness in “nudging” the participants toward a healthier lifestyle through suggestive reductions in tobacco and alcohol use and waist circumference.

The results of the analysis highlight the importance of continued research on community-based promotion of healthy lifestyles. After all, many health conditions could be prevented if all middle-aged individuals adhered to lifestyles with high physical activity, healthy eating habits, no tobacco, limited alcohol, and adequate sleep—the risk factors targeted in the program. Moreover, such health-promoting interventions complement existing policy efforts to support healthy aging.

Implications

Enabling healthy aging in resource-constrained settings requires careful design of policies and programs to support cost-effective prevention and management for those suffering from diabetes, cardiovascular disease, and other noncommunicable diseases. To control costs and address the growing chronic disease burden, India’s public programs should integrate curative hospital services with the most cost-effective preventive and primary care interventions.

Evidence-based approaches to noncommunicable disease interventions are essential for providing cost-effective care and creating models for future programs like the Kerala Diabetes Prevention Program. Additional studies advancing evidence-based approaches—ones that cover larger and more representative populations over longer time periods—remain important for generalizable assessments to inform policy decisions.

This article is based on correspondence by Karen Eggleston and Radhika Jain published in the journal BMC Medicine.

Resources

K. Eggleston and R. Jain. 2020. Cost-Effective Interventions to Prevent Non-communicable Diseases: Increasing the Evidence Base in India and Other Low- and Middle-Income Settings. BMC Medicine. 18 (379).

K. Singh et al. 2018. Cost-Effectiveness of Interventions to Control Cardiovascular Diseases and Diabetes Mellitus in South Asia: A Systematic Review. BMJ Open. 8 (4).

K.S. Reddy et al. 2011. Towards Achievement of Universal Health Care in India by 2020: A Call to Action. Lancet. 377 (9767). pp. 760–768.

L. E. Downey et al. 2017. Institutionalising Health Technology Assessment: Establishing the Medical Technology Assessment Board in India. BMJ Global Health. 2 (2). e000259.

M. Cecchini et al. 2010. Tackling of Unhealthy Diets, Physical Inactivity, and Obesity: Health Effects and Cost-Effectiveness. Lancet. 376 (9754). pp. 1775–1784.

S. Prinja et al. 2015. A Systematic Review of the State of Economic Evaluation for Health Care in India. Applied Health Economics and Health Policy. 13 (6). pp. 595–613.

T. Sathish et al. 2020. Cost-Effectiveness of a Lifestyle Intervention in High-Risk Individuals for Diabetes in a Low- and Middle-Income Setting: Trial-based Analysis of the Kerala Diabetes Prevention Program. BMC Medicine. 18 (251).

T. A. Gaziano, G. Galea, and K.S. Reddy. 2007. Scaling Up Interventions for Chronic Disease Prevention: The Evidence. Lancet. 370 (9603). pp. 1939–1946.

V. Patel et al. 2011. Chronic Diseases and Injuries in India. Lancet. 377 (9763). pp. 413–428.

Ask the Experts

  • Karen Eggleston
    Deputy Director, Shorenstein Asia–Pacific Research Center, Stanford University

    Karen Eggleston is a senior fellow at the Freeman Spogli Institute for International Studies and Director of the Asia Health Policy Program. Her research focuses on government and market roles in the health sector and Asia health policy, especially in the People’s Republic of China, India, Japan, and the Republic of Korea; healthcare productivity; and the economics of the demographic transition. She holds a PhD in Public Policy from Harvard University and MA degrees in Economics and Asian Studies from the University of Hawaii.

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  • Radhika Jain
    2019–2022 Asia Health Policy Postdoctoral Fellow, Shorenstein Asia-Pacific Research Center, Stanford University

    Radhika Jain’s research focuses on healthcare markets, the effectiveness of public health policy, and gender disparities in health. Her work has been supported by grants from the Weiss Family Fund and the Jameel Poverty Action Lab. She holds a PhD in Global Health from Harvard University. Her dissertation examined the extent to which private hospitals capture government subsidies for healthcare under insurance and whether accountability measures can help patients claim their entitlements.

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  • Walter H. Shorenstein Asia–Pacific Research Center (Shorenstein APARC)

    Founded in 1983, Shorenstein APARC addresses critical issues affecting the countries of Asia, their regional and global affairs, and U.S.–Asia relations. As Stanford University’s hub for the interdisciplinary study of contemporary Asia, it produces policy-relevant research and provides education and training to students, scholars, and practitioners. It also strengthens dialogue and cooperation between counterparts in the Asia–Pacific and the United States. 

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