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Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys

Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys Wanrudee Isaranuwatchai, Rachel A. Archer, Yot Teerawattananon and Anthony J. Culyer (eds)
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Non-communicable diseases (NCDs) are the leading cause of death worldwide, contributing to over 73% of all deaths annually. Each day NCDs cause more than 100,000 deaths, 80% of which occur in low- and middle-income countries. NCDs, however, are largely preventable, and a great deal of technical knowledge exists about how to prevent and manage them. Why, then, have we, as a global community, not been more successful at reducing this NCD burden? Does a universal problem not have a universal solution?

Created by an international consortium of experts, this informative and accessible book provides practical guidelines, key learning points, and dynamic, real-world case studies to aid NCD program managers, policy officers and decision-makers in low- and middle-income countries, so that they can assess interventions for the prevention and control of NCDs.

The book was commissioned by the Prince Mahidol Award Conference (PMAC), an annual international conference centred on policy of global significance related to public health. Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys emphasises the importance of context in NCD control and prevention, arguing that the success of an intervention lies in an ability to respond to local needs and environments. The book comprises ten chapters, which collectively explore the reasons behind, and strategies for, preventing and managing the NCD burden. It spans key themes such as political economy, the transferability of economic evidence, the role of cross-sectoral policies, the importance of deliberative processes, and health technology assessment.

This book is written for the benefit of the global health community, and is primarily targeted at those individuals who are involved in NCD programs. This book will also be of interest to NCD champions, policy advocates, and educators spearheading the movement for increased visiblity of NCDs.

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Non-Communicable Disease Prevention: Best Buys, Wasted Buys and Contestable Buys
Wanrudee Isaranuwatchai, Rachel A. Archer, Yot Teerawattananon and Anthony J. Culyer (eds) | December 2019
220 pp. | 10 color illustrations | 6.14" x 9.21" (234 x 156 mm)
ISBN Paperback: 9781783748631
ISBN Hardback: 9781783748648
ISBN Digital (PDF): 9781783748655
ISBN Digital ebook (epub): 9781783748662
ISBN Digital ebook (mobi): 9781783748679
ISBN Digital (XML): 9781783748686
DOI: 10.11647/OBP.0195
Subject codes: BIC: MB (Medicine: general issues), MBNH (Personal and public health), MBN (Public health and preventive medicine); MED000000 (MEDICAL / General), MED022000 (MEDICAL / Diseases), MED076000 (MEDICAL / Preventive Medicine); OCLC Number: 1132418494.

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Notes on Contributors
  1. Introduction
    Wanrudee Isaranuwatchai, Rachel A. Archer and Anthony J. Culyer
  2. Non-Communicable Diseases, NCD Program Managers and the Politics of Progress
    Sumithra Krishnamurthy Reddiar and Jesse B. Bump
  3. Framework for Implementing Best Buys and Avoiding Wasted Buys
    Yot Teerawattananon, Alia Luz, Manushi Sharma and Waranya Rattanavipapong
  4. Best Buys
    Tazeem Bhatia, Arisa Shichijo and Ryota Nakamura
  5. Wasted Buys
    Yot Teerawattananon, Manushi Sharma, Alia Luz, Waranya Rattanavipapong and Adam G. Elshaug
  6. Assessing the Transferability of Economic Evaluations: A Decision Framework
    David D. Kim, Rachel L. Bacon and Peter J. Neumann
  7. Finding the Best Evidence
    Thunyarat Anothaisintawee
  8. Cross-Sectoral Policies to Address Non-Communicable Diseases
    Melitta Jakab and Peter C. Smith
  9. Deliberative Processes in Decisions about Best Buys, Wasted Buys and Contestable Buys: Uncertainty and Credibility
    Kalipso Chalkidou and Anthony J. Culyer
  10. Summing Up
    Wanrudee Isaranuwatchai, Rachel A. Archer and Anthony J. Culyer
Glossary of Abbreviations
List of Illustrations and Tables
Thunyarat Anothaisintawee, MD., Ph.D., is a Family Physician. She holds a Ph.D. in Clinical Epidemiology and has worked as a faculty staff member at the Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand. She is an expert in systematic reviews and meta-analysis and published several papers about the association between sleep factors and risk of developing diabetes mellitus in international medical journals. Currently, she is conducting the Prediabetes cohort study in Thailand. This cohort aims to investigate the association between sleep factors, eating habits, level of physical activity, genetic factors and risk of developing diabetes mellitus and chronic kidney disease in prediabetes people in Thailand.

Rachel A. Archer
, M.P.H., is a Project Associate at the Health Intervention and Technology Assessment Program (HITAP). Her work focuses on health system strengthening and supporting evidence-informed health policy making in low- and middle-income countries (LMICs). She is the focal point at HITAP for the Total Systems Effectiveness (TSE) project, an approach to strengthen vaccine decision-making in LMICs, and she currently leads the PMAC Commissioned Work project. Rachel has also supported capacity-building activities for Indonesia, Kenya and The Philippines. Rachel holds a Master’s degree in Public Health from the University of Sheffield and a Bachelor of Arts in International Development from the University of Leeds. Whilst studying, she interned with various non-profit organizations across East and West Africa. For her Master’s thesis, Rachel collaborated with a non-profit to investigate the trend towards teenage pregnancy in Luwero District, Uganda, through an intersectional framework. She was awarded the Carpenter Prize for Best Dissertation.

Rachel L. Bacon
, M.P.H., is the Project Manager for global health initiatives at the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies (ICRHPS) at Tufts Medical Center. Rachel is a public health professional with knowledge and applied experience in global health, reproductive health, health economics, health systems strengthening, population health management, clinical business management and quality improvement. She has a strong cross-cultural work history, with consulting experience developed internationally within the United States, Sub-Saharan Africa, Europe and the Asia Pacific. She is a member of the Consortium of Universities for Global Health (CUGH), the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the Institute for Health Care Improvement (IHI). She is also a trained labor and delivery birth doula with the Doula Organization of North America (DONA). Rachel holds a Master’s of Public Health from Boston University and a Bachelor of Arts in Anthropology from the University of New Hampshire.

Tazeem Bhatia, MPhil., MD., MRCGP, is a Public Health and Primary Care physician with twenty years’ experience of medical and public health practice in England, Myanmar, Afghanistan, Tajikistan and India. She has extensive expertise in the public health approach and tackling the wider determinants of health; community engagement and primary care; Universal Health Coverage (UHC) and models of social protection; and communicable and non-communicable disease (NCD) systems in high and low-income settings. She has conducted national level service and impact evaluations and sector wide health needs assessments, influencing senior leaders at a strategic level. She has worked in diverse environments and resource settings, from NGOs and think tanks, to Local Government, the NHS and UK Civil Service. Tazeem currently leads Public Health England’s global engagement on non-communicable disease with a focus on obesity. This includes advocating through evidence generation for action on the upstream social determinants of health.

Jesse B. Bump, M.P.H, Ph.D., is Executive Director of the Takemi Program in International Health and Lecturer on Global Health Policy in the Department of Global Health and Population at the Harvard T. H. Chan School of Public Health. He leads the global health field of study in the Master of Public Health degree and teaches on the political economy of global health. His research focuses on the intellectual ecology of global health, examining the historical, political and economic forces that are among the most fundamental determinants of ill health, and the most significant contextual factors that shape institutions and the approaches they embrace. This work addresses major themes in global health history and in the political economy of global health to analyze these macro forces and develop strategies for navigating solutions within them.

Kalipso Chalkidou, MD., Ph.D., is the Director of Global Health Policy and a Senior Fellow at the Center for Global Development, based in London and a Professor of Practice in Global Health at Imperial College London. Her work concentrates on helping governments build technical and institutional capacity for using evidence to inform health policy as they move towards Universal Healthcare Coverage. She is interested in how local information, local expertise and local institutions can drive scientific and legitimate healthcare resource allocation decisions. She has been involved in the Chinese rural health reforms and in national health reform projects in Colombia, Turkey and the Middle East, working with the World Bank, the Pan American Health Organization (PAHO), the Department for International Development (DFID) and the Inter-American Development Bank (IDB), as well as national governments. Between 2007 and 2008, she spent a year at the Johns Hopkins School of Public Health, as a Harkness fellow in Health Policy and Practice, studying how comparative effectiveness research can inform policy and US government drug pricing policies.
Kalipso led the establishment of NICE International, which she ran for eight years, and, more recently, of the international Decision Support Initiative (iDSI) which she directs and which is a multi-million, multi-country network working towards better health around the world through evidence-informed spending in healthcare in low to middle income countries. IDSI is funded by the Bill and Melinda Gates Foundation, the UK’s Department for International Development and the Rockefeller Foundation and is currently involved in national reform projects in China, India, Vietnam, Ghana, Indonesia and South Africa working together with key organizations such as the Thai Health Intervention and Technology Assessment Program (HITAP), the US Center for Global Development and PRICELESS, at Wits University in South Africa.

Anthony J. Culyer, Ph.D., is Emeritus Professor of Economics at the University of York (England), Senior Fellow at the Institute of Health Policy, Management and Evaluation at the University of Toronto (Canada) and Visiting Professor at Imperial College London. He is Chair of the Board of the international Decision Support Initiative (iDSI). He was the founding Organizer of the Health Economists’ Study Group. For thirty-three years he was the founding Co-Editor, with Joe Newhouse at Harvard, of Journal of Health Economics. He was founding Vice Chair of the National Institute for Health and Care Excellence (NICE) until 2003. He is Editor-in-Chief of the online Encyclopaedia of Health Economics. For many years he was chair of the Department of Economics & Related Studies at York and, for six of them, was also deputy vice-chancellor. He has published widely, mostly in health economics.
He is a Founding Fellow of the Academy of Medical Sciences, an Honorary Fellow of the Royal College of Physicians of London and an Honorary Member of the Finnish Society for Health Economics (2013). He holds an honorary doctorate from the Stockholm School of Economics and is a Commander of the British Empire (CBE). He has been a member or chaired many policy committees and boards in the UK and Canada including authoring the 1994 reforms of NHS Research and Development and being a director of the Canadian Agency for Drugs and Technologies in Health (CADTH).

David D. Kim, Ph.D., is an Assistant Professor of Medicine at Tufts University School of Medicine and a Program Director of the CEA Registry at the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies (ICRHPS) at Tufts Medical Center. As a health economist, he has been passionate about generating the best available economic evidence to inform health care decisions and public health policies through mathematical modeling. His primary research focuses on developing disease simulation models; improving methodology in economic evaluation and research prioritization; understanding health and economic consequences of health policies; and examining access to and utilization of cost-effective health interventions. He has developed several disease models for hepatitis C, alcohol use disorders, diabetes, cancer and cardiovascular diseases. Also, as a lead author of the worked example included in the Second Edition of Cost-Effectiveness in Health and Medicine, he conducted a cost-effectiveness analysis to reflect the comprehensive guidelines and recommendations. David received his doctorate in Health Economics at the University of Washington and his Master’s degree in Biostatistics from the University of Michigan.

Adam Elshaug, M.P.H., Ph.D., is a researcher specializing in the calculation of low-value care and a policy advisor on approaches to reducing waste to optimize value in health care. He is Professor of Health Policy and Co-Director of the Menzies Centre for Health Policy (MCHP) at The University of Sydney, Australia and is a Visiting Fellow with the USC-Brookings Schaeffer Initiative for Health Policy at The Brookings Institution in the USA. Professor Elshaug has numerous committee and Board appointments, including as a Ministerial appointee to the (Australian) Medicare Benefits Schedule (MBS) Review Taskforce. This is a five-year process to review Australia’s entire Medicare fee-for-service system utilizing Health Technology Assessment (HTA) principles and processes. Professor Elshaug was a 2010–2011 Commonwealth Fund Harkness Fellow based at the US Agency for Healthcare Research and Quality (AHRQ). From mid-2011 to mid-2013, he served as the National Health and Medical Research Council (NHMRC) Sidney Sax Fellow in Harvard Medical School’s Department of Health Care Policy. He is the recipient of numerous research awards and has published over 130 technical reports and peer review articles with first-author publications in journals such as The New England Journal of Medicine, BMJ and Journal of the American Medical Association. Professor Elshaug was Co-Lead of 2017 ‘Right Care’ Series of papers in The Lancet.

Wanrudee Isaranuwatchai, Ph.D., is a Senior Researcher at the Health Intervention and Technology Assessment Program (a part of the Ministry of Public Health) in Bangkok, Thailand, a Director at the Centre for Excellence in Economic Analysis Research of St. Michael’s Hospital and a Senior Health Economist at the Canadian Centre for Applied Research in Cancer Control in Canada. She is also an Assistant Professor at the Institute of Health Policy, Management and Evaluation, University of Toronto. Her research focuses on how to apply economic evaluation in the real world setting as well as how to advance methods in economic evaluation. She has experience conducting economic evaluations using person-level data and decision modelling. She has collaborated with researchers and decision-makers in various areas to help communicate the value of health initiatives using economic evidence. Dr. Isaranuwatchai is dedicated to promoting the use of evidence in healthcare decision making.

Melitta Jakab, M.Sc., Ph.D., is a senior health economist at the WHO Barcelona Office for Health Systems Strengthening. She has twenty years of experience in health system strengthening, health financing, policy analysis and education in global health. Her work includes advising WHO Member States on health financing policy design and implementation, in particular in Moldova, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Ukraine and Uzbekistan. She has been leading a multidisciplinary work program on the Health System Response to NCDs. She has been co-director of the Barcelona Courses on Health Systems Strengthening and Health Financing. She is co-editor of Health Systems Respond to NCDs: Time for Ambition (Jakab, Farrington, Borgermans, Mantingh, WHO Regional Office for Europe 2018) and of Implementing Health Financing Reform: Lessons from Countries in Transition (Kutzin, Cashin and Jakab, European Observatory, 2010). She has a PhD from Harvard University and M.Sc. in Health Policy for the Harvard School of Public Health.

Sumithra Krishnamurthy, M.P.H., has a particular interest in the political and social implications of NCDs for vulnerable populations, with an emphasis on access to services. Sumithra holds an M.P.H. in Global Health from the Harvard T. H. Chan School of Public Health and received her Bachelor’s degree in International Development from the University of Sussex in the UK. Her current research focuses on the political economy of NCDs from a global perspective. Sumithra has previously served at the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) as well as various civil society organizations in support of human rights and health in the UK, Mexico and Rwanda. She has also supported national health systems strengthening projects through consultancies in Mexico and Burkina Faso.

Alia Luz
, M.Sc., works as a Project Associate with the management and research team of the international unit at Health Intervention and Technology Assessment Program (HITAP). She provides technical support in international and local economic evaluation projects, as well as administrative coordination for the organization’s regional and country projects. Her portfolio of work includes management of HITAP projects in the Philippines, as well as the Guide to Economic Analysis and Research (GEAR) online resource. In 2018, she received her Masters of Science (M.Sc.) in Health Policy, Planning and Financing (HPPF) from both the London School of Hygiene and Tropical Medicine (LSHTM) and the London School of Economics (LSE). Alia graduated from Bryn Mawr College in 2013 with a degree in economics. Post-graduation, she worked in Liberia on renewable energy economics for a project funded by the United States Agency for International Development (USAID).

Ryota Nakamura, M.A., Ph.D., is an Associate Professor based in the Hitotsubashi Institute for Advanced Study (HIAS), Hitotsubashi University. He also serves as a Visiting Associate Professor at the Institute of Statistical Mathematics. He is an applied microeconomist specializing in health. He holds a B.A. and an M.A. in Economics from Kyoto University and a Ph.D. in Economics from the University of York in the UK. Prior to joining Hitotsubashi University in 2016, he held positions at the University of East Anglia and the University of York. His research interests include empirical and theoretical investigations of health-related behavior, as well as of healthcare systems to inform national and international public health policies, using a wide range of research methods including micro-econometric analysis of observational data e.g., impact evaluation), economic experiment, modelling and evidence synthesis.

Peter J. Neumann, Sc.D., is Director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and Professor of Medicine at Tufts University School of Medicine. He is the Founder and Director of the Cost-Effectiveness Analysis Registry. Dr. Neumann has written widely on clinical and economic evidence and on regulatory and reimbursement issues. He served as co-chair of the 2nd Panel on Cost-Effectiveness in Health and Medicine. He is the author or co-author of over 250 papers in medical literature, the author of Using Cost-Effectiveness Analysis to Improve Health Care (Oxford University Press, 2005) and co-editor of Cost-Effectiveness in Health and Medicine, 2nd Edition (Oxford University Press, 2016). Dr. Neumann has served as President of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). He is a member of the editorial advisory board of Health Affairs and the health policy advisory board for the Congressional Budget Office. He has held several policy positions in Washington, including Special Assistant to the Administrator at the Health Care Financing Administration. He received his doctorate in health policy and management from Harvard University.

Waranya Rattanavipapong
, M.Sc., joined Health Intervention and Technology Assessment Program (HITAP) in February 2010. She gained her Master’s degree in Health Economics and Decision Modelling from the University of Sheffield in 2014. She has strong expertise in health economic evaluations and has been involved in several research projects to support the Thai government as well as the public agencies in Bhutan, Indonesia, India and Vietnam.

Manushi Sharma, M.B.A., is an International Cooperation Officer at the Health Intervention and Technology Assessment Program (HITAP). She is a pharmacist by training with a Master’s in Business Management (M.B.A.). Previously, she worked with the Public Health Foundation of India with the health-economics and financing group. In the past, as a part of HITAP international unit (HIU), she has managed the iDSI Indonesia workstream. Currently, she is leading the monitoring and evaluation for all projects under HIU along with networking activities.

Arisa Shichijo, M.P.P., joined the project as a chapter team member. She received a B.A. in Law and Political science from Kyoto University and she is a second-year Master’s student at the School of International and Public Policy Hitotsubashi University. Her main field of research is health economics with a special focus on the process of policymaking and implementations in health-related areas and empirical analysis to inform public health interventions. She also completed a one-year exchange at McGill University, with a focus on Health Policy. She is now a Research Assistant at the Hitotsubashi Institute for Advanced Study (HIAS).

Peter C. Smith, Ph.D., is Emeritus Professor of Health Policy at Imperial College London and Honorary Professor of Health Economics, University of York. He is a mathematics graduate from the University of Oxford, with previous appointments at the University of Cambridge and the University of York, where he was Director of the Centre for Health Economics. His main research interest is in the economics of health, and his recent work has focused mainly on the financing and efficiency of health systems in low- and middle-income countries. Peter has published over 150 academic articles and twelve books, and has advised many governments and international agencies, including the World Health Organization, the International Monetary Fund, the Global Fund, the World Bank, the European Commission and the Organization for Economic Cooperation and Development.

Yot Teerawattananon
, MD., Ph.D., is the founding leader of the Health Intervention and Technology Assessment Program (HITAP), which is a semi-autonomous research institute of Thailand’s Ministry of Public Health. The works of HITAP have been used to inform policy decisions regarding the adoption of medicines, medical devices, health promotion and disease prevention programmes under the Universal Health Coverage Scheme and the national pharmaceutical reimbursement list, the National List of Essential Medicines. Recently, he joins the National University of Singapore as a visiting professor at Saw Swee Hock School of Public Health as well as is the Executive Board of the international Decision Support Initiative (iDSI). He has published more than 140 peer-reviewed journal articles and provided technical support on HTA capacity building in Asia and Africa. He is also one of the founders of HTAsiaLink, a regional network comprising governmental health technology assessment agencies in the Asia and Pacific region.
Chapter 1: Introduction (Wanrudee Isaranuwatchai, Rachel A. Archer, and Anthony J. Culyer)

This first chapter provides general information to set the context for the book, such as information on non-communicable diseases (NCDs), the concept of Best Buys, Wasted Buys and Contestable Buys and general definitions and central ideas in economic evaluation and health technology assessment (e.g., the cost-effectiveness plane and willingness-to-pay threshold). This chapter also shares the story of the book, and more details on this project, its output and journey, including the target audiences: those working to support NCD prevention (in various roles).

Chapter 2: Non-Communicable Diseases, NCD Program Managers, and the Politics of Progress (Sumithra Krishnamurthy Reddiar and Jesse B. Bump)

Non-communicable diseases (NCDs) are a defining problem of the twenty-first century, accounting for the top 3 causes of death worldwide and 7 out of every 10 deaths in developing countries. Over the last decade, there have been several high-level international political attempts to affirm NCD action as essential to national and regional development. These political actions have been supported and reinforced by substantive technical guidance from the World Health Organization, including a global monitoring framework and the identification of Best Buy interventions. However, the continued rise of NCDs shows that increased political attention to and knowledge of prevention strategies have yet to translate into effective policy implementation at national and local levels. For example, NCDs receive very limited funding, most of which has been concentrated on ensuring political commitment, as opposed to implementation activities. These challenges raise many questions, including how to build political momentum, augment capacities and identify resources. To analyse these obstacles, we focused on NCD program managers. In most cases an NCD program manager oversees an NCD unit within a national ministry of health and has a mandate over all or most NCDs. We conducted seventeen semi-structured interviews to learn about their experiences and perspectives. Our sample included eight NCD managers and nine others who worked with or above NCD managers, as well as five people at regional or global multilateral organizations and one urban-level official. We used the "Three-I’s” framework (Institutions, Ideas and Interests) to structure our findings and conclusions with recommendations for advancing progress against NCDs. Our interviews revealed several reasons why the attention paid to NCDs has not often translated into the implementation of effective programs, despite reported positive developments at legislative and upstream levels. In many cases, we found that ministries of health are organized into vertical directorates, and NCD program managers reported challenges in pursuing NCD work that would logically fall outside their own directorate, making it difficult for them to support both the treatment and prevention sides. This scenario is further compounded by the breadth of NCDs over which the units have a mandate, which creates operational challenges and confusion among stakeholders. NCD managers also noted the contrast between the multi-sectoral nature of NCD risk factors and intervention strategies, and the limited institutional mechanisms for facilitating multi-sectoral action. Additionally, global-level leadership has spurred many countries to establish NCD units and adopt legislation on NCDs, but these actions have not been accompanied by national political commitment to implementation. Our recommendations include: 1) expand global support for engaging political leadership in NCD agendas; 2) expand the managerial and institutional structures responsible for NCDs; and 3) generate effective guidance and support to stimulate multi-sectoral coordination, collaboration and action.

Chapter 3: Framework for Implementing Best Buys and Avoiding Wasted Buys (Yot Teerawattananon, Alia Luz, Manushi Sharma, and Waranya Rattanavipapong)

When non-communicable disease (NCD) program managers are faced with a decision to invest in an intervention, determining whether it is a Best Buy or Wasted Buy is not always easy or straightforward. Often, this is because Best Buys and Wasted Buys are two sides of the same coin, wherein an intervention that is a Best Buy could easily turn into a Wasted Buy if, for example, it were to be unwisely implemented. Chapter 3 introduces a framework called the SEED (Systematic thinking for Evidence-based and Efficient Decision-making) Tool, which outlines a step-by-step process for practical considerations to implement Best Buys and avoid Wasted Buys. Providing a backbone for in-depth discussions in other chapters of the book, the SEED Tool lays out a set of five fundamental questions (considerations) that aim to answer whether the intervention: has a sound theoretical basis (Consideration 1); is supported by good-quality evidence (Consideration 2); is transferable to the implementation setting (Consideration 3); can be implemented at reasonable cost (Consideration 4); and has sufficient political investment (Consideration 5). Should an intervention be lacking in any of these considerations, the framework suggests ways to improve the likelihood of turning it into a Best Buy by incorporating different types of measures. With this framework, a deliberate and evidence-oriented approach to decision-making for NCDs interventions can be adopted not just for individual interventions but throughout the system as a whole, with the ultimate aim, of improving health outcomes.

Chapter 4: Best Buys (Tazeem Bhatia, Ryota Nakamura, and Arisa Shichijo)

Chapter 4 provides practical considerations for achieving Best Buys in non-communicable disease (NCD) prevention. The World Health Organization (WHO) published an updated list of Best Buys and other recommended cost-effective policy interventions to prevent and control NCDs in 2017. Today, policy makers are required to judge whether a potential Best Buy intervention is effective and cost-effective in their own setting. However, data on the cost-effectiveness of NCD prevention are generally scarce in low- and middle-income countries. Moreover, the cost-effectiveness of a policy is crucially sensitive to the local context in which it is implemented; hence, available data from other settings are not always applicable or transferable to one’s own setting. We show through an analysis of case studies on NCD prevention that the current policy practice is largely informed by Contested Buys; these are policies that aspire to cost-effectiveness, rather than being direct, local evidence to demonstrate that they are a Best Buy. The analysis also identifies important factors that are associated with the successful implementation of preventive policies that prove to be Best Buys. We develop a list of considerations for policy implementors and we apply this list to featured case studies from different countries, in order to explore what else matters beyond cost effectiveness. We also examine the challenges in achieving a Best Buy and approaches to finding solutions.
Chapter 5: Wasted Buys (Yot Teerawattananon, Manushi Sharma, Alia Luz, Waranya Rattanavipapong, and Adam G. Elshaug)

The existence of Wasted Buys and even Contestable Buys has only started to gain traction in the health community. The concept of Wasted Buys is broad and examples abound in many countries. Chapter 5 is an attempt to demonstrate that tackling inefficient spending or ‘Wasted Buys’ is a value-enhancing agenda, which acts as a catalyzer in achieving the ultimate goals of a healthy society and healthcare ecosystem. It provides an operational, pragmatic definition of a Wasted Buy, which will help program managers and policy-makers to identify inefficient spending and initiate a constructive dialogue. This chapter explains the common characteristics of inefficient spending incurred in the prevention of NCDs by using current examples, and shows how inefficient spending can be avoided by substituting better programs or care.

Chapter 6: Assessing the Transferability of Economic Evaluations: A Decision Framework (David D. Kim, Rachel L. Bacon, and Peter J. Neumann)

Chapter 6 provides a practical decision-making framework and checklist to help researchers and decision-makers who wish to apply existing economic evidence to their local settings. This transferability is defined as ‘the extent to which particular study findings can be applied to another setting or context.’ Results from highly transferable studies could be used in various decision-making contexts without further adjustment. In this chapter, after reviewing the existing literature on the transferability of economic evaluations, we summarize critical factors for consideration and provide a decision-making framework to help determine whether local decision-makers should accept external evidence without further adjustment, modify it to reflect local data, or reject it altogether. We develop a worked example to provide a step-by-step illustration of how to perform a transferability assessment using our framework. We also discuss the use of an ‘Impact Inventory’ to aid decision-makers who wish to conduct for themselves original economic evaluations in local settings. The final section of the chapter provides conclusions and future steps.

Chapter 7: Finding the Best Evidence (Thunyarat Anothaisintawee)

Knowledge changes constantly. Therefore, non-communicable disease (NCD) program managers must be able to find up-to-date evidence, and to interpret and integrate that evidence into their local decision-making processes. Chapter 7 reviews the armory of research designs that may be used to understand causes and effects in NCD prevention intervention and treatment. In addition, this chapter uses an umbrella review of systematic reviews to demonstrate the process of evidence synthesis, and how this process can affect the efficacy of lifestyle interventions on health-harming behavior for type 2 diabetes mellitus, cardiovascular diseases, and hypertension. The evidence synthesis can be used to inform policy development and to identify the most effective intervention; however, monitoring and evaluation of policy implementation remains the key component to ensure that the policy remains a Best Buy.

Chapter 8: Cross-Sectoral Policies to Address Non-Communicable Diseases (Melitta Jakab and Peter C. Smith)

Many promising interventions designed to prevent or mitigate non-communicable diseases (NCDs) require collaboration with sectors other than the health system, such as the education sector or private employers. As well as seeking to improve health, such cross-sectoral interventions often also promote the objectives of the other sectors involved, and so should be evaluated with those multiple perspectives in mind. Chapter 8 notes that the design and implementation of cross-sectoral interventions is complex because of the different perspectives of the partners involved. It nevertheless shows that it is possible to assess such projects using a simple analytic framework that is consistent with conventional cost-effectiveness analysis but takes account of the objectives of the other sectors involved. However, this chapter notes that the most challenging barrier to successful cross-sectoral working arises from the different institutional structures, priorities and lines of accountability in the participating sectors. It therefore argues that great attention should be given to the governance of cross-sectoral interventions, possibly involving the commitment and authority of a high level of government or legal enforcement. Two case studies highlight the importance of governance arrangements.

Chapter 9: Deliberative Processes in Decisions about Best Buys, Wasted Buys, and Contestable Buys: Uncertainty and Credibility (Kalipso Chalkidou and Anthony J. Culyer)

Everyone involved in non-communicable disease (NCD) prevention and treatment needs to be aware that social values permeate all aspects of both. Decisions are not merely ‘technical’, let alone scientific. Moreover, since uncertainty abounds, all decisions require the exercise of judgment about issues including the quality of the evidence, the difficulty of implementation, the value of the outcome and the value of what is forgone when resources are committed to specific purposes, to name but a few. As a result, any criterion for what constitutes a Best Buy embodies value judgments. Chapter 9 discusses deliberation as a means of eliciting and incorporating value judgements in the decision-making process. We revisit the definition of ‘evidence’ through the lens of deliberation and from the perspective of different stakeholders both within and beyond the research community; we explore the uncertainty about and credibility of processes and end decisions; and we finish with a case study of the National Institute for Health and Care Excellence (NICE), the agency that provides evidence for policy decisions in the UK’s National Health Service, which, during its early days at least, had a stated and applied commitment to deliberation as a means of using evidence to inform decisions. We conclude with eight reasons why deliberation is deemed to enhance the impact of decisions about Best Buys and Wasted Buys. Without implying or guaranteeing consensus, deliberation is about facing up to inevitable difficulties rather than burying them and demonstrating reasonability in the ways they are handled. This makes deliberative processes and their outputs credible.

Chapter 10: Summing up (Wanrudee Isaranuwatchai, Rachel A. Archer, and Anthony J. Culyer)

The final chapter summarizes the space between an ideal world and the real world in which we live. We highlight how this book has tried to bring the two worlds together and has made a number of suggestions for enhancing the ability of societies to address the rising burden of non-communicable diseases (NCDs) more effectively and efficiently. While this book cannot solve all problems related to the NCDs, it does offer key considerations and guidance for assessing and implementing NCD prevention interventions. We are not denying that there is a long road ahead and that universal problems may lack universal solutions. Buys, in the case of NCD prevention, are often complex, constantly changing and unique to each jurisdiction. There is no ‘one-stop shop’ for policy-makers, but there are positive steps we can take to continue our efforts to support NCD prevention.
Online Appendix 2
Interview Guide NCD Managers Download

Online Appendix 4A
Analysis of the Global Health Cost Effectiveness Analysis Registry Download

Online Appendix 4A (2)
Analysis of the Global Health Cost Effectiveness Analysis Registry (2) Download

Online Appendix 4B
Analysis of the 47 case studies on evidence use and additional considerations Download

Online Appendix 6
The Transferability of Economic Evaluations Across Settings Download

Online Appendix 7
Methods of Umbrella Review Download