Monetary Value of Disability-Adjusted-Life-Years Lost from All Causes in Mauritius

Monetary value of disability-adjusted-life-years lost from all causes in Mauritius

Laurent MUSANGO (  [email protected] ) Organisation mondiale de la Sante https://orcid.org/0000-0003-4016-5718 Ajoy Nundoochan World Health Organization Country Ofce for Mauritis Philippe Van Wilder Universite Libre de Bruxelles Ecole de Sante Publique Joses Muthuri Kirigia Consultant

Research article

Keywords: Mauritius, disability-adjusted-life-year, monetary value, Sustainable Development Goal

Posted Date: November 26th, 2019

DOI: https://doi.org/10.21203/rs.2.17812/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License

Page 1/41 Abstract

Background The Republic of Mauritius lost a total of 402,565 disability-adjusted-life-years (DALY) from all causes in 2017. The objectives of this study were (a) to estimate the monetary value of DALY lost in 2017, and projected to be lost from all causes in Mauritius in 2030; and (b) to estimate the monetary value of DALY savings in year 2030, if the country would attain the United Nations Sustainable Development Goal 3 (SDG3) targets 3.1, 3.2, 3.3, 3.4 and 3.6.Methods Human capital approach is used to monetarily value DALY lost from 293 causes in 2017. The monetary value of DALY lost in 2017 from each cause is equal to the Mauritius net gross domestic product (GDP) per capita multiplied by the number of DALY lost from a specifc cause. The percentage reductions implied in the fve SDG3 targets were used in the projections of the monetary values of DALY expected in 2030. The potential savings equals monetary value of DALY lost in 2017 minus monetary value of DALY expected in 2030. The DALY data was obtained from the Institute of Health Metrics and Evaluation Global Burden of Disease Study 2017 database; the current health expenditure per capita data was from the WHO Global Health Expenditure Database; and the per capita GDP data was obtained from the IMF outlook database.Results The DALY lost in 2017 had a total monetary value of Int$9,564,741,771. Of which, 82.9% resulted from non-communicable diseases; 10.2% from communicable, maternal, neonatal and nutritional diseases; and 6.9% from injuries. Full attainment of the fve SDG 3 targets would avert DALY losses with a value of Int$2,986,241,156.Conclusions Diseases and injuries causes a signifcant DALY lost per year with a substantive monetary value. Full achievement of the SDG3 targets 3.1, 3.2, 3.3, 3.4 and 3.6 might potentially save the country about 9.351% of the total GDP of Mauritius in 2019. In order to achieve such savings, the country require to further strengthen the national health system, the other systems that tackle social determinants of health, and the national health research system.

Background

The Republic of Mauritius is one of the 16 Southern African Development Community (SADC) member states [1]. It has an estimated population of 1.279 million persons. In 2019, the estimated total gross domestic product (GDP) is International Dollars (Int$) 31.935 billion; and the GDP per capita is Int$ 24,966.505 [2]. In 2017, the country had a high human development index (HDI) of 0.790; and the income inequality Gini coefcient was 35.8 [3].

Mauritius lost a total of 402,565 disability-adjusted-life-years (DALY) from all causes in 2017 [4] compared to 132,813 DALY in 1993 [5]. Out of that, 333,713 (82.9%) DALY were from non-communicable diseases (NCD); 40,968 (10.2%) DALY from communicable, maternal, neonatal, and nutritional diseases (CMNND); and 27,883 (6.9%) DALY from injuries (INJ).

About 25.5% of the NCD DALY lost resulted from diabetes and kidney diseases; 21.5% from cardiovascular diseases; 10.6% from neoplasms; 8.0% from musculoskeletal disorders; 6.1% from mental disorders; 6.1% from neurological disorders; 5.0% from chronic respiratory diseases; 4.6% from other noncommunicable diseases; 4.2% from sense organ diseases; 3.7% from digestive diseases; 2.5% from skin

Page 2/41 and subcutaneous diseases; and 2.2% from substance use disorders (see Figure 1). Nearly 47% of the NCD-related DALY lost were attributed to diabetes and kidney diseases, and cardiovascular diseases.

Approximately, 12.4% of the CMNND DALY lost was caused by HIV/AIDS and sexually transmitted infections; 20.7% by respiratory infections and tuberculosis (TB); 6.9% by enteric infections; 10.0% by neglected tropical diseases (NTD); 4.9% by other infectious diseases; 28.6% by maternal and neonatal disorders; and 16.5% by nutritional defciencies [4]. Almost half of the CMNND DALY lost were caused by maternal and neonatal disorders, and respiratory infections and TB.

Almost 36% of the injury DALY lost was attributed to transport injuries; 36% to unintentional injuries; and 28% to self-harm and interpersonal violence [4].

On 25 September 2015, the United Nations General Assembly (UNGA) adopted resolution A/RES/70/1 entitled “Transforming our world: the 2030 Agenda for Sustainable Development” [5], which contains 17 Sustainable Development Goals (SDGs) and 169 targets. The SDG 3 on ensuring healthy lives and promoting well-being for all at all ages has 13 targets. The following fve of the SDG3 targets are intended for reducing the abovementioned disease burden [6]:

“Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under- 5 mortality to at least as low as 25 per 1,000 live births. Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing. Target 3.6: By 2020, halve the number of global deaths and injuries from road trafc accidents” (p.14).

The current health expenditure (CHE) per capita in Mauritius was US$553 in 2016 [7]. It consisted of the domestic general government health expenditure of US$244 per capita; domestic private health expenditure of US$308 per capita (of which US$266 was from out-of-pocket spending); and external health expenditure of US$1 per capita. The Mauritius current health expenditure per capita ranged between US$ 297 (minimum) and US$ 984 (maximum) per person per year of health systems investment recommended for attaining SDG3 among upper middle-income economies [8]. The fact that out-of-pocket payments (OOPS) constitutes 48% of CHE is a matter of concern. This is because according to WHO [9], when OOPS exceed 20% of total health expenditure, the incidence of fnancial catastrophe and impoverishment increases. In 2012, 1.79% of households reported experiencing catastrophic health expenditure as a result of OOPS compared to 1.22% in 2012 at a threshold where total OOP payments exceed 25% of total household expenditure. Increasing the threshold to 40%, the incidence of catastrophic

Page 3/41 health expenditure was 1.25% in 2012 compared to 0.93% in 2006. In the same vein impoverishment due to OOPS based on an International Poverty Line of US$ 3.1 daily rose from 0.2% in 2006 to 0.34% in 2012 [10].

The Mauritius domestic general government health expenditure as a percentage of the general government expenditure of 10% was below the African Heads of State and Government 2001 target of allocating at least 15% national budget to health development [11]. Furthermore, the Mauritius per capita CHE of US$553 (2.2% of GDP per capita) was about 7-fold lower than the average of US$4,003 (9.0% of average GDP per capita) for the OECD countries [12]. As a result, the country has a universal coverage index of 64%, denoting a gap in essential health services coverage of 36% [13].

Embracing the principles of a welfare state Mauritius ensures provision of free health care at point of use in any public facilities. Steady economic growth over the last decade has enabled the national economy to sustain social protection systems, including health [10,14]. In order to attain SDG3, Mauritius needs to sustainably increase its investments into the national health system and the other systems that address social determinants of health [15]. Even though health is wealth for Mauritius, the health sector will have to keep on competing for the scarce budgetary allocations with economic sectors. Thus, it is imperative that the health and health-related sectors ought to mount sustained evidence-based advocacy within the government and the private sector to sustain and grow funding for health development to bridge existing gap in access to essential health services.

People who control the national resources in public and private sectors are not public health experts [14]. And thus, they may not fully understand the intricacies around the negative impact of disability and premature mortality (from various causes) on economic indicators, such as, the GDP. Therefore, health sector stakeholders will have to couch their advocacy messages in a language that those who control national resources can understand [16,17,18].

Evidence from economic burden of disease studies in both economically developed and developing countries continue to be used to advocate for increased investments in health development [19-32]. The WHO Regional Ofce for Africa (WHO/AFRO) report entitled “A heavy burden: the productivity cost of illness in Africa” contains useful aggregated economic evidence for use in advocacy at global and regional forums [33]. However, it is of limited usefulness to individual countries for two reasons: (a) it is not disaggregated by countries and diseases; and (b) the analysis was based on 2015 DALY data. Mauritius policy-makers require updated and contextualized economic evidence for use in making a case for increased investment in health development.

The specifc objectives of this study were: (a) to estimate the monetary value of DALY lost from all causes in Mauritius in 2017; (b) to estimate the monetary value of DALY expected to be lost from all causes in Mauritius in 2030; and (c) to estimate the monetary value of DALY savings in year 2030, if Mauritius was to attain SDG3 disease and injury related targets 3.1, 3.2, 3.3, 3.4 and 3.6.

Methods Page 4/41 The DALY

The seminal application of the DALY to measure global burden of disease was in 1993 by the World Bank in its report entitled ‘World Development Report 1993: Investing in Health’, which “..examined the interplay between human health, health policy, and economic development (p. iii)” [34]. However, it was only in 1994 that Professor CJL Murray developed and published in the Bulletin of the World Health Organization the conceptual basis for the DALY [35]. He defned DALY as the sum of potential years of life lost (PYLL) due to premature death and years lived with disability (YLD).

WHO [36] further explains that DALY for a specifc cause are calculated using the following formula:

for specifc disease or injury c, age a, sex s and year t.

Even though debate has been ranging since 1996 around various real and perceived short-comings of the DALY [37-40], it has withstood the test of time, and continues to be a useful metric in the global health discourse [41].

In the study reported in this paper, we calculated the monetary value of DALY lost in Mauritius in 2017 from 293 causes. The DALY data were acquired from the Institute for Health Metrics and Evaluation (IHME) global burden of disease (GBD) study 2017 database [4]. Methodological details and sources of data used in the Global Burden of Disease study 2017 can be found in the article published by the GBD 2017 DALY and HALE Collaborators [42].

Estimating the money value of DALY lost in Mauritius in 2017

This study employed human capital approach initially suggested by Weisbrod [43], and subsequently, adapted to fnancially value DALY in Kenya among the elderly [44] and 15-59 year olds [45], the Arab Maghreb Union [46], the Central African Economic and Monetary Community [47], the East African Community [48], and the African region [33], to estimate the economic value of DALY lost in 2017 in Mauritius. The development of health-related human capital begins at birth and ends at death; and thus, diseases have inter- and intra-generational negative impact on the process of human capital creation [43].

(See Formulas 1 in the Supplementary Files)

Estimating expected monetary value of DALY lost in 2030

We adapt in this subsection, the formulae used in past studies in Africa [44-49] to estimate the monetary value of DALY losses in 2030, assuming the fve disease-related SDG3 targets in Table 1 are fully accomplished in Mauritius.

Page 5/41 Table 1. Health SDG3 targets and expected percentage reductions for Mauritius Target Description Percentage reduction envisaged in SDG targets SDG By 2030, reduce the global maternal mortality ratio (MMR) to less 22.64% 3.1 than 70 per 100,000 live births [5]. Mauritius in 2015 had a MMR of (AARR= 53 per 100,000 live births, i.e. SDG 3.1 had been exceeded [50]. 1.817002967%) However, the country set a MMR 2030 target of 41 per 100,000 live births [50]. Average Annual Rate of Reduction (AARR) formula [13,51]. SDG By 2030, end preventable deaths of newborns, with all countries 25.00% 3.2 aiming to reduce neonatal mortality to at least as low as 12 per (AARR= 1,000 live births [6]. Since Mauritius had already achieved this target 2.033903324%) by 2015, the country set a 2030 target of neonatal mortality of 6 per 1,000 live births [13,50,51]. SDG By 2030, end the epidemics of AIDS, tuberculosis, malaria and 3.3 neglected tropical diseases and reduce hepatitis, water-borne diseases and other communicable diseases [6]. (a). Reduce global HIV-related deaths from 1,062,352 in 2015 to 54.55% below 500,000 by 2020 [51,52]. (AARR= 5.476185967%) (b). The number of tuberculosis (TB) deaths will be reduced by 90% 90% from 2015 to 2030 [4,51,53]. (AARR= 15.17%) (c). Mortality due to vector-borne diseases will be reduced globally 75% by at least 75% from 2016 to 2030 [4,54]. (AARR=9.427633574%) (d). Globally reduce viral hepatitis B and C deaths from 1.4 million 64.29% deaths reduced to less than 500,000 by 2030 [51,55]. (AARR= 7.090496208%) SDG By 2030, reduce premature mortality due to NCDs by one third 33.333% 3.4 through prevention and treatment and promote mental health and (AARR= well-being [4,6,51,57]. 2.854607339%) SDG By 2020, halve the number of global deaths and injuries from road 50% 3.6 trafc accidents [4,6,51]. (AARR=4.830484699%

The reductions in the monetary value of DALY lost from maternal disorders (SDG 3 target 3.1); neonatal disorders (SDG 3 target 3.2); HIV/AIDS (SDG 3 target 3.3a); tuberculosis (SDG 3 target 3.3b); neglected tropical disease (SDG 3 target 3.3c); viral hepatitis (SDG 3 target 3.3d); NCD (SDG 3 target 3.4); and transport injury (SDG 3 target 3.6) were estimated using the eight equations contained in Additional File 1. For example, the equation used in estimating the SDG 3 target 3.1 envisaged reduction in the monetary value of DALY from maternal disorders (MD) was as follows:

(See Formulas 2 n the Supplementary Files)

Data sources

Page 6/41 The DALY data for the 293 causes was obtained from the IHME GBD study 2017 database [4]; the current health expenditure per capita data was gotten from the WHO Global Health Expenditure Database [7]; and the per capita GDP data was obtained from the IMF outlook database [2].

Data analysis

The analysis was conducted using Excel Software developed by Microsoft (New York). It was undertaken in 7 steps.

Step 1: Construction of economic model on Excel software

The economic model containing the 13 equations was built on Excel spreadsheet.

Step 2: Collating DALY data

The 2017 data on DALY lost from 293 causes was extracted from the IHME GBD [4] and saved in an Excel spreadsheet. The data was then sorted by the three broad categories of health conditions, i.e. NCDs, CMNND and INJ. That was followed by organizing the 293 causes under relevant broad category.

Step 3: Collating health expenditure data

The Mauritius current health expenditure per capita () of Int$1,207 was obtained from the WHO Global Health Expenditure Database [7].

Step 3: Collating the per capita GDP data

The Mauritius GDP per capita () of Int$24,966.51 was acquired from the IMF World Economic Outlook Database [2].

Step 4: Calculating the non-health per capita GDP

The non-health GDP per capita was estimated as a difference between GDP per capita and current health expenditure per capita. The non-health per capita GDP (NHGDPPC) = GDPPC – CHEPC = Int$24,966.51 - Int$1,207 = Int$23,759.51.

Step 5: Estimating the 2017 monetary value of DALY lost from each cause

(See Formulas 3 in the Supplementary Files)

Results

Money value of the DALY lost in Mauritius in 2017

In 2017, Mauritius lost a total of 402,565 DALY from all causes with a monetary value of Int$ 9,564,741,771. Of which, Int$7,928,861,951 (82.9%) resulted from NCD; Int$ 973,387,357 (10.2%) from

Page 7/41 CMNND; and Int$662,492,462 (6.9%) to INJ. About Int$6,052,204,025 (63%) of the monetary value DALY lost occurred among the 15-64 years old, i.e. the most productive age bracket (see Figure 2). Additional File 2 presents the DALY lost in Mauritius in 2017 from all causes and their monetary values in 2019 purchasing power parity (or Int$).

Communicable, maternal, neonatal and nutritional diseases

Out of the Int$973.4 million from CMNND, 12.4% resulted from HIV/AIDS and sexually transmitted infections; 20.7% from respiratory infections and tuberculosis; 6.9% from enteric infections; 9.9% from neglected tropical diseases; 4.9% from other infectious diseases; 28.6% from maternal and neonatal disorders; and 16.5% from nutritional defciencies. Figure 3 presents the money value of DALY lost from CMNND. About 77.2% of the monetary value was for DALY lost from neonatal disorders, lower respiratory infections, dietary iron defciency, HIV/AIDS and schistosomiasis alone.

HIV/AIDS and sexually transmitted infections: The money value of DALY lost from HIV/AIDS and sexually transmitted infections (STI) was Int$121,135,767. HIV/AIDS and STI (excluding HIV) accounted for 93.7% and 6.3%, respectively.

Respiratory Infections and TB: The respiratory infections and TB caused a DALY loss valued at Int$201,568,464. Out of which, 7.8% was from TB, 79% from lower respiratory infections, 10.5% from upper respiratory infections, and 2.7% from otitis media.

Enteric infections: The enteric infections bled DALY with a value of Int$ 66,997,219. Out of that, 98.5% was from diarrheal diseases, 0.06% from typhoid and paratyphoid, 1.4% from invasive non-typhoidal salmonella (iNTS), and 0.1% from other intestinal infectious diseases.

Neglected tropical diseases (NTD): Table 2 shows the distribution of monetary values of DALY lost from the various NTDs. The NTDs led to a DALY loss valued at Int$ 96,352,531. Schistosomiasis and cysticercosis accounted for 87.2% of the monetary value of DALY lost from NTDs.

Table 2: Monetary value of DALYs lost from NTDs (2019, Int$ or PPP)

Causes Monetary value in Int$ Percent Schistosomiasis 75,202,993 78 Cysticercosis 8,845,830 9.2 Dengue 5,080,425 5.3 Intestinal nematode infections 425,214 0.4 Leprosy 379,126 0.4 Rabies 1,659 0 Other neglected tropical diseases 6,417,284 6.7 Total 96,352,531 100

Page 8/41 Other infectious diseases: Table 3 shows other infectious diseases caused a DALY loss valued at Int$47,730,413. About 69% of monetary value was attributed to DALY lost from meningitis, encephalitis and acute hepatitis.

Table 3: Monetary value of DALYs lost from other infectious diseases (2019, Int$ or PPP) Causes Monetary value in Int$ Percent Meningitis 12,122,304 25.4 Encephalitis 10,858,597 22.7 Acute hepatitis 9,990,314 20.9 Varicella and herpes zoster 1,981,210 4.2 Whooping cough 232,712 0.5 Measles 189,082 0.4 Tetanus 21,990 0.0 Diphtheria 2,484 0.0 Other unspecifed infectious diseases 12,331,721 25.8 Total 47,730,413 100.0

Maternal and neonatal disorders: Table 4 portrays the monetary value of DALY lost from maternal and neonatal disorders.

Table 4: Monetary value of DALYs lost from maternal and neonatal disorders (2019, Int$ or PPP) Maternal disorders Monetary value in Int$ Percent Maternal haemorrhage 576,769 6.3 Maternal sepsis and other maternal infections 1,051,918 11.5 Maternal hypertensive disorders 484,637 5.3 Maternal obstructed labour and uterine rupture 154,120 1.7 Maternal abortion and miscarriage 1,995,255 21.8 Ectopic pregnancy 194,042 2.1 Indirect maternal deaths 2,583,137 28.3 Late maternal deaths 340,510 3.7 Maternal deaths aggravated by HIV/AIDS 13,076 0.1 Other maternal disorders 1,746,967 19.1 Neonatal disorders Neonatal preterm birth 144,497,683 53.6 Neonatal encephalopathy due to birth asphyxia and trauma 47,985,914 17.8 Neonatal sepsis and other neonatal infections 43,341,151 16.1 Haemolytic disease and other neonatal jaundice 1,737,966 0.6 Other neonatal disorders 32,166,138 11.9

These disorders resulted into a total DALY loss valued at Int$ 278,869,282. About Int$9,140,430 (3.3%) was attributed to maternal disorders; of which 61.6% was from indirect maternal deaths, maternal abortion and miscarriage, and maternal sepsis and other maternal infections. Neonatal disorders

Page 9/41 accounted for Int$269,728,852 (96.7%); out of which 71.4% was from neonatal preterm birth and neonatal encephalopathy due to birth asphyxia and trauma.

Nutritional defciencies: The nutritional defciencies resulted in a DALY loss valued at Int$1,340,157,975. Out of which, 83.1% was attributed to DALY lost from dietary iron defciency, 10% from protein-energy malnutrition, 3.7% from vitamin A defciency, 1.5% from iodine defciency, and 1.7% from other nutritional defciencies.

Non-communicable diseases

As alluded to earlier, the NCDs combined caused a loss of 333,713.26 DALY, with a monetary value of about Int$ 7.93 billion. We present below the contributions of different groups of NCDs to that monetary value.

Neoplasms: Figure 4 depicts the monetary value of DALY lost form neoplasms (or cancers) was Int$843,622,095, i.e. 10.6%. About half of the monetary value was from breast cancer, colon and rectum cancer, stomach cancer, leukaemia, and tracheal, bronchus, and lung cancer. Of the Int$33.97 million value of DALY lost due to liver cancer, 32.8% was from liver cancer due to hepatitis B, 26.2% from liver cancer due to hepatitis C, 25.4% from liver cancer due to alcohol use, 10.2% from liver cancer due to NASH (non-alcoholic steatoHepatitis), and 5.4% from liver cancer due to other causes. Of the Int$42.41 million DALY worth lost from leukaemia, 11.1% was from acute lymphoid leukaemia, 1.4% from chronic lymphoid leukaemia, 21.4% from acute myeloid leukaemia, 4.6% from chronic myeloid leukaemia, and 61.5% from other leukaemia.

Cardiovascular diseases: Figure 5 displays the monetary value of DALY lost from cardiovascular diseases was Int$1,704,386,581. Around 89.5% of that fnancial value was from ischemic heart disease, stroke and hypertensive heart disease. Of the Int$543.4 million value of DALY lost due to stroke, 52.1% was from intracerebral haemorrhage, 36.1% from ischemic stroke, and 11.8% from subarachnoid haemorrhage.

Chronic respiratory diseases: The DALY lost from chronic respiratory diseases had a monetary value of Int$393,895,127; out of which 55.8% was from chronic obstructive pulmonary disease; 0.1% from pneumoconiosis; 30.9% from asthma; 8.4% from interstitial lung disease and pulmonary sarcoidosis; and 4.8% from other chronic respiratory diseases.

Digestive diseases: Figure 6 portrays the monetary value of DALY lost from digestive diseases was Int$291,807,418. Cirrhosis and other chronic liver diseases, upper digestive system diseases and pancreatitis made up 86.9% of the monetary value of DALY lost from digestive diseases.

Neurological disorders: The DALY lost from neurological disorders had a value of Int$482,770,731; out of which 45.8% was from headache disorders, 29.3% from Alzheimer's disease and other dementias, 15.1% from epilepsy, 5.3% from Parkinson's disease, 0.3% from multiple sclerosis, 0.5% from motor neuron disease, and 3.7% from other neurological disorders.

Page 10/41 Mental disorders: Figure 7 shows the monetary value of DALY lost from mental disorders was Int$482,912,628. The depressive disorders, anxiety disorders and Schizophrenia accounted for 70.2% of that monetary value.

Substance use disorders: The DALY lost due to substance use disorders had a monetary value of Int$175.72 million. The drug use disorders led to a loss of DALY valued at Int$62.44 million, of which 46.2% were from opioid use disorders, 13.8% from amphetamine use disorders, 3.6% from cannabis use disorders, 0.5% from cocaine use disorders, and 35.9% from other drug use disorders.

Diabetes and kidney diseases: The DALY lost from diabetes and kidney diseases had a monetary value of Int$2,022,634,430. Out of that, diabetes mellitus accounted for Int$1.37 billion (67.7%), which in turn was made up of 12.9% type 1 diabetes mellitus and 87.1% of type 2 diabetes mellitus.

The chronic kidney disease was responsible for DALY with a monetary value of Int$653.8 million (32.3%). Of which, 32.6% was attributed to chronic kidney disease due to diabetes mellitus type 2; 23.8% to chronic kidney disease due to hypertension; 12.5% to chronic kidney disease due to diabetes mellitus type 1; 11.3% to chronic kidney disease due to glomerulonephritis; and 19.8% to chronic kidney disease due to other unspecifed causes.

Skin and subcutaneous diseases: Figure 8 portrays that DALY lost from skin and subcutaneous diseases were worth Int$196,821,441. About 62.2% was attributed to dermatitis, scabies, psoriasis and fungal skin diseases.

Sense organ diseases: The DALY lost from sense organ diseases had a monetary value of Int$ 334,396,273. Out of that, 55.1% was from age-related and other hearing lost, 41.5% was from blindness and vision impairment, and 3.4% from other sense organ diseases.

Musculoskeletal disorders: The DALY lost from musculoskeletal disorders had a value of Int$632,983,114. Nearly, 45.9% of the monetary value was attributed to low back pain; 16.7% neck pain; 8.1% to osteoarthritis; 1.2% to rheumatoid arthritis; 1% to gout; and 27.1% to other musculoskeletal disorders.

Other non-communicable diseases: Figure 9 shows that other NCDs resulted to DALY lost with a monetary value of Int$366,916,157. Out of which, 39.0% was from congenital birth defects; 23.4% from oral disorders; 12.2% from gynaecological diseases; 8.2% from endocrine, metabolic, blood, and immune disorders; 8.1% from haemoglobinopathies and haemolytic anaemias; 7.1% from urinary diseases and male infertility; and 1.9% from sudden infant death syndrome.

Injuries

Figure 10 shows the money value of DALY lost from various forms of injuries was Int$662,492,462. About 35.9% was attributed to transport Injuries; 36.0% to unintentional injuries; and 28.0% from self-harm and interpersonal violence.

Page 11/41 Transport injuries: The transport injuries caused a DALY loss valued at Int$238,076,901, i.e. 35.9%. Road injuries resulted in a DALY loss valued at Int$216,339,017, i.e. 90.9% of monetary value related to transport injuries. Other transport injuries caused a DALY loss valued at Int$21,737,884, i.e. 9.1% of monetary value related to transport injuries.

Unintentional injuries: The money value of DALY lost from unintentional injuries was Int$238,783,290. Out of which, 27.3% emanated from falls; 20.9% from drowning; 16.3% from adverse effects of medical treatment; 12.3% from fre, heat, and hot substances; 10.5% from foreign body; 5.3% from exposure to mechanical forces; 1.9% from poisonings; 0.7% animal contact; 0.7% from environmental heat and cold exposure; 0.1% from exposure to forces of nature; and 4.1% from other unintentional injuries. Therefore, 76.7% of the unintentional injuries was attributed to falls, drowning, adverse effects of medical treatment, and fre, heat, and hot substances.

Self-harm and interpersonal violence: Self-harm and interpersonal injuries caused a DALY loss worth Int$185,632,271. Of which, 73% from self-harm, 26.9% from interpersonal violence, and 0.1% from executions and police confict.

Expected monetary value of DALY lost in 2030

Table 5 shows the monetary value of DALY lost in 2017, monetary value of DALY lost in 2030, and potential savings from DALY lost prevented assuming the fve disease-related SDG3 targets are attained.

Page 12/41 Table 5: Money value of DALYs lost distributed by SDG health conditions (Int$ or PPP) Health (A). Money Value (B). Money Value (C). Reduction/Savings in Money condition/diseases of DALYS lost in of DALYS lost in Value of DALYS lost in 2030 2017 (Int$) 2030 (Int$) (Int$) [C=A-B)] SDG 3.1: Maternal 9,140,430 7,070,899 2,069,531 disorders SDG 3.2: Neonatal 269,728,852 202,296,639 67,432,213 disorders SDG 3.3: 15,742,571 1,574,257 14,168,314 Tuberculosis SDG 3.3: HIV/AIDS 113,516,975 51,598,625 61,918,350 SDG 3.3: Acute 9,990,314 3,840,263 6,422,345 hepatitis SDG 3.3: NTDs 96,352,531 24,088,133 72,264,398 (a+b..+l) (a). Schistosomiasis 75,202,993 18,800,748 56,402,245 (b). Intestinal 425,214 106,304 318,911 nematode infections (c). Cysticercosis 8,845,830 2,211,458 6,634,373 (d). Dengue 5,080,425 1,270,106 3,810,319 (e). Rabies 1,659 415 1,244 (f). Leprosy 379,126 94,782 284,345 (h). Other neglected 6,417,284 1,604,321 4,812,963 tropical diseases SDG 3.4: Non- 7,928,861,952 5,285,934,398 2,642,927,554 communicable diseases (a+b+c+..+l) (a). Neoplasms 843,622,095 562,417,542.07 281,204,553 (b). Cardiovascular 1,704,386,581 1,136,263,401.96 568,123,179 Diseases (c) Chronic 393,895,127 262,598,064 131,297,063 respiratory diseases (d). Digestive 291,807,418 194,539,251 97,268,167 diseases (e).Neurological 482,770,731 321,848,763 160,921,968 Disorders (f). Mental Disorders 482,912,628 321,943,362 160,969,266 (g). Substance Use 175,715,957 117,144,557 58,571,400 Disorders (h). Diabetes and 2,022,634,430 1,348,429,695 674,204,735 Kidney Diseases (i). Skin and 196,821,441 131,214,950 65,606,491 Subcutaneous Diseases (j). Sense Organ 334,396,273 222,931,963 111,464,310 Diseases (k). Musculoskeletal 632,983,114 421,990,853 210,992,261 Disorders (l).Other non- 366,916,157 244,611,994 122,304,163 communicable Page 13/41 diseases SDG 3.6: Transport 238,076,901 119,038,451 119,038,451 injuries TOTAL (INT$) 8,681,410,526 5,695,441,665 2,986,241,156

The DALY lost from the fve SDG3 health conditions (maternal disorders, neonatal disorders, TB, HIV/AIDS, acute hepatitis, NTD, NCD and injuries) in 2017 were valued at Int$8,681,410,526. Assuming that the fve SDG3 targets (3.1, 3.2, 3.3, 3.4 and 3.6) are fully achieved by 2030, there would still be DALY losses valued at Int$5,695,441,665. Therefore, the reduction/savings in money value of DALY lost by 2030 would be Int$2,986,241,156.

Discussion

In 2017, Mauritius lost a total of 402,565 DALY from all causes with a total monetary value of Int$9,564,741,771. About 82.9% of the latter was attributed to NCDs, 10.2% to CMNND and 6.9% to INJ. In comparison, approximately 61.3%, 28.4% and 10.3% of the total monetary value of DALY lost in the Economic and Monetary Community of Central Africa (CEMAC) in 2015 was due to CMNND, NCDs and INJ, respectively [47]. In the East African Community (EAC), approximately 58.2%, 30.3% and 11.5% of the total monetary value of DALY lost in 2015 was attributed to CMNND, NCDs and INJ, respectively [48]. Therefore, the lion’s share of the monetary value of DALY lost in Mauritius was from NCDs, unlike in CEMAC and EAC, where CMNND dominated.

The diseases and injuries related to SDG 3 targets 3.1, 3.2, 3.3, 3.4 and 3.6 caused DALY lost valued at Int$8,681,410,526, i.e. 90.76% of the total monetary value of DALY lost in Mauritius. We found that full attainment of the fve targets would yield an estimated Int$2.99 billion saving in the monetary value of SDG-related DALY lost by 2030.

SDG Targets 3.1 and 3.2: Maternal and neonatal disorders

Attainment of SDG3 targets 3.1 and 3.2 by 2030 would avert DALY with a monetary value of Int$69,501,744. The projected savings might be achieved assuming the national sexual and reproductive health policy [56]; the health sector strategy 2017-2021 [57]; the sexual and reproductive health strategy and plan of action [58]; and the white paper on health sector development and reform [59] are fully implemented. The legal framework in Additional File 3 underpin the implementation of those policy and strategic documents.

The formulation and implementation of the national policy and strategies are buttressed by the SADC strategy for sexual and reproductive health rights [60]; the SADC regional gender based violence strategy and framework for action [61]; the African Union (AU) ministers of health commitments on universal health coverage [62] and ending preventable maternal and child deaths in Africa [63]; the AU Assembly

Page 14/41 decision on progress on maternal, new born and child health [64]; and the AU Assembly declaration on addressing social determinants of health using health in all policies approach [65].

Mauritius efforts to reduce child and maternal morbidity, disability and deaths are informed and supported by various pertinent WHO Governing Bodies resolutions, for example, the Regional Committee for Africa (RC) strategic plan for immunization [66] and its resolution [67]; the World Health Assembly (WHA) resolution on reduction of perinatal and neonatal mortality [68]; the global vaccine action plan [69] and related WHA resolution [70]; and the global strategy for women’s, children’s and adolescents’ health 2016–2030 [71,72] plus the associated WHA resolution [73,].

The United Nations General Assembly (UNGA) resolutions on rights of the child [74,75] and preventable maternal mortality and morbidity and human rights [76] provides high-level political backing for full implementation of the Mauritius policies and strategies.

SDG Target 3.3: HIV/AIDS, Tuberculosis, acute hepatitis and NTDs

The achievement of SDG target 3.3 by 2030 would avert DALY with a monetary value of Int$61.92 million from HIV/AIDS, Int$14.2 million from TB, Int$6.42 million from acute hepatitis and Int$72.3 million from NTDs. Therefore, the full attainment of the target 3.3 may enable Mauritius to save DALY with a total monetary value of Int$154.8 million. These savings are potentially achievable, if communicable diseases prevention and control services planned in chapter 7 of the Mauritius health sector strategy [77]; the national HIV and AIDS policy [78]; the national HIV action plan [79]; and the national multi-sectoral HIV and AIDS strategic framework [80] are made universally accessible to all the people in need. The implementation of pertinent policies, strategies and plans is augmented with the legal framework in Additional File 3.

The Mauritius battle against HIV/AIDS, TB and hepatitis is also guided by the SADC strategy for HIV prevention, treatment and care and sexual and reproductive health [81]; the framework for the prevention and control of sexually transmitted infections [82]; and the strategic plan for the control of TB [83]; and the advocacy strategy on HIV/AIDs, TB and sexually transmitted infections [84].

Moreover, communicable disease control policies, strategies and plans in Mauritius and the SADC are informed and reinforced by the WHO Governing Bodies documents and resolutions, including the end TB strategy [85]; the global health sector strategy on HIV [86]; the HIV/AIDS strategy for the African Region [87] and resolution AFR/RC62/R2 [88]; the global health sector strategy on viral hepatitis [89]; the framework for action on prevention, care and treatment of viral hepatitis in the African region [90] and resolution AFR/RC64/R5 [91]; the global health sector strategy on sexually transmitted infections [92]; the neglected tropical diseases [93]; the regional strategy on NTDs in the WHO African Region [94] and its resolution AFR/RC63/R6 [95]; the global vector control response strategy [96] and its resolution WHA70.16 [97]; the regional strategy for integrated disease surveillance and response [98] and its draft resolution AFR/RC69/WP2/Rev1 [99]; and the health promotion strategy for the African region [100] and resolution AFR/RC62/R4 [101].

Page 15/41 The implementation of the aforementioned Mauritius communicable diseases policies and strategies is further bolstered by a number of relevant political decisions/declarations/resolutions of the AU [102-106] and the UNGA [107-111].

SDG Target 3.4: Non-communicable diseases

We estimated that Mauritius could potentially avert DALY worth Int$2.643 billion, if the country succeeds to decrease NCDs burden by one third by 2030 (SDG3 target 3.4). Such savings might be realized assuming Mauritius made accessible, to everyone in need (i.e. with capacity to beneft), the prevention and control health interventions and services planned for in the health chapter of the national development strategic plan [112]; the health sector strategic plan, chapter 8, which contains strategic actions for combating NCDs [77]; the national sport and physical activity policy [113]; the national cancer control programme action plan [114]; and the national action plan on tobacco control [115]. The implementation of NCD strategies and plans is supported by the set of legislations contained in Additional File 3; and the UN General Assembly Political declaration on the prevention and control of noncommunicable diseases as well as the African Union commitment on NCDs [116, 117].

The Mauritius NCD strategies and plans were partially informed by various WHA and RC resolutions on global strategy for the prevention and control [118] and its resolution WHA53.17 [119]; the global action plan for the prevention and control of NCD [120] and its endorsing resolution WHA66.10 [121]; the global action plan on the public health response to dementia [122] and related resolution WHA70(17) [123]; the comprehensive mental health action plan [124] and its resolution WHA66.8 [125]; the WHO Framework Convention on Tobacco Control (FCTC) [126] and related resolution WHA53.16 [127]; strategies to reduce the harmful use of alcohol resolution WHA61.4 [128]; cancer prevention and control resolution WHA70.2 [129]; the global action plan 2014–2019 on universal eye health [130] and its resolution WHA66.4 [131]; the global action plan on physical activity resolution WHA71.6 [132]; the NCD regional strategy for the African region [133] and its resolution AFR/RC50/R4 [134]; the Brazzaville declaration on NCDs prevention and control in the African region [135] and its resolution [136]; the strategic plan to reduce the double burden of malnutrition [137] and its resolution AFR/RC69/WP1/Rev1 [138]; the regional oral health strategy [139] and the resolution AFR/RC66/R1 [140]; and the health promotion strategy for the African region[100] and its resolution AFR/RC62/R4 101].

The UNGA declaration on NCDs [141], ageing [142-143], food [144] and nutrition [145] commits the Mauritius Government to provide high-level political leadership and requisite resources to prevent and control NCDs.

SDG Target 3.6: Transport injuries

Mauritius could potentially avert DALY with a monetary value of Int$ 119.04 million if the country succeeds in reducing by half the transport-related injuries. With a view to realizing those potential savings, related to attainment of SDG target 3.6, the government will need to fully implement its national road safety strategy 2016 – 2025, whose overarching objective is to achieve a 50% reduction in the

Page 16/41 number of non-fatal injuries and deaths by the year 2025 [146]. The strategy has ten strategic felds of action, i.e. improving safety standards of the road infrastructure; reorganising control of roadworthiness vehicles; strengthening of the road trafc law and enforcement; re-engineering of the driving licensing scheme; improving medical testing of ftness to drive; provision of post-crash trauma care; starting a road safety academy; creating a transport and road safety research and development programme; launching an effective education and communication strategy; and funding implementation of the road safety strategy [147]. The institutions mandated by Road Trafc Act to spearhead implementation of the strategy consists of the National Transport Authority and National Road Safety Council [148].

The development of the Mauritius national road safety strategy was informed by the AU road safety charter [149], the AU road safety action plan 2011-2020 [150], the WHO global plan for the decade of action for road safety [151], the WHO global 2018 status report on road safety [152], the 69th WHA resolution on outcome of the second global high-level conference on road safety [153], and the status report on the implementation of the decade of action for road safety in the African region [154].

The UNGA resolutions A/RES/64/255 [155], A/RES/66/260 [156], A/RES/68/269 [157], A/RES/70/260 [158], A/RES/72/271 [159] and A/RES/70/1 [6] provides high-level political support for full implementation of the Mauritius national road safety strategy 2016 – 2025 to reduce by at least half the number of transport related non-fatal injuries and human lives.

Limitations

This kind of study has limitations surrounding the GDP calculus; the human capital approach; and the DALY index.

Limitations in GDP calculations: The per capita GDP was used in this study as a numeraire for converting DALY lost into their monetary equivalent. The current systems of national accounts which measures GDP omits unpaid household production (e.g. full-time homemaker’s services within a household, including cooking, cleaning, childcare, nursing ailing household members, etc) and leisure; and contribution of the elderly in reconciling differences among family members (social cohesion) and transmitting community values and indigenous knowledge to children and youth [160]. The index also does not capture the negative effects of economic production processes on the environment, animal and human health [161]. In addition, GDP does not account for inequalities in distribution of income and wealth across households and individuals [162], and also does not indicate whether societal quality of life has improved as a result of GDP growth [163].

Limitations in the human capital approach: Strictly applied the use of human capital approach would have confned the analysis only on marketed production and working population. Therefore, DALY lost within the age groups below the minimum legal age for working [164] and above retirement age of 60 years and above [165] would have been monetarily valued at zero. In addition, the DALY lost among persons who cannot work due to disability would be valued at zero. However, since the constitution of Mauritius [166], the constitution of WHO [167] and the UN universal declaration of human rights [168]

Page 17/41 prohibits discrimination against any person, we valued every DALY lost (irrespective of the age group) at the same non-health GDP per capita. Our approach is very much consistent with lifetime income-based approach developed and applied by Jorgenson and Fraumeni [169-172] in the context of education- related human capital.

Limitations in the DALY calculations: We recap a few limitations, already discussed by the GBD Study, inherent in calculation of the two components (YLD and YLL) of the DALY. According to the GBD 2017 Mortality Collaborators [173] the mortality “Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites (p. 1684).” Some of the limitations the authors highlight include the use of sibling history data might introduce survivor bias and recall bias; and estimates of the completeness of vital registration are based on the use of uncertain death distribution methods; and they were not able to capture all fatal discontinuities [173]. Unlike the rest of WHO African region, where completeness of primary cause of death data is 6%, due to fragility of vital registration systems, in Mauritius it is 100% [13]; meaning that mortality estimates are likely to be more accurate.

The GBD 2017 Disease and Injury Incidence and Prevalence Collaborators [174] explains that “YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity (p.1789)”. Some of the limitations highlighted by authors include the fact that even though comorbidity distributions are known to vary by cause, age, sex, location, and time, the comorbidity adjustment in GBD 2017 assumes independent distributions of comorbid conditions. In addition, calculations GBD for some causes depend greatly on clinical data, which is prone to selection bias for segments of the population that have disproportionate access to health services [174].

In the calculations of DALY, the GBD 2017 DALY and HALE Collaborators [42] assumed independence of uncertainty between YLLs and YLDs, even though it might lead to underestimation of the total uncertainty for DALY. The authors also highlight that DALY estimates are infuenced by the availability of data for YLL and YLD estimations.

Conclusion

The DALY lost in 2017 had a substantive monetary value equivalent to 29.95% of the GDP for Mauritius. Full achievement of the SDG3 targets 3.1, 3.2, 3.3, 3.4 and 3.6 would save the country about Int$2,986,241,156, i.e. 9.351% of the total GDP of Mauritius in 2019. The country has health-related policies, strategies and plans, which if fully implemented, might give the country a high chance of averting signifcant number of DALY. The implementation process is also buttressed with a strong legislative framework aimed at addressing the causes of ill-health in Mauritius.

However, as the African Union ministers of health underscored in their commitment on accountability mechanism, the existence of policies, strategies, declarations, decisions and resolutions does not Page 18/41 necessarily assure attainment of the national and internationally agreed health development goals [175]. They called upon governments and other relevant stakeholders at national, regional and continental levels to provide committed, sustained, and aligned resources for accelerated and monitored implementation of national health development policy framework.

In terms of all socioeconomic indicators, Mauritius has accomplished far much more than other WHO African region countries [13]. However, it’s important not to be complacent, in order to sustain the health (and related) gains. Therefore, it is vital for the Mauritius Government and the domestic private sector to work together to further strengthen the national health system (including the social protection mechanisms to reduce reliance on OOPS), the other systems that tackle social determinants of health [15], and the national health research system [176,177] with a view to further reducing the burden of disease and advancing the quality of life of the people of Mauritius.

Abbreviations

See Abbreviations list in the Supplementary Files

Declarations

Acknowledgements

We thank the World Health Organization for funding this study. The views expressed in this paper are solely those of the authors and should not be attributed to the institutions they are afliated to.

Authors contributions

All authors participated in the design of the study; literature review; downloading of DALY data from IHME database, current health expenditure per capita from WHO database, and per capita GDP from IMF database; development of the economic model on Excel software; development of results tables and generation of fgures; and drafting of the manuscript. All the authors read and approved the fnal version of this paper.

Funding

The study was funded by the World Health Organization through Agreement for Performance of Work Purchase Order Number 202341143. LM is current employee of the WHO. He participated in design of the study, collating of data, analysis, interpretation of fndings and writing the manuscript.

Availability of data and materials

All data generated or analysed during this study are included in the published article and its supplementary information fles.

Ethics approval and consent to participate Page 19/41 Not applicable. No ethical approval was required since the study relied completely on analysis of secondary data publicly available the Institute of Health Metrics and Evaluation Global Burden of Disease Study 2017 database; the WHO Global Health Expenditure Database; and IMF outlook database.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Additional File Legends

Additional File 1: Disability-adjusted life years (DALY) lost in Mauritius in 2017 and their monetary values (2019, Int$ or PPP)

Additional fle 2: Legislative framework for health development in Mauritius

Figures

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DALYs lost from various broad causes in Mauritius in 2017

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Monetary value of DALYs lost by age in Mauritius (2019, Int$ or PPP)

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Monetary value of DALYs lost from communicable, maternal, neonatal, and nutritional diseases (2019, Int$ or PPP)

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Monetary value of DALYs lost form neoplasms or cancers (2019, Int$ or PPP)

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Monetary value of DALYs lost from cardiovascular diseases (2019, Int$ or PPP)

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Monetary value of DALYs lost from digestive diseases (2019, Int$ or PPP)

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Monetary value of DALYs lost from mental disorders (2019, Int$ or PPP)

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Monetary value of DALYs lost from skin and subcutaneous diseases (2019, Int$ or PPP)

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Monetary value of DALYs lost from other non-communicable diseases (2019, Int$ or PPP)

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Monetary value of DALYs lost from injuries (2019, Int$ or PPP)

Supplementary Files

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Formulas2.jpg Abbreviations.pdf Formulas3.jpg

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