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Appendices Table of Contents

Table of Contents ...... 1 Appendix 0.A Key messages and key findings ...... 3 Appendix 1.A. Extreme persists ...... 5 Appendix 1.B. Prevalence of 5 of 8 deprivations in education and living standards (poorest billion poverty), and other selected indicators ...... 7 Appendix 1.C. Years of Life Lived with Disability and Years of Life Lost among the Poorest Billion ...... 16 Appendix 1.D. Causes of death by socioeconomic status at INDEPTH Network HDSS sites .... 42 Appendix 1.E. Primary data on extreme poverty and morbidity due to NCDIs ...... 43 Appendix 1.F. Expert perspectives on extreme poverty, occurrence, and case-fatality ... 44 Appendix 1.G. NCDI DALY rate comparison between the poorest billion and high-income countries ...... 46 Appendix 1.H. Behavioral, Metabolic, and Environmental Risk Factor Exposure among the Poorest Billion ...... 48 Appendix 1.I. Risk-attributable disease burden ...... 52 Appendix 1.J. Infectious Risks for NCDIs among the Poorest Billion ...... 56 Appendix 1.K. Disease-specific Adjusted Age at Death (HAAD) ...... 60 Appendix 2.A. Equity Scoring ...... 62 Appendix 2.B. Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by cause group ...... 64 Appendix 2.C. Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by health system platform and integrated care team (ICT) ...... 76 Appendix 2.D. Intersectoral NCDI Interventions from DCP3 Essential UHC Package ...... 89 Appendix 2.E. Cost-effectiveness and Equity of health sector interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by cause groups and by level of the health system ...... 93 Appendix 2.F. Prototypical Staffing of Integrated Care Teams for NCDIs ...... 95 Appendix 2.G. Costing interventions grouped by integrated care teams (ICTs) ...... 96 Appendix 2.H. Mapping “sentinel” NCDI conditions onto Integrated Care Teams ...... 97 Appendix 2.I. Impact estimation for implementation of DCP3 Essential Universal Health Coverage Package (EUHC) and injury prevention interventions ...... 98 Appendix 3.A. Health financing and expenditures on NCDIs in low- and lower-middle-income countries ...... 100 Appendix 3.B. Modelling catastrophic expenditure due to NCDIs among the Poorest Billion . 102 Appendix 3.C. Development Assistance for Health targeted to NCDs in the Poorest Countries103

Appendices Page 1 Appendix 3.D. Projected health financing capacity in low- and lower-middle-income countries, 2017-2030 ...... 106 Appendix 4.A. NCDs and the Poorest Billion on two separate tracks: 1948-2015 ...... 109 Appendix 4.B. Review of Global Governance Documents ...... 110 Appendix 4.C. Review of National NCD Strategic Plans ...... 117 Appendix 4.D. Review of Strategic Papers ...... 125 Appendix 4.E. Composition, current status, and examples of country-level impacts of NCDI Poverty Commissions, Groups, and Consortia established since 2016 ...... 128 Appendix 5.A.: Voices of NCDI Poverty ...... 130 References ...... 138

Appendices Page 2 Appendix 0.A Key messages and key findings

Here, we briefly describe methods used to generate the key messages and key findings and refer to additional sections of the Appendix for more detail. The original research outputs of the Commission are enumerated in Table 1.

Working Group Original Research Outputs Poverty and Burden of NCDIs 1. Who are the world’s poor? A new profile of global multidimensional poverty 2. Burden of Disease among the World’s Poorest Billion People 3. Risk-attributable NCDI Burden among the Poorest Billion 4. Comparison of mortality by socioeconomic status across seven health and demographic surveillance systems 5. Lifetime loss of health by disease categories 6. Global burden of NCDs from infectious causes Integrated Intervention Impact 7. Cost and impact of interventions for NCDIs in low- and lower-middle income countries 8. Mortality impacts of interventions for unintentional injuries 9. Mapping priority interventions to integrated care teams 10. Availability of Equipment and Medications for NCDIs at Public First-Referral Level Hospitals Financing 11. Public expenditure on NCDs in India: a budget-based analysis 12. Disaggregating catastrophic expenditure by disease area 13. Domestic spending on NCDIs in low- and middle-income countries 14. Analysis of external NCD financing targeted to the poorest countries 15. Projected health financing capacity versus NCDI intervention costs in the poorest countries History, Advocacy and Governance 16. The origins of the 4 x 4 framework for NCDs at WHO 17. Textual Analysis of NCD Strategic Plans 18. Textual analysis of NCD framing at global institutions National NCDI Poverty Commissions 19. The Afghanistan NCDI Poverty Commission Report 20. The Ethiopia NCDI Commission Report 21. The NCDI Poverty Commission Report 22. The Liberia NCDI Poverty Commission Report 23. The Malawi NCDI Poverty Commission Report 24. The Nepal NCDI Poverty Commission Report 25. The Mozambique NDI Poverty Commission Report 26. The Haiti NCDI Poverty Commission Report Table 1: Commission Original Research Outputs Key findings pertaining to the disease burden among the poorest billion were supported by analysis of estimates from the Global Burden of Disease Study and poverty data from a number of household surveys across countries as described in Section 1 of the Commission report. The data on poverty are further described in Appendix 1.A and Appendix 1.B. We defined “avoidable” burden in the poorest billion as disability-adjusted life years (DALYs) in excess of how many DALYs there would be if the poorest billion experienced age- and cause-specific DALY rates estimated for high-income countries. The estimates of disease burden among the poorest billion are further described in Appendix 1.C.

Key messages pertaining to interventions for reducing the burden of NCDIs among the poorest billion drew on previous work from the Disease Control Priorities 3rd Edition (DCP3) as described in Section 2 of the Commission report. We examined the impact of scaling up the interventions included in the DCP3 set of essential interventions for Universal Health Coverage (EUHC) among the poorest billion living in low- and lower-middle-income countries (LLMICs) by applying effect sizes to Global Burden of Disease estimates and weighting for population sizes in the poorest billion. We also included the implementation of a set of evidence-based interventions to prevent drowning and road traffic injury deaths. Further explanation of these methods can be found in Appendix 2.I.

Key findings pertaining to financing of health services that address NCDIs drew on evidence from National Health Accounts from the WHO Estimates, estimates of donor assistance for health from the Institute for Health Metrics and Evaluation, and a novel analysis attributing catastrophic health expenditure by cause. Further detail on these estimates can be found in Section 3 of the Commission report and Appendix 3.A-D.

Key findings pertaining to policy and governance were supported by analysis of archival documents from the World Health Organization, as well as global and national policy documents as discussed in Section 4. Description of the methodology underlying the document analysis can be found in Appendix 4.A-C.

Appendices Page 4 Appendix 1.A. Extreme poverty persists

A first step for the Commission was to review what was already known about those living in poverty. In order to support analyses of disease burden specifically among the poorest billion at global, national, sub-national, and household levels we adapted a non-monetary poverty index derived from aggregated household microdata (see Appendix 1.B below). We were also interested in looking at historical trends and future projections regarding the prevalence and geographical distribution of poverty. We found that approaches based on an international monetary poverty line were helpful to understand changes in poverty over time (which is not possible to the same degree using non-monetary indices). This multifaceted approach to poverty assessment is consistent with the recommendations of the 2017 Commission on Global Poverty.1

Historical poverty calculations and forecasts from the World Bank reveal a remarkable consistency to estimates of around one billion people living in extreme monetary poverty over the past two centuries of rapid population and economic growth (see Figure 1).2-5 Although the number of people living in extreme poverty has remained relatively constant, the geography of this kind of suffering has changed dramatically. Once a global phenomenon affecting all but the lucky few, extreme poverty was virtually eradicated in Europe and North America by the mid- 20th century, and became increasingly rare in Latin America and East Asia as the 20th century drew to close (particularly with falling ). Extreme poverty is now heavily concentrated in sub-Saharan Africa and South Asia. Projections from the World Bank suggest that by 2030, 87% of extreme poverty will be limited to sub-Saharan Africa alone.6 At the same time, many of the countries in these regions have graduated from low-income to lower-middle- income status, despite large within-country inequalities. As a consequence, a larger fraction of the extreme poor are now living in lower-middle-income countries.7 The World Bank’s most recent estimate has been that if historical trends in economic growth persist, around 6% of the world’s population (500 million people) will still be living in extreme poverty in 2030.6

Appendices Page 5

Figure 1: Historical and projected estimates of population living in extreme poverty – 1820-2030

Appendices Page 6 Appendix 1.B. Prevalence of 5 of 8 deprivations in education and living standards (poorest billion poverty), and other selected indicators

For our definition and analysis of the poorest billion, we utilized the aggregated dataset assembled by the Oxford Poverty and Human Development Initiative (OPHI). This dataset had previously been used to construct the global Multidimensional Poverty Index (MPI), which has been included in the United Nations’ Human Development Report since 2010.8,9 The primary sources for the OPHI data repository cover 106 low- and middle-income countries and include data from Demographic and Health Surveys (DHS), the Multiple Indicators Cluster Surveys (MICS), as well as other high-quality national household surveys with similar content (see Table 2).10 We only included surveys conducted in or after 2005 in our analysis, and 98 percent of the population (5.7 billion) in these surveyed countries had surveys conducted in or after 2010. We were not able to find high-quality recent surveys from two low-income countries (Eritrea and North Korea), eight lower-middle income countries (Angola, Cabo Verde, Kiribati, Kosovo, the Federated States of Micronesia, Papua New Guinea, the Solomon Islands, and Sri Lanka), and 24 upper-middle income countries (American Samoa, Botswana, Bulgaria, Costa Rica, Cuba, Dominica, Equatorial Guinea, Fiji, Grenada, Iran, Lebanon, Malaysia, the Marshall Islands, Mauritius, Nauru, Paraguay, Romania, the Russian Federation, Samoa, St. Vincent and the Grenadines, Tonga, Turkey, Tuvalu, and Venezuela) with a total population of 527 million people (country classifications from World Bank for year 2017). For these countries, we used the average prevalence of poorest billion population by age and sex from the corresponding country income groups. For consistency with burden of disease estimates, we used 2017 population estimates from the Global Burden of Disease Study 2017. 11 Kosovo, Nauru, and Tuvalu are not included in the additional population estimate of 527 million because they were not included in the GBD Study.

Country Survey Survey Year Sub-Saharan Africa Benin DHS 2012 Burkina Faso DHS 2010 Burundi DHS 2010 Cameroon DHS 2011 Central African Republic MICS 2010 Chad DHS 2015 Comoros DHS-MICS 2012 Congo DHS 2012 Congo, Democratic Republic of the DHS 2014 Côte d'Ivoire DHS 2012 Ethiopia DHS 2011 Gabon DHS 2012 Gambia DHS 2013 Ghana DHS 2014

Appendices Page 7 Country Survey Survey Year Guinea DHS-MICS 2012 Guinea-Bissau MICS 2014 Kenya DHS 2014 Lesotho DHS 2014 Liberia DHS 2013 Madagascar DHS 2009 Malawi DHS 2016 Mali DHS 2013 Mauritania MICS 2011 Mozambique DHS 2011 Namibia DHS 2013 Niger DHS 2012 Nigeria DHS 2013 Rwanda DHS 2015 Sao Tome and Principe MICS 2014 Senegal DHS 2015 Sierra Leone DHS 2013 Somalia MICS 2006 South Africa NIDS 2015 South Sudan MICS 2010 Sudan MICS 2014 Swaziland MICS 2014 Tanzania DHS 2016 Togo DHS 2014 Uganda DHS 2011 Zambia DHS 2014 Zimbabwe DHS 2015

South Asia Afghanistan DHS 2016 Bangladesh DHS 2014 Bhutan MICS 2010 India IHDS 2012 Maldives DHS 2009 Nepal MICS 2014 Pakistan DHS 2013

Middle East and North Africa Algeria MICS 2013 Djibouti MICS 2006

Appendices Page 8 Country Survey Survey Year Egypt DHS 2014 Iraq MICS 2011 Jordan DHS 2012 Libya PAPFAM 2007 Morocco PAPFAM 2011 Palestine MICS 2014 Syrian Arab Republic PAPFAM 2009 Tunisia MICS 2012 Yemen DHS 2013 Latin America Belize MICS 2011 Bolivia DHS 2008 Brazil PNAD 2014 Colombia DHS 2010 Dominican Republic MICS 2014 Ecuador ECV 2014 El Salvador MICS 2014 Guatemala DHS 2015 Guyana MICS 2014 Haiti DHS 2012 DHS 2012 Jamaica JSLC 2012 Mexico MICS 2015 Nicaragua DHS 2012 Peru DHS-Cont 2012 Saint Lucia MICS 2012 Suriname MICS 2010 East and Central Europe Albania DHS 2009 Armenia DHS 2010 Azerbaijan DHS 2006 Belarus MICS 2005 Bosnia and Herzegovina MICS 2012 Georgia MICS 2005 Kazakhstan MICS 2015 Kyrgyzstan MICS 2014 Macedonia MICS 2011 Moldova MICS 2012 Montenegro MICS 2013 Serbia MICS 2014

Appendices Page 9 Country Survey Survey Year Tajikistan DHS 2012 Turkmenistan MICS 2016 Ukraine MICS 2012 Uzbekistan MICS 2006 East Asia and Pacific Cambodia DHS 2014 China CFPS 2014 Indonesia DHS 2012 Lao MICS/DHS 2012 Mongolia MICS 2013 Myanmar DHS 2016 Philippines DHS 2013 Thailand MICS 2012 Timor-Leste DHS 2010 Vanuatu MICS 2007 Vietnam MICS 2014 DHS = Demographic and Health Surveillance Survey; MICS = Multiple Indicator Cluster Survey; PAPFAM = Pan Arab Project for Family Health (Syrian Arab Republic, Libya, Morocco); NIDS = National Income Dynamics Study (South Africa); ENNyS = Encuesta Nacional de Nutrición y Salud (Argentia); CFPS = China Family Panel Studies; ECV = Encuesta de Condiciones de Vida (Ecuador); IHDS = India Human Development Survey; JSLC = Jamaica Survey of Living Conditions; PNAD = Pesquisa Nacional por Amostra de Domicilios (Brazil) Table 2: Countries with household surveys available since 2005 used to calculate poverty rates In contrast to the MPI (which includes health and nutritional indicators), we limited the Commission’s poverty index (PI) to include only indicators of deprivation in education and living standards in order to avoid confounding (see Table 3). To estimate the level of deprivation found among the world’s poorest billion, we calculated the age and sex-specific prevalence of each indicator for each country for which we had data available. We assumed no change in indicator prevalence since the time of the most recent household survey and multiplied this rate by 2017 population estimates.

Indicators Definition MPI* PI** Health (2) Child mortality + - years. Nutrition 2 + - the median weight (moderate and severe underweight). Education (2) Years of Schooling + + years of schooling. School Attendance Any school-aged child (e.g. 5-15) is not attending school up to the + + age at which he/she would complete class 8. Living Standards (6) Cooking Fuel The household cooks with dung, wood or charcoal. + + Improved The household does not have a flush toilet or latrine, or does not + + have or must share one of the following with other households: a ventilated improved pit or composting toilet.

Appendices Page 10 Safe The household does not have piped water, a public tap, a + + borehole or pump, a protected well or spring or rainwater within a 30 minutes roundtrip walk. Electricity The household has no electricity. + + Flooring The household has a dirt, sand, dung or ‘other’ (unspecified) type + + of floor. Assets The household does not own a car or truck and does not own + + more than one of the following: a radio, TV, telephone, bicycle, motorbike or refrigerator. * MPI = Multidimensional Poverty Index; ** Commission PI = Poverty Index Table 3: Poverty Index We examined the number of people in 2017 living in each World Bank region with at least 5 of 8 deprivations in education and/or living standards compared with those living with at least 4 of 8 deprivations. We also compared the number of people living beyond these poverty index thresholds with those living below the international monetary poverty line of $1.9 per day (2011 Purchasing Power Parity) used by the World Bank to define extreme poverty (see Table 4). We estimated that the total number of people living with at least 5 of 8 poverty index deprivations was 873 million in 2017 (34 million in countries without recent household survey data), which was similar to the number living in extreme monetary poverty in that same year (768 million). We chose the threshold of 5 of 8 poverty index deprivations as our definition of “poorest billion” poverty.

Population Meeting Poverty Definitions

(millions) in 2017 Poverty Index Monetary Poverty 5 of 8 4 of 8 World Bank Region $1.90 PPP* per day indicators indicators East Asia & Pacific 41 88 74 Europe, Central Asia, Middle East, &North 17 29 18 Africa Latin America & Caribbean 15 28 30 South Asia 288 549 249 Sub-Saharan Africa 513 647 390 Other High-Income Countries ND ND 7 Global 873 1,340 768 * PPP = Purchasing Power Parity. ND = No Data. Sources: Poverty Index = author’s calculations; Monetary Poverty: World Bank: http://iresearch.worldbank.org/PovcalNet/home.aspx Table 4: Where are the Poorest Billion by Region? We found that Poorest Billion live largely in low and lower-middle income countries (LLMICs), with 59% living in sub-Saharan Africa, and 33% living in South Asia (see Table 5). In these countries and regions, the Poorest Billion are largely found in rural areas and are nearly universally deprived in access to non-biomass cooking fuels. On average, the Poorest Billion in South Asia and in lower-middle income countries suffer fewer deprivation, are somewhat older on average, and are less likely to have household members employed in as compared with the Poorest Billion in sub-Saharan Africa and low-income countries.

Appendices Page 11 Country Region Income Group Lower- Low South sub-Saharan Total Middle Income Asia Africa Income Pattern of Deprivation^ Low Household Education 48% 48% 49% 51% 47% Low Child School Attendance 40% 46% 37% 33% 45% Biomass Cooking Fuel 98% 100% 99% 100% 100% Unimproved Sanitation 92% 92% 93% 95% 92% Unsafe Drinking Water 58% 75% 44% 26% 76% No Electricity 86% 97% 77% 69% 97% Poor Flooring 88% 88% 89% 94% 88% Few Assets 72% 70% 74% 82% 67% Age Distribution# Median 5-year Age Group 15-19 15-19 15-19 20-24 15-19 Under age 50 (% of PB*) 87% 90% 85% 83% 91% Under age 40 (% of PB*) 79% 83% 77% 74% 83% Under age 30 (% of PB*) 67% 72% 64% 61% 73% Under age 5 (% of PB*) 16% 18% 15% 13% 18% Percent Rural^ 92% 91% 93% 95% 91% Percent Employed in 65% 77% 53% 50% 74% Agriculture (n=35 countries) *PB = Poorest Billion, ^ Based on countries with available surveys, # Including LMICs without surveys and imputed prevalence of poorest billion as described in text Table 5of 8 poverty index deprivations) in 2017 The world’s poorest people are not concentrated in particular countries or large sub-national geographies (see Table 6). Although there are around 47 countries with more than 2 million “poorest billion” people each, the poor are widely dispersed in many of these countries. In fact, most of the world’s poorest (62%) live in countries in which they are the minority. All of the countries with more than 50 percent extreme poverty prevalence are in sub-Saharan Africa (with the sole exception of Timor-Leste), and these countries only account for 38 percent of the world’s poorest. Only about 52 percent of the poorest live in countries where they are the majority even in a single large sub-national region. Similarly, only 58 percent of the poorest live in countries where they are the majority in rural areas.

Appendices Page 12 # of Countries % of Poorest Billion Countries with large numbers of the poorest people 47 97% Countries with a high national prevalence of poorest billion poverty 5 15% 18 38% 41 65% 63 96% Countries with poverty concentrated in sub-national regions - 18 52% - 58 98% Countries with high poverty prevalence in rural areas poorest billion 31 58% 52 96% Table 6: National and sub-national concentration of the poorest billion One consequence of the geographical diffuseness of poorest billion poverty is that there are very few countries (Niger, Somalia, Central African Republic, Ethiopia, South Sudan, and Chad), in which national summary data reflects the situation of the world’s poorest. It would be difficult to characterize the poorest based on national data sets in a country such as Brazil, for example, where 500,000 people live in extreme poverty, but no sub-national region has more than 5 percent poverty prevalence.

In order to facilitate our analysis, we identified 55 LLMICs that had at least one sub-national region with at least 25% poorest billion poverty at a sub-national level (see Table 7). These 55 “poorest billion countries” have a combined population of 820 million people living in poorest billion poverty (94% of the poorest billion).

Appendices Page 13 No. Nurses & Income GNI/ deprivations deprivations Physicians Country midwives Group capita12 in 2017 in 2017 per 1,000 per 1,000 (millions) Sub-Saharan Africa South Sudan LIC ND 88.7 8.8 ND ND Chad LIC $640 82.6 12.6 0.5 3.6 Ethiopia* LIC $740 81.5 83.8 1 8.4 Niger LIC $360 77.7 16.6 0.5 3.1 Somalia LIC ND 76.3 12.9 0.2 0.6 Central African Republic LIC $420 74.9 3.5 0.6 2 Burundi LIC $280 72.8 7.9 0.5 6.8 Congo, Democratic LIC $460 68.9 55.8 0.9 4.7 Republic of the Madagascar* LIC $400 65.2 17 1.8 1.1 Mozambique* LIC $430 65.1 19.6 0.7 4.4 Burkina Faso LIC $590 64.7 13.7 0.6 5.7 Sierra Leone* LIC $520 62.2 4.9 ND 10 Uganda* LIC $620 58.4 22.8 0.9 6.3 Mali LIC $770 58.1 11.8 1.4 3.8 Tanzania* LIC $970 56.2 30.4 0.4 4.1 Guinea LIC $830 55.3 6.5 0.8 3.8 Guinea-Bissau LIC $680 52.4 1 2 14 Rwanda* LIC $730 49.2 6.2 1.3 8.3 Malawi* LIC $340 48.5 8.3 0.2 2.5 Liberia* LIC $620 48.3 2.3 0.4 1 Zambia* LMIC $1,300 46.7 8.1 0.9 8.9 Sudan LMIC $2,390 46 18.5 4.1 8.3 Benin LIC $800 44.4 5.1 1.6 6.1 Mauritania LMIC $1,120 43 1.7 1.8 10.3 Kenya* LMIC $1,440 38.9 18.8 2 15.4 Cameroon LMIC $1,340 36.4 10.1 ND ND Nigeria LMIC $2,100 33.9 69.8 3.8 14.5 Congo LMIC $1,480 31.5 1.5 ND ND Togo LIC $590 31.2 2.3 0.5 3 Senegal LIC $1,280 30.8 4.5 0.7 3.1 Côte d'Ivoire LMIC $1,480 29.4 7.3 2.3 8.5 Zimbabwe* LIC $1,370 28.6 4.2 0.8 11.5 Namibia UM $4,800 25.3 0.6 ND ND Lesotho LMIC $1,300 25.1 0.5 ND ND Gambia LIC $650 23.6 0.5 1.1 16.3 Comoros LIC $1,280 22.9 0.2 1.7 9.2 South Asia Bangladesh LMIC $1,520 25.2 39.6 5.3 3.1 Afghanistan* LIC $550 25.1 8.3 2.8 3.2 Pakistan LMIC $1,500 16.4 35.1 9.8 5 India* LMIC $1,830 14.3 197.5 7.8 21.1 Nepal* LIC $850 12.6 3.8 6.5 26.9 Bhutan LMIC $2,890 11 0.1 3.7 15.1 Latin America and the Caribbean Haiti* LIC $760 39 4.6 ND ND Bolivia LMIC $3,090 14.5 1.7 16.1 7.4 Nicaragua LMIC $2,090 11.4 0.7 9.1 13.8 Guatemala UM $4,060 9.9 1.7 ND ND Middle East and North Africa Yemen LIC $1,060 20.7 6.3 3.1 7.3 Djibouti LMIC $2,040 15.8 0.2 2.2 5.3 East Asia Pacific Timor-Leste LMIC $1,810 51.2 0.7 7.2 16.7 Vanuatu LMIC $2,810 27.8 0.1 1.7 13.9 Lao LMIC $2,240 16.7 1.2 5 9.8 Cambodia LMIC $1,230 13.6 2.2 1.7 9.5

Appendices Page 14 No. Nurses & Income GNI/ deprivations deprivations Physicians Country midwives Group capita12 in 2017 in 2017 per 1,000 per 1,000 (millions) Myanmar LMIC $1,200 12.9 6.8 8.6 9.8 Mongolia LMIC $3,230 12.6 0.4 28.9 39.8 Indonesia LMIC $3,530 3.6 9.2 3.8 20.6 *Countries that have organized National NCD Poverty Commissions/Groups/Consortia; LIC = Low-income country, LMI = Lower-middle-income country, ND = no data; Robles Aguilar and Sumner 2020. 13 Original analysis using data from household surveys up to 2016. Source for health worker rates from Global Health Observatory 2016. 14 Per capita GNI from year 2017. Population calculated from GBD 2017. Doctor and nurse/midwife estimates taken from most recent year from 2012 to 2017. Table 7: Characteristics of low- and lower-middle income countries with at least one sub-national regional

Appendices Page 15 Appendix 1.C. Years of Life Lived with Disability and Years of Life Lost among the Poorest Billion

For our first analysis, we have built on the work done previously by Gwatkin and colleagues. 15,16 We utilized publicly available national estimates for 195 countries regarding age- and sex-specific mortality, prevalence, incidence, and disability weights for 360 causes of death and disability from the Global Burden of Disease (GBD) 2017 Study.17,18 These estimates use a Bayesian meta- regression framework described elsewhere in detail, and represent the most comprehensive review and synthesis of epidemiological data that is currently available. 19 Although these estimates have been previously analyzed extensively according to World Bank income group, and more recently by an index that integrates national education, fertility, and income data (the sociodemographic index or SDI), here we have made estimates specifically for the approximately 873 million people in the world who experienced five or more of the eight deprivations on our poverty index (the poorest billion).

We have tried to address the problem that current models of disease burden only generate estimates for national (and increasingly sub- national) disease rates but that most of the poorest are a minority in countries where they live. 20 If there are major differences in disease rates among the poorest compared with the less-poor or non-poor within countries (as suggested by theories of epidemiologic polarization), then aggregating from national estimates may be misleading.21 We pursued an ecological analysis to address this issue, predicting within-country difference based on between-country trends. We regressed YLD rates and death rates (Measure ratel) from each cause of morbidity and mortality on the proportion of the population in the poorest billion across countries (PPBl), by age group and sex, and with r) to better isolate country-to-country variation not driven by large regional differences.

log( ) = + + +

From these regressions, we predicted rates in hypothetical populations with 100% prevalence of extreme poverty and 0% prevalence of extreme poverty. Then, in each country, we scaled these rates to national rates using the proportion of the population in the poorest billion, resulting in predicted rates for the population in the poorest billion and the population not in the poorest billion that were consistent with national-level estimates from the GBD. First, we solved for the scalar (k) in the equation below for each location (l), age group (a), sex (s), and cause (c). Then, we multiplied the rates by k to make the adjustment.

,,,,,, ,, + ,,, ,, = ,,, ,,

To choose conditions to model using this ecological approach, we used information from our survey of expert perspectives on the relationship between poverty and disease within countries (described in Appendix 1.F.). We considered incidence or case fatality to be higher in the poorest or in the non-poorest if the median of the expert perceptions differed significantly from the “no difference”

Appendices Page 16 response, as tested using a signed-rank test. For conditions that were considered nonfatal in the GBD Study, we used this ecological approach if (a) incidence was perceived by the experts to be higher or lower in the poorest billion compared to the non-poorest within countries, and (b) that perception was matched by the direction of the cross-country relationship. For conditions that cause mortality in addition to morbidity, we used this model if both incidence and case fatality were thought to be significantly different in the poorest compared to the non-poor, as long as the cross-country ecological relationship was in the same direction as the expert survey result. For some conditions, the direction of the associations in the ecological analysis varied by age. We chose to model conditions if the above rules were met in at least 50% of age groups and in both sexes (for that were not sex-specific). If the criteria for using the ecological relationship were not met, we assumed no difference in rates between the poorest and other populations and simply split burden using the proportion of the population in the poorest billion. From these predictions specific to lowest-level diseases in the GBD hierarchy by age, sex, and country, we aggregated to broader categories for consistency. We also calculated YLLs from deaths using the standard GBD methods, and aggregated YLLs and YLDs to create DALYs.

YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Population 139,827,617 246,762,948 304,160,475 181,985,654 139,827,617 246,762,948 304,160,475 181,985,654 Injuries 87,669 566,910 2,331,098 2,586,680 9,565,869 4,033,691 9,140,380 6,451,086 Self-harm and 13,882 80,694 546,753 394,333 577,020 508,428 3,763,827 1,531,998 interpersonal violence

Conflict and terrorism 4,937 28,276 300,728 230,043 285,058 238,017 654,654 98,189 Executions and police 296 1,205 8,903 5,937 13,135 13,506 103,739 23,282 conflict Interpersonal violence 8,650 50,834 224,075 140,966 278,827 143,093 1,233,765 401,692 Physical violence by 241 691 3,330 4,589 48,256 26,295 424,392 123,759 firearm Physical violence by 5,955 18,629 70,654 79,874 189,661 97,554 522,712 175,841 other means Physical violence by 1,235 4,896 20,048 20,187 40,910 19,243 286,661 102,092 sharp object Sexual violence 1,218 26,618 130,042 36,317 - - - - Self-harm - 378 13,047 17,386 - 113,812 1,771,669 1,008,835 Self-harm by firearm - 7 112 462 - 4,200 127,424 65,347 Self-harm by other - 370 12,935 16,925 - 109,613 1,644,245 943,488 specified means Transport injuries 15,854 90,571 370,962 511,369 1,486,571 1,151,736 3,214,418 1,874,309

Appendices Page 17 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Other transport 12,104 49,227 122,745 144,696 102,571 80,301 272,903 149,256 injuries Road injuries 3,750 41,344 248,217 366,672 1,384,000 1,071,435 2,941,516 1,725,053 Cyclist road injuries 495 7,280 37,595 52,049 29,492 60,540 122,225 101,299 Motor vehicle road 641 6,806 46,860 75,474 583,607 413,733 1,287,328 667,606 injuries Motorcyclist road 1,019 8,406 60,172 88,079 95,303 81,173 609,930 236,279 injuries Other road injuries 307 3,575 17,458 26,619 16,553 12,954 24,929 17,459 Pedestrian road 1,288 15,277 86,131 124,452 659,045 503,035 897,104 702,411 injuries Unintentional injuries 57,933 395,645 1,413,383 1,680,978 7,502,281 2,373,528 2,162,134 3,044,782 Adverse effects of 1,956 2,196 4,162 4,736 391,013 69,499 154,736 225,662 medical treatment Animal contact 5,813 28,956 80,948 94,694 471,744 366,481 242,431 431,047 Non-venomous animal 2,247 7,762 22,015 35,904 108,465 40,919 27,946 37,444 contact Venomous animal 3,566 21,194 58,933 58,790 363,279 325,562 214,485 393,603 contact Drowning 472 2,336 5,387 6,055 3,135,626 1,003,496 410,029 253,886 Environmental heat 5,345 29,937 88,790 96,561 157,293 28,198 79,165 127,091 and cold exposure Exposure to forces of 454 24,458 94,830 36,883 23,915 35,528 55,073 20,382 nature Exposure to 14,090 54,195 164,946 187,508 418,667 132,447 295,167 210,265 mechanical forces Other exposure to 12,490 49,017 149,166 171,585 353,308 114,015 210,342 168,981 mechanical forces Unintentional firearm 1,600 5,179 15,780 15,923 65,359 18,432 84,826 41,283 injuries Falls 9,914 111,496 487,647 830,599 692,298 340,788 281,617 1,228,674 Fire, heat, and hot 6,424 82,646 322,419 217,729 935,242 164,984 271,525 275,447 substances Foreign body 6,304 20,566 39,638 33,578 775,444 71,001 70,154 72,999 Foreign body in eyes 2,403 5,369 8,555 8,347 - - - - Foreign body in other 2,742 11,641 25,931 22,235 36,002 5,489 8,186 6,386 body part

Appendices Page 18 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Pulmonary aspiration 1,159 3,556 5,151 2,996 739,442 65,511 61,968 66,613 and foreign body in airway Other unintentional 6,164 31,117 108,742 163,019 207,386 103,704 218,458 120,766 injuries Poisonings 998 7,745 15,875 9,617 293,657 57,402 83,775 78,582 Poisoning by carbon 222 1,293 2,565 1,718 31,324 13,526 30,029 26,648 monoxide Poisoning by other 776 6,452 13,310 7,899 262,333 43,876 53,746 51,933 means Non-communicable 2,636,176 8,012,507 21,571,845 27,515,107 21,935,294 3,207,915 10,991,164 59,268,089 diseases Cardiovascular 20,499 125,695 391,166 1,609,592 1,020,660 352,528 3,151,750 26,483,762 diseases Aortic aneurysm ------21,150 167,111 Atrial fibrillation and - - 5,565 130,734 - - 802 158,966 flutter Cardiomyopathy and 1,127 3,446 7,006 30,539 220,926 36,469 144,651 407,395 myocarditis Alcoholic - - 831 6,068 - - 18,762 75,746 cardiomyopathy Myocarditis 469 1,905 2,814 3,801 32,469 7,724 31,858 37,993 Other cardiomyopathy 657 1,541 3,362 20,670 188,458 28,745 94,031 293,656 Endocarditis 692 462 541 1,423 129,668 19,342 55,668 95,804 Hypertensive heart - - 4,094 71,097 - - 104,993 1,334,749 disease Ischemic heart - - 27,057 345,825 - - 1,208,417 12,147,720 disease Non-rheumatic - - 169 13,137 - - 36,502 104,644 valvular heart disease Non-rheumatic calcific - - 16 3,234 - - 9,423 44,529 aortic valve disease Non-rheumatic - - 130 9,842 - - 20,894 54,709 degenerative mitral valve disease Other non-rheumatic - - 22 60 - - 6,184 5,406 valve diseases

Appendices Page 19 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Other cardiovascular 7,967 24,034 52,967 175,072 180,820 45,620 177,330 680,182 and circulatory diseases Peripheral artery - - - 34,363 - - - 21,545 disease Rheumatic heart 4,289 65,447 184,923 93,859 149,098 138,522 487,903 1,008,753 disease 6,425 32,306 108,844 713,543 340,149 112,575 914,335 10,356,987 Intracerebral 2,428 10,850 35,044 130,429 178,608 71,022 623,889 6,632,865 hemorrhage Ischemic stroke 3,567 19,123 61,439 518,923 29,616 7,778 111,292 2,894,925 Subarachnoid 430 2,333 12,361 64,192 131,926 33,775 179,154 829,201 hemorrhage Chronic respiratory 229,413 565,292 782,632 2,620,911 321,455 132,902 571,818 6,634,706 diseases 213,406 444,835 283,302 300,465 225,178 91,130 311,913 1,540,364 Chronic obstructive 6,956 51,835 390,069 2,202,972 34,138 11,395 181,856 4,748,249 pulmonary disease Interstitial lung 5 42 3,230 32,876 6,093 3,263 14,685 188,407 disease and pulmonary sarcoidosis Other chronic 9,047 68,580 105,515 82,032 56,046 27,115 60,777 128,542 respiratory diseases Pneumoconiosis - 0 516 2,566 - - 2,586 29,144 Asbestosis - 0 198 730 - - 285 3,583 Coal workers - 0 89 533 - - 357 5,408 pneumoconiosis Other pneumoconiosis - 0 71 630 - - 1,413 10,757 Silicosis - 0 158 673 - - 532 9,397 Diabetes and kidney 8,921 65,130 823,974 2,636,037 449,572 197,605 932,395 4,919,035 diseases

Acute 39 92 96 120 10,243 4,461 4,466 9,604 glomerulonephritis Chronic kidney 8,517 37,017 160,421 405,310 394,139 156,760 664,166 2,036,393 disease Chronic kidney 320 1,307 3,945 8,696 1,502 1,178 61,550 186,313 disease due to

Appendices Page 20 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus diabetes mellitus type 1 Chronic kidney 63 575 6,200 89,521 1,002 636 17,681 552,571 disease due to diabetes mellitus type 2 Chronic kidney 2,224 10,208 41,767 37,262 130,907 65,907 284,344 347,921 disease due to glomerulonephritis Chronic kidney 1,101 4,676 25,627 71,006 2,708 2,676 64,846 540,711 disease due to hypertension Chronic kidney 4,810 20,251 82,882 198,825 258,019 86,364 235,744 408,876 disease due to other and unspecified causes Diabetes mellitus 365 28,021 663,457 2,230,606 45,189 36,383 263,763 2,873,039 Diabetes mellitus type 365 10,819 37,303 27,975 45,189 36,383 214,778 978,942 1 Diabetes mellitus type - 17,202 626,154 2,202,631 - - 48,985 1,894,097 2 Digestive diseases 109,142 177,201 704,312 771,905 1,068,196 436,972 1,873,711 5,564,497 Appendicitis 1,941 9,649 15,433 6,595 82,265 63,778 94,896 113,405 Cirrhosis and other 8,977 17,741 30,831 66,330 213,605 164,928 1,059,966 3,457,633 chronic liver diseases Cirrhosis and other - - 3,415 12,768 - - 144,790 847,008 chronic liver diseases due to alcohol use Cirrhosis and other 145 1,025 10,019 23,362 8,859 17,810 451,101 1,302,221 chronic liver diseases due to hepatitis B Cirrhosis and other 105 763 7,299 18,513 1,972 4,857 198,021 793,327 chronic liver diseases due to hepatitis C Cirrhosis and other 8,726 15,954 8,672 6,527 202,774 142,261 225,704 287,421 chronic liver diseases due to other causes Cirrhosis due to NASH - - 1,427 5,159 - - 40,351 227,658

Appendices Page 21 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Gallbladder and biliary 32 72 393 680 28,170 16,000 37,731 145,855 diseases Inflammatory bowel 87 971 5,557 9,765 19,200 4,255 17,455 45,803 disease Inguinal, femoral, and 32,737 32,140 47,350 84,608 11,992 6,814 24,604 85,745 abdominal hernia Other digestive 14,795 14,420 23,897 32,130 61,477 24,249 44,985 131,420 diseases Pancreatitis 184 887 4,358 8,785 2,143 3,688 65,490 175,277 Paralytic ileus and 708 739 1,072 1,747 575,892 103,799 232,377 593,096 intestinal obstruction Upper digestive 49,501 100,475 575,257 560,746 58,748 46,898 286,667 717,630 system diseases Gastritis and 49,501 94,290 289,789 272,866 20,104 10,450 93,770 150,329 duodenitis Gastroesophageal - - 247,063 247,895 - - - - reflux disease Peptic ulcer disease - 6,184 38,404 39,985 38,645 36,448 192,897 567,301 Vascular intestinal 181 107 166 519 14,703 2,562 9,540 98,623 disorders Mental disorders 228,772 2,111,395 5,590,494 3,824,282 - 9 219 59 Anxiety disorders 12,651 546,421 1,236,460 721,670 - - - - Attention- 2,809 60,036 49,339 8,689 - - - - deficit/hyperactivity disorder Autism spectrum 103,243 172,031 182,571 86,428 - - - - disorders - 64,683 524,383 282,142 - - - - Conduct disorder - 738,815 305,966 - - - - - Depressive disorders 311 292,610 1,954,486 1,846,157 - - - - Dysthymia 61 33,085 357,120 373,326 - - - - Major depressive 250 259,525 1,597,365 1,472,831 - - - - disorder Eating disorders - 17,755 183,471 21,783 - 9 219 59 Anorexia nervosa - 9,634 37,491 3,010 - 4 67 24 Bulimia nervosa - 8,121 145,980 18,773 - 5 152 35

Appendices Page 22 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Idiopathic 109,758 204,871 207,337 83,155 - - - - developmental intellectual disability Other mental - 10,346 499,988 389,471 - - - - disorders - 3,827 446,495 384,786 - - - - Musculoskeletal - 331,065 3,384,700 5,971,124 - 21,370 63,154 193,331 disorders Gout - - 9,376 58,133 - - - - Low back pain - 288,103 1,975,806 2,844,868 - - - - Neck pain - 27,736 505,052 1,156,967 - - - - Osteoarthritis - - 36,532 508,200 - - - - Other musculoskeletal - 11,890 815,724 1,266,711 - 18,543 58,229 101,125 disorders Rheumatoid arthritis - 3,337 42,210 136,245 - 2,827 4,925 92,206 Neoplasms 12,232 7,576 46,976 230,134 1,272,657 969,660 2,405,009 11,998,177 Bladder - - 482 6,893 - - 9,322 183,071 Brain and central 1,542 1,061 1,259 2,820 184,754 169,258 152,821 229,592 nervous system cancer Breast cancer - - 8,650 41,730 - - 249,631 1,179,045 Cervical cancer - - 13,415 28,218 - - 295,037 1,246,595 Colon and - - 1,478 17,941 - - 103,749 846,670 cancer Esophageal cancer - - 457 7,846 - - 61,477 743,248 Gallbladder and biliary - - 85 2,085 - - 13,906 218,894 tract cancer Hodgkin lymphoma 205 366 944 860 23,841 53,038 98,037 59,677 Kidney cancer 2,024 484 605 3,873 47,410 11,352 10,809 90,931 Larynx cancer - - 283 5,404 - - 18,522 270,428 Leukemia 2,900 2,136 2,180 5,910 343,902 297,657 253,795 341,062 Acute lymphoid 1,137 1,003 529 461 107,442 131,742 61,649 31,350 leukemia

Appendices Page 23 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Acute myeloid 598 302 484 994 100,253 61,992 79,197 108,328 leukemia Chronic lymphoid - - 66 1,240 - - 2,537 27,549 leukemia Chronic myeloid - - 331 738 - - 36,191 55,134 leukemia Other leukemia 1,165 831 771 2,478 136,207 103,923 74,221 118,700 Lip and oral cavity - - 2,071 10,181 - - 78,317 445,018 cancer Liver cancer - 132 753 8,832 - 41,309 132,300 997,642 Liver cancer due to - - 102 1,901 - - 17,218 213,713 alcohol use Liver cancer due to - 97 440 2,998 - 30,021 78,276 364,301 hepatitis B Liver cancer due to - 3 65 2,554 - 890 11,071 271,321 hepatitis C Liver cancer due to - - 52 789 - - 9,093 81,067 NASH Liver cancer due to - 33 94 591 - 10,398 16,643 67,240 other causes Malignant skin - - 350 966 - - 22,197 50,462 melanoma Mesothelioma - - 63 455 - - 4,636 22,124 Multiple myeloma - - 172 2,189 - - 12,329 128,878 Nasopharynx cancer - 217 685 2,103 - 7,392 24,039 112,345 Non-Hodgkin 1,275 910 1,437 4,791 165,668 136,931 160,941 337,231 lymphoma Non-melanoma skin - - 28 230 - - 10,529 77,671 cancer Non-melanoma skin - - 10 27 - - - - cancer (basal-cell carcinoma) Non-melanoma skin - - 17 203 - - 10,529 77,671 cancer (squamous-cell carcinoma) Other malignant 4,213 1,985 3,117 8,494 480,059 231,769 305,466 547,634 neoplasms Other neoplasms 72 157 176 423 27,022 17,865 22,889 64,990

Appendices Page 24 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Benign and in situ ------cervical and uterine neoplasms Benign and in situ ------intestinal neoplasms Myelodysplastic, 72 157 176 423 19,918 10,036 14,768 62,432 myeloproliferative, and other hematopoietic neoplasms Other benign and in - - - - 7,105 7,829 8,121 2,558 situ neoplasms Other pharynx cancer - - 341 4,191 - - 31,868 300,046 Ovarian cancer - - 3,139 7,698 - - 49,744 273,598 Pancreatic cancer - - 124 3,130 - - 21,736 347,564 Prostate cancer - - 171 22,167 - - 4,807 564,954 Stomach cancer - - 873 10,084 - - 124,569 937,005 Testicular cancer - - 409 143 - - 17,552 5,601 Thyroid cancer - 129 2,357 3,506 - 3,088 30,867 63,794 Tracheal, bronchus, - - 472 11,691 - - 71,720 1,186,519 and lung cancer Uterine cancer - - 401 5,280 - - 11,401 125,887 Neurological disorders 254,663 1,164,684 3,434,834 2,332,712 824,530 298,575 875,291 1,998,298 Alzheimer's disease - - - 283,714 - - - 1,282,380 and other dementias Epilepsy 196,810 448,125 491,336 241,614 710,877 254,777 816,987 375,332 Headache disorders - 585,441 2,842,526 1,698,637 - - - - Migraine - 478,847 2,507,633 1,462,030 - - - - Tension-type - 106,595 334,893 236,607 - - - - headache Motor neuron disease 200 461 502 763 1,755 203 960 10,225 Multiple sclerosis - 101 5,802 8,500 - - 7,627 20,736 Other neurological 57,652 130,555 93,517 40,856 111,899 43,594 49,264 44,591 disorders Parkinson's disease - - 1,150 58,627 - - 454 265,037

Appendices Page 25 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Other non- 629,984 1,103,008 2,093,666 1,861,053 16,796,723 783,501 797,799 937,155 communicable diseases Congenital birth 389,753 478,857 542,299 296,132 14,333,249 445,624 225,810 59,983 defects Congenital heart 57,066 34,824 13,747 3,204 4,852,683 240,610 133,643 32,483 anomalies Congenital 104,112 129,170 184,634 112,165 234,019 10,204 6,503 1,195 musculoskeletal and limb anomalies Digestive congenital 11,230 18,012 21,701 12,385 1,286,281 10,874 2,934 1,181 anomalies Down syndrome 5,605 8,817 10,473 5,742 451,897 16,554 17,017 8,239 Klinefelter syndrome 68 110 292 40 - - - - Neural tube defects 43,668 49,109 49,611 24,830 3,784,989 48,204 11,728 1,424 Orofacial clefts 8,663 10,871 12,235 7,232 162,932 - - - Other chromosomal 26,403 27,952 25,885 13,900 314,834 6,440 4,552 656 abnormalities Other congenital birth 128,642 194,336 218,714 116,026 2,964,237 102,010 44,044 8,661 defects Turner syndrome 321 494 685 78 - - - - Urogenital congenital 3,976 5,163 4,322 528 281,378 10,728 5,390 6,144 anomalies Endocrine, metabolic, 64,625 146,540 160,665 108,218 227,608 39,531 57,106 138,679 blood, and immune disorders Gynecological - 932 637,028 308,416 - - 25,469 25,793 diseases Endometriosis - - 208,526 64,936 - - 596 489 Female infertility - - 32,419 7,323 - - - - Genital prolapse - - 9,615 29,387 - - 455 2,185 Other gynecological - - 50,611 22,351 - - 20,295 15,571 diseases Polycystic ovarian - 932 27,743 8,954 - - 38 8 syndrome Premenstrual - - 271,389 98,463 - - - - syndrome

Appendices Page 26 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Uterine fibroids - - 36,725 77,003 - - 4,086 7,541 Hemoglobinopathies 162,655 352,082 280,513 169,528 781,945 247,026 318,746 215,646 and hemolytic G6PD deficiency 1,132 1,634 1,376 940 14,981 12,622 31,180 77,915 G6PD trait 9 15 22 12 - - - - Other 46,160 120,314 115,859 84,952 2,253 1,784 8,895 82,954 hemoglobinopathies and hemolytic anemias Sickle cell disorders 20,236 39,248 30,076 1,767 707,627 211,696 273,877 54,679 Sickle cell trait 59,950 122,648 81,623 47,958 - - - - Thalassemias 1,361 550 76 1 57,085 20,925 4,795 99 Thalassemias trait 33,807 67,673 51,481 33,899 - - - - Oral disorders 9,944 120,680 438,887 746,864 - - - - Caries of deciduous 9,944 13,699 ------teeth Caries of permanent - 29,239 70,962 38,481 - - - - teeth Edentulism and - - 57,865 294,583 - - - - severe tooth loss Other oral disorders - 77,742 178,559 124,126 - - - - Periodontal diseases - - 131,500 289,674 - - - - Sudden death - - - - 1,165,264 - - - syndrome Urinary diseases and 3,007 3,918 34,274 231,894 288,656 51,319 170,667 497,053 male infertility Benign prostatic - - - 212,160 - - - - hyperplasia Male infertility - - 16,093 3,512 - - - - Other urinary diseases 1,498 1,368 4,047 3,525 149,093 24,844 65,718 181,493 Urinary tract 1,417 1,932 7,054 3,678 139,564 25,649 103,000 301,937 Urolithiasis 91 618 7,081 9,019 - 825 1,949 13,623 Sense organ diseases 156,232 503,185 1,334,988 4,298,888 - - - -

Appendices Page 27 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Age-related and other 72,217 269,788 708,177 1,797,473 - - - - hearing loss Blindness and vision 66,970 211,949 583,972 2,389,144 - - - - impairment Age-related macular - - - 47,259 - - - - degeneration Cataract - - 41,464 963,179 - - - - Glaucoma - - - 76,632 - - - - Near vision loss 5,158 36,251 261,151 695,627 - - - - Other vision loss 7,220 16,226 56,716 198,159 - - - - Refraction disorders 54,591 159,473 224,641 408,287 - - - - Other sense organ 17,045 21,449 42,838 112,272 - - - - diseases Skin and 986,074 1,847,323 1,453,184 809,475 181,504 14,796 50,930 172,787 subcutaneous diseases Acne vulgaris - 59,369 137,128 9,186 - - - - Alopecia areata 1,969 5,334 24,637 11,248 - - - - Bacterial skin 6,362 8,853 6,487 4,474 177,053 11,602 44,859 151,078 diseases Cellulitis 1,885 2,078 3,464 3,047 16,157 3,702 8,457 25,034 Pyoderma 4,476 6,775 3,023 1,427 160,896 7,899 36,402 126,045 Decubitus ulcer 375 989 2,086 7,960 1,828 1,586 3,690 18,734 Dermatitis 356,965 652,565 368,639 161,408 - - - - Atopic dermatitis 356,542 621,437 288,551 108,327 - - - - Contact dermatitis - 30,498 79,025 52,272 - - - - Seborrhoeic dermatitis 423 631 1,063 809 - - - - Fungal skin diseases 140,471 249,638 172,182 163,388 - - - - Other skin and 22,816 32,495 64,579 98,268 2,623 1,608 2,381 2,975 subcutaneous diseases Pruritus 6,195 13,945 25,462 25,777 - - - - Psoriasis 10,575 58,398 139,753 143,302 - - - -

Appendices Page 28 YLDs YLLs Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Scabies 91,298 210,027 248,992 79,509 - - - - Urticaria 200,294 233,266 175,430 81,639 - - - - Viral skin diseases 148,755 322,445 87,808 23,318 - - - - Substance use 244 10,952 1,530,920 548,995 - - 269,084 366,204 disorders Alcohol use disorders 244 9,590 595,302 275,714 - - 123,270 254,713 Drug use disorders - 1,362 935,617 273,281 - - 145,815 111,491 Amphetamine use - 139 26,000 2,463 - - 4,535 3,944 disorders Cannabis use - 1,131 29,241 4,824 - - - - disorders Cocaine use disorders - - 5,009 2,869 - - 5,265 5,529 Opioid use disorders - - 847,460 254,786 - - 97,660 57,256 Other drug use - 91 27,908 8,339 - - 38,355 44,762 disorders Blank estimates for one of several reasons: (1) conditions included in the Global Burden of Disease (GBD) Study 2017 as nonfatal have no YLL estimates, (2) conditions with age exclusions in GBD have no estimates for certain age groups, or (3) estimates are 0 in age group. Table 8: Years lived with disability (YLDs) and years of life lost (YLLs) in the poorest billion

We modeled incidence and prevalence separately using the same modeling strategies described above. We did not use an epidemiological model that would ensure consistency between the incidence, prevalence, and death estimates, and we only report incidence and prevalence below in the Appendix table for reference.

Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Population 139,827,617 246,762,948 304,160,475 181,985,654 139,827,617 246,762,948 304,160,475 181,985,654 Injuries 111,081 51,404 150,529 255,133 5,865,064 12,659,171 19,045,388 14,281,444 Self-harm and 6,697 6,559 61,895 49,735 650,228 939,514 2,565,031 796,502 interpersonal violence

Appendices Page 29 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Conflict and terrorism 3,314 3,039 10,508 2,857 233,632 498,740 1,107,811 188,136 Executions and police 153 173 1,682 653 20,306 46,020 258,491 53,970 conflict Interpersonal violence 3,230 1,838 20,254 12,009 396,290 380,844 1,067,410 479,506 Physical violence by 559 339 6,957 3,499 6,216 4,570 21,287 12,566 firearm Physical violence by 2,195 1,250 8,571 5,421 327,837 280,694 838,495 393,116 other means Physical violence by 476 250 4,726 3,090 62,237 95,580 207,629 73,824 sharp object Sexual violence ------Self-harm - 1,509 29,451 34,216 - 13,911 131,318 74,890 Self-harm by firearm - 56 2,108 2,211 - 232 878 4,213 Self-harm by other - 1,453 27,343 32,005 - 13,678 130,440 70,677 specified means Transport injuries 17,285 14,668 52,851 64,563 495,478 1,098,504 2,221,718 1,303,705 Other transport injuries 1,192 1,029 4,516 4,866 316,035 292,649 298,189 249,988 Road injuries 16,093 13,638 48,335 59,697 179,443 805,855 1,923,529 1,053,716 Cyclist road injuries 345 775 2,005 3,537 30,783 189,426 345,090 190,556 Motor vehicle road 6,780 5,266 21,050 22,656 35,092 174,039 515,489 292,986 injuries Motorcyclist road injuries 1,106 1,039 10,068 7,294 37,007 101,749 382,282 151,782 Other road injuries 192 165 409 629 23,242 121,901 193,384 128,038 Pedestrian road injuries 7,671 6,394 14,803 25,582 53,319 218,740 487,284 290,354 Unintentional injuries 87,099 30,178 35,784 140,835 4,719,357 10,621,152 14,258,639 12,181,237 Adverse effects of 4,512 884 2,591 9,867 191,905 215,611 407,977 463,934 medical treatment Animal contact 5,484 4,666 4,043 15,934 983,289 2,303,934 3,375,181 2,981,394 Non-venomous animal 1,261 519 459 1,439 621,464 1,266,868 1,588,980 1,530,448 contact Venomous animal 4,224 4,146 3,584 14,495 361,826 1,037,066 1,786,201 1,450,946 contact Drowning* 36,567 12,729 6,576 9,999 * * * *

Appendices Page 30 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Environmental heat and 1,815 358 1,299 6,165 186,697 317,607 360,634 287,732 cold exposure Exposure to forces of 278 456 901 646 11,173 79,267 79,494 35,937 nature Exposure to mechanical 4,839 1,682 4,893 7,482 1,399,460 1,697,271 2,509,224 1,369,708 forces Other exposure to 4,083 1,447 3,501 5,896 1,338,685 1,641,983 2,419,112 1,331,819 mechanical forces Unintentional firearm 756 235 1,392 1,587 60,775 55,288 90,113 37,888 injuries Falls 8,008 4,352 4,778 68,858 729,497 3,574,676 4,486,292 4,961,799 Fire, heat, and hot 10,855 2,092 4,503 11,719 107,713 395,428 446,581 184,864 substances Foreign body 8,931 901 1,159 3,282 545,426 866,501 1,073,994 669,080 Foreign body in eyes - - - - 320,492 684,919 945,491 585,769 Foreign body in other 417 70 138 260 164,133 158,982 120,142 78,207 body part Pulmonary aspiration and 8,514 831 1,021 3,022 60,800 22,600 8,361 5,104 foreign body in airway Other unintentional 2,408 1,327 3,647 4,111 465,792 967,236 1,411,803 1,191,977 injuries Poisonings 3,401 732 1,393 2,771 87,230 192,164 99,956 25,612 Poisoning by carbon 363 172 500 969 21,845 31,886 22,330 9,260 monoxide Poisoning by other 3,039 560 893 1,801 65,385 160,279 77,625 16,352 means Non-communicable 252,207 40,957 189,376 2,841,772 104,506,379 217,665,167 291,047,200 181,777,274 diseases Cardiovascular diseases 11,781 4,529 55,513 1,300,387 230,207 1,894,854 6,074,683 25,325,186 Aortic aneurysm - - 373 8,339 - - - - Atrial fibrillation and - - 15 12,661 - - 66,240 1,697,429 flutter Cardiomyopathy and 2,541 466 2,493 17,488 * * * 313,901 myocarditis* Alcoholic cardiomyopathy - - 338 2,774 - - 9,036 70,722 Myocarditis 374 99 533 1,641 6,466 24,102 39,007 56,986 Other cardiomyopathy 2,167 367 1,621 13,073 7,093 16,629 36,322 249,817

Appendices Page 31 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Endocarditis 1,495 249 946 4,244 8,178 5,626 6,504 17,454 Hypertensive heart - - 1,875 71,472 - - 45,622 873,890 disease Ischemic heart disease - - 21,743 600,202 - - 486,319 7,757,860 Non-rheumatic valvular - - 609 5,140 - - 89,636 1,073,562 heart disease Non-rheumatic calcific - - 160 2,313 - - 11,713 233,901 aortic valve disease Non-rheumatic - - 348 2,573 - - 92,862 871,223 degenerative mitral valve disease Other non-rheumatic - - 102 254 - - 242 655 valve diseases Other cardiovascular and 2,082 583 3,048 32,502 144,160 439,546 982,213 3,436,393 circulatory diseases Peripheral artery disease - - - 1,372 - - - 6,654,932 Rheumatic heart disease 1,742 1,783 8,191 43,861 89,571 1,370,806 3,896,248 1,981,943 Stroke 3,921 1,448 16,220 503,107 7,513 129,701 667,871 4,638,899 Intracerebral hemorrhage 2,056 914 11,109 294,120 18,991 83,214 260,018 910,231 Ischemic stroke 341 100 1,963 176,024 26,010 142,041 462,337 3,403,475 Subarachnoid 1,525 434 3,148 32,963 3,179 17,337 87,735 454,804 hemorrhage Chronic respiratory 3,755 1,702 9,883 361,974 5,237,751 11,294,206 10,022,939 23,508,530 diseases Asthma 2,631 1,170 5,367 72,745 5,328,741 11,162,400 7,184,065 8,050,064 Chronic obstructive 399 145 3,179 273,089 50,821 385,749 2,999,884 17,222,540 pulmonary disease Interstitial lung disease 71 41 260 9,736 40 368 28,556 322,043 and pulmonary sarcoidosis Other chronic respiratory 655 346 1,031 4,974 - - - - diseases Pneumoconiosis - - 45 1,430 - 1 3,283 16,174 Asbestosis - - 5 173 - 0 1,261 4,588 Coal workers - - 6 268 - 0 564 3,384 pneumoconiosis

Appendices Page 32 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Other pneumoconiosis - - 24 550 - 0 451 3,964 Silicosis - - 10 438 - 0 1,008 4,239 Diabetes and kidney 5,207 2,532 15,918 230,506 76,292 1,702,290 23,499,440 53,601,781 diseases

Acute glomerulonephritis 118 57 75 434 766 1,826 1,892 2,377 Chronic kidney disease 4,568 2,007 11,228 93,209 131,610 1,322,666 16,015,388 39,524,165 Chronic kidney disease 17 15 1,121 5,852 8,033 44,294 109,948 96,827 due to diabetes mellitus type 1 Chronic kidney disease 12 8 321 26,502 1,500 80,842 2,120,667 7,292,089 due to diabetes mellitus type 2 Chronic kidney disease 1,519 845 4,712 14,626 13,456 100,841 660,222 1,732,632 due to glomerulonephritis Chronic kidney disease 31 35 1,146 28,427 21,678 201,033 838,429 1,283,329 due to hypertension Chronic kidney disease 2,989 1,104 3,928 17,803 86,944 895,655 12,286,121 29,119,290 due to other and unspecified causes Diabetes mellitus 521 469 4,615 136,863 7,457 553,531 8,876,198 25,044,659 Diabetes mellitus type 1 521 469 3,731 39,919 7,457 217,678 517,441 307,434 Diabetes mellitus type 2 - - 884 96,943 - 335,852 8,358,757 24,737,225 Digestive diseases 12,355 5,575 32,461 226,894 9,531,422 23,467,149 82,420,984 74,958,237 Appendicitis 961 815 1,550 4,878 5,989 30,744 50,225 22,691 Cirrhosis and other 2,495 2,109 18,572 131,574 8,333,626 21,737,270 58,129,338 53,811,265 chronic liver diseases Cirrhosis and other - - 2,677 31,258 - - 547,383 1,071,334 chronic liver diseases due to alcohol use Cirrhosis and other 103 229 8,005 48,874 7,278,201 17,497,178 26,330,250 16,224,934 chronic liver diseases due to hepatitis B Cirrhosis and other 23 63 3,548 29,959 753,721 3,328,779 6,421,899 6,240,676 chronic liver diseases due to hepatitis C

Appendices Page 33 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Cirrhosis and other 2,369 1,817 3,611 12,803 301,703 911,313 1,015,081 478,269 chronic liver diseases due to other causes Cirrhosis due to NASH - - 730 8,680 - - 23,814,724 29,796,052 Gallbladder and biliary 329 204 650 7,403 33,031 54,419 403,462 681,968 diseases Inflammatory bowel 224 54 299 2,058 545 6,073 34,774 64,608 disease Inguinal, femoral, and 140 87 431 4,398 323,052 317,862 477,618 904,868 abdominal hernia Other digestive diseases 718 308 762 6,199 - - - - Pancreatitis 25 47 1,163 6,719 2,932 14,291 70,907 154,076 Paralytic ileus and 6,604 1,321 3,945 25,957 2,184 2,278 3,308 5,463 intestinal obstruction Upper digestive system 686 599 4,925 32,299 1,010,572 1,934,160 33,667,247 33,773,758 diseases Gastritis and duodenitis 235 133 1,621 6,379 1,015,952 1,887,285 6,326,795 6,168,339 Gastroesophageal reflux ------28,593,970 29,800,201 disease Peptic ulcer disease 451 466 3,305 25,920 - 105,476 752,915 818,171 Vascular intestinal 172 32 165 5,410 556 331 511 1,620 disorders Mental disorders - 0 4 1 3,624,165 23,524,463 44,391,104 28,186,798 Anxiety disorders - - - - 127,040 5,525,995 12,741,085 7,859,433 Attention- - - - - 230,497 4,934,634 4,081,198 736,982 deficit/hyperactivity disorder Autism spectrum - - - - 667,421 1,115,051 1,196,263 592,405 disorders Bipolar disorder - - - - - 304,856 2,519,676 1,435,309 Conduct disorder - - - - - 6,124,268 2,547,920 - Depressive disorders - - - - - 1,538,623 11,178,702 11,274,928 Dysthymia - - - - 591 331,920 3,635,153 3,992,144 Major depressive - - - - 1,133 1,228,006 7,714,921 7,578,010 disorder

Appendices Page 34 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Eating disorders - 0 4 1 - 74,739 868,375 103,667 Anorexia nervosa - 0 1 1 - 44,391 176,386 14,440 Bulimia nervosa - 0 3 1 - 37,680 692,870 91,306 Idiopathic developmental - - - - 2,662,025 5,009,334 5,226,027 2,169,944 intellectual disability Other mental disorders - - - - - 132,620 6,586,358 5,396,216 Schizophrenia - - - - - 5,401 682,782 621,824 Musculoskeletal - 274 1,055 9,895 - 3,003,724 31,068,690 58,787,161 disorders Gout ------278,204 1,899,898 Low back pain - - - - - 2,673,617 17,325,937 25,589,475 Neck pain - - - - - 264,451 4,951,800 11,883,955 Osteoarthritis ------1,102,851 16,181,801 Other musculoskeletal - 238 971 4,823 - 131,663 9,272,910 15,259,977 disorders Rheumatoid arthritis - 36 84 5,072 - 22,961 302,686 1,060,908 Neoplasms 14,803 12,360 41,903 499,212 184,091 58,724 439,183 1,965,257 Bladder cancer - - 166 9,398 - - 5,261 63,921 Brain and central nervous 2,150 2,155 2,575 8,387 19,371 8,870 9,466 19,690 system cancer Breast cancer - - 4,624 41,809 - - 105,414 499,566 Cervical cancer - - 5,402 42,691 - - 182,180 327,040 Colon and rectum cancer - - 1,846 38,976 - - 13,645 159,590 Esophageal cancer - - 1,108 31,480 - - 2,800 40,780 Gallbladder and biliary - - 251 9,974 - - 372 6,650 tract cancer Hodgkin lymphoma 278 679 1,612 2,145 2,533 3,680 8,994 6,838 Kidney cancer 552 143 191 3,852 42,232 9,095 10,110 57,254 Larynx cancer - - 338 10,639 - - 2,569 48,289 Leukemia 4,001 3,787 4,153 13,955 40,681 19,850 17,319 39,043 Acute lymphoid leukemia 1,251 1,672 983 1,137 13,443 9,299 4,424 3,593

Appendices Page 35 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Acute myeloid leukemia 1,167 792 1,304 4,210 4,505 1,472 2,658 4,430 Chronic lymphoid - - 42 1,354 - - 560 8,241 leukemia Chronic myeloid - - 620 2,200 - - 2,619 5,270 leukemia Other leukemia 1,584 1,323 1,204 5,055 22,733 9,079 7,058 17,508 Lip and oral cavity cancer - - 1,384 17,804 - - 22,150 95,932 Liver cancer - 526 2,359 40,379 - - 102 8,746 Liver cancer due to - - 324 8,759 - - 557 9,197 alcohol use Liver cancer due to - 383 1,382 13,135 - 418 2,390 15,650 hepatitis B Liver cancer due to - 11 205 12,153 - 12 356 11,949 hepatitis C Liver cancer due to - - 159 3,712 - - 278 3,569 NASH Liver cancer due to other - 132 290 2,621 - 141 509 2,923 causes Malignant skin melanoma - - 389 1,966 - - 4,641 11,356 Mesothelioma - - 82 878 - - 339 2,310 Multiple myeloma - - 220 5,617 - - 761 7,913 Nasopharynx cancer - 95 420 4,052 - 2,386 7,269 18,236 Non-Hodgkin lymphoma 1,931 1,739 2,716 13,580 16,795 9,645 13,970 43,569 Non-melanoma skin - - 185 3,844 - - - 3,358 cancer Non-melanoma skin ------2,335 6,099 cancer (basal-cell carcinoma) Non-melanoma skin - - 185 3,844 - - 373 4,516 cancer (squamous-cell carcinoma) Other malignant 5,576 2,969 4,996 22,097 67,768 19,473 24,000 64,233 neoplasms Other neoplasms 314 227 390 2,915 25,080 43,547 91,460 192,818

Appendices Page 36 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Benign and in situ - - - - 63 183 3,148 4,189 cervical and uterine neoplasms Benign and in situ - - - - 460 907 2,662 14,968 intestinal neoplasms Myelodysplastic, 231 127 256 2,842 1,469 3,198 3,588 9,006 myeloproliferative, and other hematopoietic neoplasms Other benign and in situ 83 100 134 73 27,538 47,598 92,615 177,281 neoplasms Other pharynx cancer - - 574 11,682 - - 2,347 28,325 Ovarian cancer - - 873 10,154 - - 25,790 55,533 Pancreatic cancer - - 395 15,841 - - 573 10,754 Prostate cancer - - 83 33,352 - - 2,066 217,547 Stomach cancer - - 2,252 40,837 - - 5,344 62,066 Testicular cancer - - 299 199 - - 5,675 1,650 Thyroid cancer - 41 516 2,722 - 2,174 40,656 51,499 Tracheal, bronchus, and - - 1,299 52,694 - - 2,240 53,866 lung cancer Uterine cancer - - 206 5,290 - - 5,613 69,439 Neurological disorders 9,564 3,836 14,053 150,154 484,329 64,421,209 148,530,468 87,384,571 Alzheimer's disease and - - - 114,602 - - - 2,004,295 other dementias Epilepsy 8,248 3,272 13,116 14,018 485,772 1,111,219 1,230,684 661,250 Headache disorders - - - - - 63,601,502 147,897,577 85,625,576 Migraine - - - - - 13,943,411 70,683,254 40,782,570 Tension-type headache - - - - - 55,033,015 108,552,133 62,519,585 Motor neuron disease 20 3 17 377 943 2,169 2,361 3,586 Multiple sclerosis - - 139 683 - 360 20,790 30,805 Other neurological 1,296 561 773 1,612 986 1,782 1,625 1,380 disorders Parkinson's disease - - 8 18,862 - - 6,859 415,271

Appendices Page 37 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Other non-communicable 192,649 9,958 13,027 41,659 78,829,135 154,444,585 210,790,320 139,688,236 diseases Congenital birth defects 164,302 5,650 3,657 1,616 3,368,225 3,638,442 3,952,050 2,147,227 Congenital heart 55,650 3,056 2,176 835 1,289,961 678,846 248,510 54,913 anomalies Congenital 2,678 129 104 33 747,095 850,092 1,231,793 791,947 musculoskeletal and limb anomalies Digestive congenital 14,719 137 47 37 243,259 401,545 480,117 282,237 anomalies Down syndrome 5,196 210 279 224 65,057 102,276 121,538 49,597 Klinefelter syndrome - - - - 24,963 40,250 37,320 4,870 Neural tube defects 43,430 609 184 39 147,361 163,632 168,069 87,919 Orofacial clefts 1,861 - - - 234,115 299,441 346,518 213,631 Other chromosomal 3,601 82 73 17 290,823 330,947 306,641 121,323 abnormalities Other congenital birth 33,951 1,291 705 233 629,920 1,107,740 1,366,581 812,999 defects Turner syndrome - - - - 23,195 35,683 32,218 4,251 Urogenital congenital 3,214 137 90 199 162,603 243,347 227,045 27,764 anomalies Endocrine, metabolic, 2,620 504 975 5,958 1,893,764 3,330,679 5,853,177 3,899,168 blood, and immune disorders Gynecological diseases - - 431 885 - 106,843 46,690,393 28,665,872 Endometriosis - - 10 12 - - 2,251,274 718,059 Female infertility ------5,709,212 1,393,841 Genital prolapse - - 8 89 - - 3,013,140 9,555,517 Other gynecological - - 340 489 - - 2,668,314 1,210,994 diseases Polycystic ovarian - - 1 0 - 106,768 3,117,473 1,058,865 syndrome Premenstrual syndrome ------32,466,285 12,092,394 Uterine fibroids - - 73 295 - - 3,697,583 8,206,509

Appendices Page 38 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Hemoglobinopathies and 9,074 3,153 5,113 8,910 48,098,459 84,277,054 105,016,501 61,885,582 hemolytic anemias G6PD deficiency 174 162 521 2,757 10,968,308 19,091,569 22,521,390 12,882,849 G6PD trait - - - - 22,170,929 38,774,718 50,033,087 29,526,427 Other 26 23 150 4,785 1,371,295 2,751,540 5,010,918 3,509,064 hemoglobinopathies and hemolytic anemias Sickle cell disorders 8,214 2,703 4,369 1,366 400,750 464,316 288,576 12,750 Sickle cell trait - - - - 16,907,767 29,291,933 34,895,227 20,085,013 Thalassemias 660 264 73 2 21,060 8,657 1,044 7 Thalassemias trait - - - - 3,282,992 6,096,196 7,701,339 5,012,468 Oral disorders - - - - 41,911,439 101,110,092 133,352,384 100,850,183 Caries of deciduous teeth - - - - 42,327,416 58,424,432 - - Caries of permanent - - - - - 48,673,526 119,218,542 66,228,664 teeth Edentulism and severe ------2,017,402 10,840,101 tooth loss Other oral disorders - - - - - 2,634,885 6,114,443 4,408,387 Periodontal diseases ------19,854,533 44,998,273 Sudden infant death 13,326 - - - 13,326 - - - syndrome Urinary diseases and 3,328 651 2,851 24,289 36,798 40,835 2,944,572 7,181,843 male infertility Benign prostatic ------6,542,054 hyperplasia Male infertility ------2,689,822 650,266 Other urinary diseases 1,722 315 1,104 8,542 - - - - Urinary tract infections 1,606 326 1,712 15,100 41,878 57,054 211,823 114,642 Urolithiasis - 11 34 648 1,175 7,958 91,759 124,227 Sense organ diseases - - - - 3,740,679 13,167,416 55,760,515 111,114,068 Age-related and other - - - - 793,894 4,668,738 27,890,661 68,781,382 hearing loss Blindness and vision - - - - 2,100,256 7,679,175 30,672,711 81,112,155 impairment

Appendices Page 39 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Age-related macular ------579,170 degeneration Cataract ------360,235 11,922,287 Glaucoma ------612,191 Near vision loss - - - - 492,944 3,470,808 25,245,808 69,623,237 Other vision loss - - - - 121,041 208,421 579,829 2,065,472 Refraction disorders - - - - 1,507,846 4,081,826 5,087,968 9,085,026 Other sense organ - - - - 897,204 1,069,967 1,822,581 4,684,093 diseases Skin and subcutaneous 2,093 189 835 8,613 43,156,458 80,270,899 70,841,911 55,573,435 diseases Acne vulgaris - - - - - 2,761,904 6,426,303 430,898 Alopecia areata - - - - 58,861 159,884 746,665 351,946 Bacterial skin diseases 2,042 148 737 7,261 782,666 1,183,819 528,113 284,052 Cellulitis 187 47 137 1,144 31,790 35,026 58,407 53,393 Pyoderma 1,854 101 600 6,117 781,635 1,184,640 531,856 261,060 Decubitus ulcer 21 20 59 1,200 2,114 5,574 11,771 50,164 Dermatitis - - - - 7,993,788 15,107,823 9,652,956 4,761,217 Atopic dermatitis - - - - 8,022,496 14,032,249 6,583,431 2,601,930 Contact dermatitis - - - - - 1,188,212 3,109,284 2,156,695 Seborrhoeic dermatitis - - - - 30,431 45,365 77,007 60,427 Fungal skin diseases - - - - 24,499,923 43,673,531 30,349,407 30,152,136 Other skin and 30 21 39 152 4,047,692 5,769,683 11,567,803 18,375,860 subcutaneous diseases Pruritus - - - - 571,255 1,285,922 2,360,982 2,489,547 Psoriasis - - - - 114,929 647,734 1,578,748 1,712,851 Scabies - - - - 3,509,557 8,099,274 9,635,686 3,190,035 Urticaria - - - - 3,288,081 3,842,279 2,923,211 1,424,784 Viral skin diseases - - - - 4,791,033 10,409,404 2,852,551 789,235 Substance use disorders - - 4,724 12,476 - 107,075 9,001,821 3,659,346

Appendices Page 40 Deaths Incident (Injuries) or Prevalent (NCDs) Cases Condition Under-5 5 to 14 15 to 39 40 plus Under-5 5 to 14 15 to 39 40 plus Alcohol use disorders - - 2,224 8,449 6,143 96,593 5,880,565 2,848,340 Drug use disorders - - 2,500 4,026 - 30,793 3,256,643 850,868 Amphetamine use - - 79 121 - 1,003 195,486 17,798 disorders Cannabis use disorders - - - - - 37,736 1,007,995 166,629 Cocaine use disorders - - 93 180 - - 35,208 20,361 Opioid use disorders - - 1,667 1,922 - - 2,019,951 641,111 Other drug use disorders - - 662 1,804 - 8 70,869 45,249 Blank estimates for one of several reasons: (1) conditions included in the Global Burden of Disease (GBD) Study 2017 as nonfatal have no death estimates, (2) conditions with age exclusions in GBD have no estimates for certain age groups, (3) estimates are 0 in age group, or (4) the GBD included death estimates but no estimates of incidence/prevalence. *Estimates omitted in certain cases here because of what appears to be internal inconsistency in GBD estimates (e.g. myocarditis prevalence estimates larger than the category “cardiomyopathy and myocarditis,” which should be inclusive of myocarditis in younger age groups) Table 9: Deaths, incidence, and prevalence of conditions in the poorest billion

Appendices Page 41 Appendix 1.D. Causes of death by socioeconomic status at INDEPTH Network HDSS sites

To examine cause-specific mortality rates across socioeconomic (SES) groups, the Commission conducted an analysis with seven collaborating health and demographic surveillance system (HDSS) sites in the INDEPTH Network. 22 The analysis linked SES data from household surveys with routine demographic data that includes verbal autopsies on deaths in each of the seven collaborating sites in sub-Saharan Africa (Harar and Kersa, Ethiopia; Kombewa and Nairobi, Kenya; Cross River, Nigeria; Karonga, Malawi; Manhiça, Mozambique). We utilized the same eight-indicator poverty index, based on the Multidimensional Poverty Index, used to define the poorest billion overall for this Commission (Appendix 1.B.). The methodology for the HDSS analysis is described in full detail elsewhere. 23 In brief, causes of death were classified using the InterVA-4 model, based on responses of family, friends, or witnesses of the deaths to verbal autopsy questionnaires. Deaths and person-years lived in the site were known by household and linked to household socioeconomic data. Multiple imputation methods were used to impute data for households missing SES data, and uncertainty was propagated through the analysis. The SES index in Manhiça omitted the education indicators (for a total of 6 rather than 8 indicators) because they could not be constructed from the available data. For the Commission report, we converted deaths to YLLs using the life expectancy standards from the Global Burden of Disease Study 2016. 17 We standardized rates by age and sex using the INDEPTH Network 2013 population standards for sub-Saharan Africa. 24

Appendices Page 42 Appendix 1.E. Primary data on extreme poverty and morbidity due to NCDIs

The main source of global data regarding within-country relationships between socioeconomic status (SES) and morbidity due to NCDIs in LMICs is the World Health Survey (WHS). 25,26 Although the WHS was conducted more than a decade ago and covered only a limited set of NCDIs, no more recent global surveys provide comparable data on both SES and NCDI-related morbidity. The STEPwise approach to surveillance (STEPs) surveys have focused more on common NCDI risk factors than on symptomatic conditions, and are discussed later in this section.

WHS was conducted between 2002 and 2004 in adults over the age of 18 in 70 countries, including many in sub-Saharan Africa and South Asia. NCDIs evaluated in WHS included self- reported injury, vision, and oral health problems; angina, asthma, arthritis, diabetes, , schizophrenia (using a questionnaire-based instrument); and diabetes and cataracts (by self- reported diagnosis). Some limitations of the WHS include the problem of access to diagnosis as a confounding issue in the case of diabetes and cataracts, as well as questions about the validity of the Rose angina questionnaire and questionnaires for asthma in low-income populations. The WHS has been analyzed in relation to socioeconomic variables in India specifically, as well as in 40 other countries through WHO.25,27 The general finding has been that rates of NCDI morbidity are highest in the poorest socioeconomic quintiles for all conditions assessed except diabetes (which is confounded by access to diagnosis), and depression.

This Commission conducted a systematic review on papers published between January 2000 and December 2016 regarding the prevalence of injuries in relation to socioeconomic status in 99 LMICs. We found relevant publications from only 6 out of 55 countries with at least one sub- national region with a greater than 25% prevalence of extreme multidimensional poverty. These few studies generally showed lower rates of road-traffic injuries among the poorest compared with other populations (in Nigeria and Tanzania), and higher rates of drowning (in Bangladesh). Rates of falls were similar relative to measures of SES in India.

Primary data are even more limited on the relationship within LMICs between poverty and other, less common, and more severe NCDIs, such as cancer, rheumatic heart disease, and trauma. Prevalence of these NCDIs is low individually, and their diagnosis requires somewhat specialized equipment and expertise. Most of the data we have comes from facility-based registries that have typically collected very little in the way of socioeconomic information. While there have been population-based health examination surveys regarding particular conditions – such as surgically-amenable diseases and injuries – these have been conducted in a small number of countries and have collected limited socioeconomic information.28 Surveys such as the Demographic and Health Survey and the Multiple Indicator Cluster Survey focus mainly on infectious, nutritional, and reproductive, maternal, neonatal and child health (RMNCH) issues.29,30 Countries are increasingly including NCD modules, though the questions are limited.

Appendices Page 43 Appendix 1.F. Expert perspectives on extreme poverty, disease occurrence, and case-fatality

We conducted a survey of experts on specific disease categories with experience working in low- and lower-middle-income countries (LLMICs). The participants were from a convenience sample recruited from three groups: (1) commissioners on the Lancet NCDI Poverty Commission, (2) members of national NCDI Poverty Commissions and Groups associated with the Lancet NCDI Poverty Commission, and (3) experts identified in specific disease areas to ensure coverage of the large and diverse set of NCDI conditions in the GBD. Experts were recruited via email.

In total, we analyzed data from 93 responses, discarding four that were internally inconsistent. Over 65% of respondents lived outside of high-income countries. 69% worked clinically, 35% worked in epidemiology or health metrics, and 54% worked in health systems or health policy. 80% had a clinical degree, 25% had a PhD or equivalent, and 45% had a Master’s degree in or a Master’s of Science in a related field. 87% of respondents had 5 or more years of experience working on health in LLMICs, 66% had at least 10 years of experience working on health in LLMICs, and 29% had at least 20 years of experience. Regions of expertise (multiple possible) included areas in which the vast majority of the poorest billion live: Sub-Saharan Africa (71%), South Asia (20%), and Latin America and the Caribbean (25%).

Participants were administered the survey online using the online survey tool Qualtrics. Respondents were shown modules about diseases about which they identified as having experience. These modules asked respondents about the association (or lack of association) they perceived between poverty and disease within LLMICs. They were specifically asked about incidence and case fatality of the diseases. We chose to ask for qualitative assessments of the relationships because of feedback we received from a pilot phase that indicated making quantitative estimates about these relationships was challenging. Respondents chose whether they perceived each measure (incidence or case fatality) to be much higher in the poor, higher in the poor, no difference, higher in the non-poor, and much higher in the non-poor (5 ranked responses), where “poor” was defined using the Commission definition of the poorest billion. The definition was described to participants, and proportions of the population defined in the poorest billion were given for example countries for reference. For each of their responses, participants were also asked to rate their confidence. We tested whether the median responses for each disease were different than the “no difference” responses using a signed-rank test and plotted results below in Figure 2. While we used the median to test significance, we converted the ranked qualitative responses to a 1-5 scale and plotted the mean response (rather than the median) in order to create separation between points graphically in the figure for visual clarity.

Appendices Page 44

Original collection and analysis of survey data from 93 expert respondents. Significance determined by signed-rank test of difference in median response from “no difference.” Figure 2: Map of expert opinion regarding relationship between poverty and disease occurrence and fatality in low and middle-income countries

We recognize participation from the following individuals and would like to thank them for their contributions:

Abdul Qadir Qadir, Abha Shrestha, Abraham Haileamlak, Adamson Muula, Agnes Binagwaho, Allison Linden, Amelia (Mia) Crampin, Ann Miller, Aruyaru Stanley Mwenda, Benjamin Massenburg, Bhagawan Koirala, Bhaskar Pant, Bistra Zheleva, Bongani Mayosi, Crispin Gishoma, D Cristina Stefan, Dagnaw Wubaye Walelgne, Damian Hoy, Daniel Vigo, Dinesh Neupane, Mariam Kalomo, Cyprian Kamau, Eleana Stoufi, Eugene Richardson, Farhad Farewar, Ferozuddin Feroz, Fred Amegashie, Gedeon Ngoga, Gertrudes Machatine, Gladwell Gathecha, Hanna Kaade, Hema Magge, Hideki Higashi, Homa Akseer, Jacques Clerville, Jane Barrow, Jason Beste, Jean Pascal Blaise Uhagaze, Jennifer Furin, John Chipolombwe , John G Meara, John H. Kempen, Joia Mukherjee, Jonathan Steer-Massaro, Jones Masiye, Joseph Mucumbitsi, Judith Lindert, Julia von Oettingen, Julie Makani, Katie Cundale, Kerry Vaughan, Krishna Kumar Aryal, Leo Masamba, Liesl Zuhlke, Lillian Gondwe-Chunda, Loise Nyanjau, Luckson Dullie, Luke L. Bawo, Marie Nancy Charles Larco, Michael Udedi, Mieraf Taddesse Tolla, Marie Aimee Muhimpundu, Munirat Ogunlayi, Natasha Archer, Neil Gupta, Nelya Melnitchouk, Nicholas Campain, Nobhojit Roy, Oriol Mitjà, Paul Heidekrueger, Piet Noë, Rachel Koch, Rachel Nugent, Roderick Hay, Roger Jean-Charles, Sabrina Juran, Sam Patel, Sam Slewion, Samuel Oti, Sanctus Musafiri, Sarah Averbach, Saroj Ojha, Shada Rouhani, Sonya Shin, Thomas Koestler, Thomas Randall, Tim Walker, Valeria Macias, Valerie Luyckx, Wilnique Pierre, Yassir Turki, Yogesh Jain, Yogeshwar Kalkonde, Yoseph Mamo Azmera.

Appendices Page 45 Appendix 1.G. NCDI DALY rate comparison between the poorest billion and high-income countries

We compared the burden from NCDIs in the poorest billion (modeled as described in Appendix 1.C) with that in high-income regions by calculating rate ratios and differences. We aggregated age-, sex-, and cause-specific differences across sexes and for cause groupings to present in the main report by five-year age groups.

In addition, to examine specific causes associated with the largest disparities, we estimated differences below 40 and at age 40 and above because the NCDI burden is roughly evenly split among the poorest billion around this age, and the composition of the burden differs at young and old ages. We subtracted DALY rates (age-standardized within those broad age groups) in high-income countries in North America, Australasia, Pacific Asia, and Western Europe from those in the poorest billion. In addition to the rate differences, we calculated rate ratios. Both are shown in Table 10. Under-40 DALY Rate Ratio DALY Rate Difference

Rate Rate Difference Cause Cause Ratio (per 100,000)

Conflict and terrorism 189.6 Drowning 471 Sickle cell disorders 57.4 Congenital heart anomalies 451 Venomous animal contact 29.4 Neural tube defects 398 Rheumatic heart disease 27.5 Other congenital birth defects 311 Exposure to forces of nature 24.7 Epilepsy 307 Cirrhosis and other chronic liver 16.7 Conflict and terrorism 241 diseases due to hepatitis B Acute glomerulonephritis 16.0 Pedestrian road injuries 240 Sickle cell trait 12.8 Fire, heat, and hot substances 200 Neural tube defects 12.2 Ischemic heart disease 175 Pyoderma 11.9 Rheumatic heart disease 162 Appendicitis 11.5 Sickle cell disorders 160 Paralytic ileus and intestinal obstruction 11.0 Intracerebral hemorrhage 134 Near vision loss 10.7 Venomous animal contact 126 Other urinary diseases 10.6 Paralytic ileus and intestinal obstruction 108 Drowning 9.2 Digestive congenital anomalies 98 Bold text = Cause in top 15 causes for both rate ratio and rate difference Rates age-standardized within each age group Over-40 DALY Rate Ratio DALY Rate Difference

Rate Rate Difference Cause Cause Ratio (per 100,000)

Conflict and terrorism 127.0 Ischemic heart disease 4565 Venomous animal contact 36.6 Intracerebral hemorrhage 3339 Sickle cell disorders 24.8 Chronic obstructive pulmonary disease 2715 Exposure to forces of nature 14.0 Ischemic stroke 1349 Other urinary diseases 11.3 Diabetes mellitus type 2 1050 G6PD deficiency 11.3 Asthma 837 Scabies 10.6 Cirrhosis and other chronic liver 659 diseases due to hepatitis B Sickle cell trait 10.6 Cervical cancer 597 Appendicitis 10.4 Hypertensive heart disease 595 Cataract 9.8 Rheumatic heart disease 567 Rheumatic heart disease 9.8 Cataract 550 Cirrhosis and other chronic liver 9.5 Diabetes mellitus type 1 431 diseases due to hepatitis B Acute glomerulonephritis 7.1 Pedestrian road injuries 347 Cervical cancer 6.9 Near vision loss 330 Intracerebral hemorrhage 6.8 Peptic ulcer disease 285 Bold text = Cause in top 15 causes for both rate ratio and rate difference Rates age-standardized within each age group Table 10: Top 15 causes with the highest ratios of DALY rates between the poorest billion and high-income countries, under age 40 (A) and over age 40 (B) To the extent that comparisons with high-income populations represent opportunities for reduction in disease burden, rate ratios and differences can help explore these opportunities. Rate differences capture conditions for which a large amount of burden could theoretically be addressed by prevention and treatment. As rate ratios can be high even if overall rates are low, high rate ratios tend to capture conditions for which a high proportion of the burden in the poor

Appendices Page 46 could be prevented or treated, as it is successfully in high-income settings. In our findings, rate ratios tend to be higher at young ages, while rate differences are higher at older ages, at least in part because DALY rates increase with age in both geographic settings. Sickle cell disorders, rheumatic heart disease, appendicitis, bowel obstruction, venomous animal contact, and orofacial clefts have high rate ratios. Rate differences are high for ischemic heart disease, hemorrhagic stroke, and chronic obstructive pulmonary disease above age 40. Notably, age-specific DALY rates for several are higher at older ages in high-income populations than in the poorest billion, but cervical cancer DALY rates are substantially higher in the poorest billion.

As an extension of these rate differences, we calculated the burden in the poorest billion that was “avoidable” compared to rates of burden in high-income populations. On an age-, sex-, and cause-specific basis, we subtracted DALY rates in high-income populations from those in the poorest billion. We aggregated these differences for both sexes and by cause categories, excluding negative differences, to generate avoidable DALY rates. Then, we multiplied by populations to generate total avoidable DALYs. The avoidable burden is substantial in every age group, as noted in the main text. Some conditions have higher rates in high-income populations, implying “negative” avoidable burden. We omitted this burden to focus on the causes of burden that are higher in the poorest billion. There is more “negative” avoidable burden from mental and substance use disorders in each 5-year age group from age 5 to age 64. The same is true for cancers over age 55. Notable cancers with negative avoidable burden are lung cancer, colorectal cancer, brain and nervous system cancer, pancreatic cancer, kidney cancer, and melanoma. Musculoskeletal disorders are also generally higher in high-income populations. Other conditions with substantial negative avoidable burden include firearm injury and acne vulgaris.

Appendices Page 47 Appendix 1.H. Behavioral, Metabolic, and Environmental Risk Factor Exposure among the Poorest Billion

The first systematic attempt to quantify risk factor exposure in relation to poverty using microdata approaches was made in the context of WHO’s Comparative Risk Assessment project, led by Majid Ezzati and colleagues between 2000 and 2004 as part of the Global Burden of Disease 2000 study.31 This work relied on DHS data from 53 countries regarding maternal , as well as the Living Standards Measurement Study (LSMS) from 11 countries, and the China Health and Nutrition Survey from 1993, for data on household air pollution, alcohol, and tobacco use.32,33 These authors found that maternal obesity and overweight, alcohol, and tobacco use were generally less common among the poorest in Africa and the Americas, but that the reverse relationship was found for tobacco and alcohol in the Eastern Mediterranean and Central and Eastern Europe. Exposure to household air pollution was more common among the poorest in all regions. The study was limited by gaps in data for the South-East Asia region for alcohol and tobacco. Noting that “the association of individual-level income poverty with a given risk factor often varies by subregion and would not necessarily be inferred correctly by an ecological analysis of regional poverty and the prevalence risk factors,” the authors concluded, “During the 21st century many adverse risk factors, such as tobacco use, excessive alcohol use, and obesity, may become most prevalent among poor individuals within poor regions.” The opportunity to prevent NCDs in the poorest billion therefore depends both on preventing the rise of these risk factors and on reducing exposure to those already experienced at higher rates among the poor, many of which are tied to poverty.

Hosseinpoor and colleagues at WHO analyzed socioeconomic gradients in WHS and found that physical inactivity was uncommon in the poorest households and that low rates of fruit and vegetable consumption were pervasive in LMICs and more common among the poor.34 We are not aware of any other multi-country studies conducted within the past 10 years of within- country variation in physical inactivity, lack of fruit and vegetable consumption, or salt intake, according to socioeconomic status in LMICs.35

More recent work regarding the within-country variation in tobacco use both from the 2002– 2004 World Health Survey (WHS) for LMICs and from DHS data has found a higher prevalence of smoking among the poorest in both sub-Saharan Africa and South Asia.36-39 However, an analysis of WHS data on the absolute quantity of tobacco consumed found that the within- country rates for the poorest are only slightly higher.40 The risk of increasing tobacco consumption in LLMICs in the future is large. 39

Overweight and obesity have long been understood to be uncommon among the poorest in developing countries, and more common among the relatively poor in developed countries.41 More recent analyses based on DHS data have arrived at the same conclusion regarding the uncommonness of overweight and obesity among the poorest in low- and lower-middle-income countries.42-45 In upper-middle-income countries, however, these same studies show that there is more overweight and obesity among the relatively poor.

In order to summarize what is known about exposure to behavioral, metabolic, and environmental risks for NCDIs, the Commission conducted two sets of novel analyses: (1) ecological analysis of risk factor exposure in GBD, NCD-RisC Collaboration, and WHO estimates; and (2) original analysis of household surveys (e.g. DHS and MICS) that provide microdata on obesity, tobacco, alcohol, and use of biomass fuels.46-49

For the ecological analysis, we noted the direction of the association between risk exposures and extreme poverty prevalence across countries, including effects for broad regions in our model to account for regional differences. We used these regressions to predict risk exposures among populations with 100% of people in the poorest billion and 0% of people in the poorest billion. Using the national-level exposure estimates and the proportion of the population in the poorest billion, we scaled the “poorest billion” and “non-poorest” exposure predictions for each country such that they were consistent with the national estimates (see Appendix 1C for analogous approach, including scaling formula). Then, we aggregated for the total poorest billion population across countries (see Table 11).

For the examination of microdata, we stratified data on risk exposures among individuals in the poorest billion and those not in the poorest billion, using the household poverty index that

Appendices Page 48 defined the poorest billion (Appendix 1.B) for stratification. We noted the number of countries with significant differences in the risk exposures in Table 11.

Obesity is very low in the poorest billion, both from modeled estimates and household microdata (both between 1-3%, see Table 11). We find that even though current tobacco use prevalence within LLMICs is higher in the poorest billion than in other populations, tobacco use is relatively low in the poorest populations globally. This is mainly because the countries where many of the poorest live (i.e., in sub-Saharan Africa) have low rates of tobacco use. While the prevalence of people who have ever consumed alcohol is lower in LLMICs than in higher-income countries, the evidence about the association between alcohol use and poverty within countries is less clear. In a small number of DHS surveys, we find a lower prevalence of people who have ever consumed alcohol among the poor. We find that biomass fuel use is almost universal among the poorest (in part because it is one of the eight deprivations used in our definition of poverty). Age- standardized rates of elevated blood pressure in LLMICs, particularly those in Africa, are similar to or higher than those in high-income countries. 50 Some studies have found elevated blood pressure to be less common among the poor within these countries, though this may vary according to geographic context. 51-53

Appendices Page 49

Number of Countries with Significantly Higher/Lower Prevalence in Poorest Poorest Billion Risk Age Type of Poverty Billion within Countries Number of Risk Exposure Factor Sex Group Analysis Association (if Microdata) Sources Countries Definition Prevalence Tobacco Male 15-49 Microdata Null or + 11 higher/0 lower DHS, MICS 24 Current Cigarette Smokers 15.9% Male 15+ Ecological - IHME, OPHI, regression All Current Tobacco Smokers 11.4% Male 15+ Aggregation N/A IHME, OPHI All Current Tobacco Smokers 22.9% Female 15-49 Microdata Null or + 5 higher/1 lower DHS, MICS 30 Current Cigarette Smokers 0.76% Female 15+ Ecological - IHME, OPHI, regression All Current Tobacco Smokers 1.7% Female 15+ Aggregation N/A IHME, OPHI All Current Tobacco Smokers 3.3% Alcohol Percent of People Who Have Ever Consumed Alcohol Male 15-49 Microdata Null or - 0 higher/2 lower DHS, MICS 8 Ever Consumers 46.7% Male 15+ Ecological - WHO, OPHI, regression All Ever Consumers 19.7% Male 15+ Aggregation N/A WHO, OPHI All Ever Consumers 40.9% Female 15-49 Microdata Null or - 0 higher/5 lower DHS, MICS 12 Ever Consumers 33.3% Female 15+ Ecological - WHO, OPHI, regression All Ever Consumers 7.1% Female 15+ Aggregation N/A WHO, OPHI All Ever Consumers 22.3% Percent of People Who Binge Consume Alcohol Male 15+ Ecological - WHO, OPHI, regression All Binge Consumers 11.6% Male 15+ Aggregation N/A WHO, OPHI All Binge Consumers 20.8% Female 15+ Ecological - WHO, OPHI, regression All Binge Consumers 2.0% Female 15+ Aggregation N/A WHO, OPHI All Binge Consumers 5.5% Per Capita Alcohol Consumption (liters of 100% alcohol per year) Male 15+ Ecological - WHO, OPHI, regression All Per Capita Consumption 8.3 liters/year Male 15+ Aggregation N/A WHO, OPHI All Per Capita Consumption 17.2 liters/year Female 15+ Ecological - WHO, OPHI, regression All Per Capita Consumption 2.1 liters/year Female 15+ Aggregation N/A WHO, OPHI All Per Capita Consumption 3.8 liters/year Biomass Fuel Use + DHS, MICS, PAPFAM, NIDS, Both All Ages Microdata IHDS, JSLC, ECV, CFPS, PNAD 98 Use coal, wood, for cooking 99.4% Raised SBP Male 20+ Ecological + NCD-RisC, OPHI, regression All Elevated SBP 28.6% Male 20+ Aggregation N/A NCD-RisC, OPHI All Elevated SBP 23.4% Female 20+ Ecological + NCD-RisC, OPHI, regression All Elevated SBP 30.3% Female 20+ Aggregation N/A NCD-RisC, OPHI All Elevated SBP 20.4%

Appendices Page 50 Within- Number of Countries with Country Significantly Higher/Lower Risk Age Type of Poverty Prevalence in Poorest Billion (if Number of Factor Sex Group Analysis Association Microdata) Sources Countries Definition Poorest Billion BMI Obesity Both Under-5 Microdata Null or - 1 higher/3 lower DHS, MICS 41 Weight for Height > 3SD 1.0% Male 15-49 Microdata Null or - 0 higher/8 lower DHS, MICS 9 BMI >= 30 0.2% Male 20+ Ecological - NCD-RisC, OPHI, regression All BMI >= 30 0.6% Male 20+ Aggregation N/A NCD-RisC, OPHI All BMI >= 30 7.8% Female 15-49 Microdata Null or - 0 higher/40 lower DHS, MICS 44 BMI >= 30 2.2% Female 20+ Ecological - NCD-RisC, OPHI, regression All BMI >= 30 3.1% Female 20+ Aggregation N/A NCD-RisC, OPHI All BMI >= 30 12.6% Overweight Male 20+ Ecological - NCD-RisC, OPHI, regression All BMI >= 25 7.8% Male 20+ Aggregation N/A NCD-RisC, OPHI All BMI >= 25 32.6% Female 20+ Ecological - NCD-RisC, OPHI, regression All BMI >= 25 16.7% Female 20+ Aggregation N/A NCD-RisC, OPHI All BMI >= 25 35.8% DHS = Demographic and Health Surveys; MICs = Multiple Indicator Cluster Surveys; IHME = Institute for Health Metrics and Evaluation; OPHI = Oxford Poverty and Human Development Initiative; PAPFAM = Pan Arab Project for Family Health (Syrian Arab Republic, Libya, Morocco), ; NIDS = National Income Dynamics Study; IDHS = India Human Development Survey; JSLC = Jamaica Survey of Living Conditions; ECV = Encuesta de Condiciones de Vida (Ecuador); CFPS = China Family Panel Studies; PNAD = Pesquisa Nacional por Amostra de Domicilios (Brazil); SBP = Systolic Blood Pressure; SD = Standard Deviation; BMI = Body Mass Index Table 11: Behavioral, metabolic, and environmental risk factor exposure for NCDIs among the Poorest Billion Types of analysis: Microdata refers to survey-based tabulation of exposure to risk factor among those living in households meeting our definition of extreme poverty. Ecological refers to cross-country regressions on age- and sex-specific exposures among countries with > 2% of the population in extreme poverty that are then used to make predictions for the poorest billion and non-poorest in the countries in which the poorest billion live, scaling to remain consistent with national-level estimates and aggregating across countries. Aggregation refers to taking the national-level exposures and applying them to the proportion of the population in each country living in the poorest billion, and aggregating across countries. Poverty association is the association observed (microdata) or assumed from cross-country associations (ecological regression) in generating the estimates. For the microdata estimates, the association can vary by country, so we have noted when some of the countries show no association (null) and when some do (+/-), along with the number of countries showing that association.

Appendices Page 51 Appendix 1.I. Risk-attributable disease burden

To quantify burden attributable to multiple risk factors, we used country-specific burden and attributable fractions from the Global Burden of Disease (GBD) Study 2017. We combined the population-attributable fractions (PAF) for a set of risks r1 to rn, incorporating the mediation factors (MF) between pairs of risks used in the GBD study, and following the methodology described in that study. 51

=1(1 ((1 /)))

We did not have sufficient data to estimate risk exposures for the poorest billion for each relevant risk factor and to then calculate population-attributable fractions specifically for the poorest billion in each country. Rather, to obtain coarse estimates of burden attributable to risk factors in the poorest billion, we used age-, sex-, cause-, and country-specific morbidity and mortality estimates, along with population-attributable fractions for specific risks. We applied the age- and sex-specific proportion of the population in the poorest billion to the risk- attributable and non-attributable years of life lost (YLLs) and years lived with disability (YLDs). While the burden rates and population-attributable fractions are likely different between the poorest billion and other populations within the same countries, we used these results to compare the burden in the poorest billion to that in high-income countries. The high-level conclusions we draw are similar whether comparing results in high-income countries to low-income countries or comparing high-income countries to our results for the poorest billion using this aggregation approach.

As described in the main text, we quantified the burden attributable to the risks represented by indicators in the NCD Global Monitoring Framework based on the 2013-2020 NCD Global Action Plan (alcohol consumption, physical inactivity, sodium consumption, tobacco use, raised blood pressure, diabetes, overweight and obesity, diets high in trans fats, high cholesterol, and diets low in fruits and vegetables). 52,53 We added air pollution to our quantification, as it was added in the political declaration of the Third United Nations High-level Meeting on NCDs in 2018. 54

Under the age of 40, less than 10% of the NCD DALYs were attributable to the risk factors we identified in the 25 indicators for the NCD Global Monitoring Framework and air pollution. This contrasted with 49% of the DALYs over age 40, including 87% for cardiovascular diseases. The total burden attributable to these risk factors was much greater over age 40 compared to under age 40, despite comparable burden from NCDIs overall. Much of that burden is from NCDs not included in the 4x4 strategy outlined by the NCD Global Action Plan, such as mental disorders (which have been added as part of the 5x5 framework), neurological disorders, digestive diseases, musculoskeletal disorders, sense organ conditions, congenital conditions, as well as from cancers not linked or less strongly linked to diet, smoking, physical activity, and alcohol.

Appendices Page 52

Figure 3: Proportion of DALYs attributable to the NCD Global Monitoring Framework risk factors and air pollution in the poorest billion, above and below age 40

Appendices Page 53

Figure 4: Rates of NCDs attributable to risk factors in the NCD Global Monitoring Framework and air pollution in the poorest billion, above and below age 40 While the Global Monitoring Framework includes limited indicators related to diet (sodium consumption, trans fat consumption, and fruit and vegetable consumption), the NCD Global Action Plan references “Dietary Risks” in general. We conducted a sensitivity analysis using all dietary risk factors from the Global Burden of Disease study, including diet low in whole grains, diet low in nuts and seeds, diet low in seafood omega-3 fatty acids, diet low in fiber, diet low in legumes, diet low in polyunsaturated fatty acids, diet low in calcium, and diet low in milk. Adding these dietary risks changed results minimally (additional 1% attribution for NCDs overall), largely because many of the effects as estimated within the Global Burden of Disease study are mediated through metabolic risks, such as body-mass index, hypertension, blood glucose, and cholesterol, which are also targeted.

In addition to quantifying the burden attributable to these risk factors addressed in the NCD Global Monitoring Framework, we also quantified the burden attributable to a set of behavioral risk factors, omitting metabolic risks: tobacco; alcohol use; drug use; overweight and obesity; lack of physical activity; diet high in sugar-sweetened beverages, sodium, red meat, processed meat, trans-fatty acids; and diet low in fruits and vegetables, whole grains, nuts, seeds, fiber, legumes, calcium, seafood omega-3 fatty acids, and polyunsaturated fats. This set accounted for

Appendices Page 54 a lower proportion of the NCD burden (25%) among the poorest billion than the NCD Global Monitoring Framework risks alone (31%). This is true in part because many of these “behavioral” risk factors are mediated by metabolic risks but do not wholly account for the changes in the metabolic risks.

Appendices Page 55 Appendix 1.J. Infectious Risks for NCDIs among the Poorest Billion

The burden of infectious diseases is much higher in low-income countries compared to in high-income countries. There are many infections that are associated with risk of developing particular NCDs. 55 Higher burden from and lower access to treatment in low- and middle- income countries may make infectious risks for NCDs particularly important in the poorest billion. To assess the potential burden of NCDs attributable to infectious causes, we conducted a narrative review of the literature to identify infections leading to NCD risk. We identified pairs of infections and NCDs and sought data necessary to quantify the NCD burden attributable to these infections. The full methodology is described elsewhere. 56

Some of the burden within the GBD is classified as a result of a particular infection (for example, liver cancer due to hepatitis B). We used attributable fractions (AFs) for several cancers attributable to infections such as Epstein-Barr virus, helicobacter pylori, , and human papilloma virus from a paper published by a group from the International Agency for Research on Cancer (IARC) and applied them to GBD burden estimates by country and relevant demographic groups. 57 For some other conditions, we calculated AFs using relative risks and exposure estimates from the literature and applied these AFs to the GBD burden estimates. We included long-term non-communicable sequelae of infectious diseases in our estimates, such as blindness from . While rates of NCD burden attributable to infection almost certainly differ between the poorest billion and non-poorest within countries, the data required to estimate the burden separately are very limited. After creating country-specific estimates of NCD burden attributable to infection, we found the burden in the poorest billion using the proportion of the population in the poorest billion by age, sex, and country. This quantification may serve as a minimal estimate of the NCD burden attributable to infectious diseases in the poorest billion, as there are other infectious etiologies of NCDs that we could not capture and a combination of living conditions and lower access to health care among the poorest billion might lead to higher exposures to infection than in the rest of the population.

Among the conditions for which we were able to create quantitative estimates, we found a substantial burden of NCDs attributable to infectious causes. As much as 10% of the total burden from NCDs in the poorest billion can be attributed to infection (Table 12). Cirrhosis due to hepatitis B and C, rheumatic heart disease from streptococcal infection, cervical cancer from human papilloma virus, and stomach cancer from H. pylori were large contributors to the burden. Some of the burden is from infectious conditions, such as fungal, viral, and bacterial skin diseases, classified as NCDs in the GBD. We included these types of diseases, as they are counted towards total NCD burden in the GBD and commonly quoted estimates of NCD burden globally.

Appendices Page 56 Non-communicable Disease or Long-term Infectious Cause Infection-attributable Total DALYs from NCDs Attributable Sequela DALYs (thousands) (thousands) Fraction (%) Bladder cancer Schistosomiasis 22 200 11.1 Cervical cancer HPV 1,212 1,212 100 Hodgkin lymphoma Epstein-Barr Virus 161 237 68.1 Kaposi sarcoma HIV/AIDS 378 378 100 Larynx cancer HPV 3 295 1.1 Lip and oral cavity cancer HPV 14 536 2.7 Liver cancer Hepatitis B 409 1,022 40 Liver cancer Hepatitis C 235 1,022 23 Nasopharynx cancer Epstein-Barr Virus 121 147 82.3 Non-Hodgkin lymphoma Hepatitis C 35 809 4.4 Oropharynx cancer HPV 28 336 8.2 Stomach cancer H. pylori 871 1,073 81.2 Colon and rectum cancer Human papilloma virus 17 970 1.8 Other malignant neoplasms (penile, vulvar, HPV 50 1,583 3.2 vaginal cancer) Non-alcoholic cardiomyopathy (Chagas) 0 631 0.1 Endocarditis Various 304 304 100 Ischemic heart disease HIV/AIDS 75 13,729 0.5 Ischemic stroke HIV/AIDS 8 3,647 0.2 Hemorrhagic stroke HIV/AIDS 98 6,676 1.5 Rheumatic heart disease Streptococcus 1,247 1,247 100 Chronic obstructive pulmonary disease 847 7,627 11.1 Cirrhosis and other chronic liver diseases Hepatitis B 1,515 4,634 32.7 Cirrhosis and other chronic liver diseases Hepatitis C 1,004 4,634 21.7 Gastritis and duodenitis H. pylori 740 981 75.4 Peptic ulcer disease H. pylori 486 920 52.8 Epilepsy (YLDs) Cystic echinococcosis, Cysticercosis, Encephalitis, Food- 619 1,958 31.6 borne trematodiases, H influenzae type B meningitis, , Meningococcal meningitis, Neonatal sepsis and other neonatal infections, Other meningitis, Pneumococcal meningitis, Tetanus, Zika virus

Appendices Page 57 Non-communicable Disease or Long-term Infectious Cause Infection-attributable Total DALYs from NCDs Attributable Sequela DALYs (thousands) (thousands) Fraction (%) Epilepsy (YLLs) Cystic echinococcosis, Cysticercosis, Encephalitis, Food- 251 1,362 18.4 borne trematodiases, H influenzae type B meningitis, Malaria, Meningococcal meningitis, Neonatal sepsis and other neonatal infections, Other meningitis, Pneumococcal meningitis, Tetanus, Zika virus Other neurological disorders (Guillain-Barre) Diarrheal diseases, Lower respiratory infections, Other 3 575 0.5 unspecified infectious diseases, Upper respiratory infections, Zika virus Other musculoskeletal disorders Leprosy 6 2,279 0.3 Developmental intellectual disability Encephalitis, H influenzae type B meningitis, Malaria, 508 1,113 45.7 Meningococcal meningitis, Neonatal sepsis and other neonatal infections, Other meningitis, Pneumococcal meningitis, Tetanus, Zika virus Acute glomerulonephritis Various 29 29 100 Chronic kidney disease Hepatitis B 313 3,863 8.1 Chronic kidney disease Hepatitis C 69 3,863 1.8 Acne vulgaris Propionibacterium acnes 206 206 100 Cellulitis Cellulitis 64 64 100 Fungal skin diseases Fungal skin diseases 634 634 100 Scabies Scabies 515 515 100

Viral skin diseases Viral skin diseases 582 582 100 Blindness and vision impairment Encephalitis, H influenzae type B meningitis, Malaria, 199 3,451 5.8 Meningococcal meningitis, Neonatal sepsis and other neonatal infections, , Other meningitis, Pneumococcal meningitis, Tetanus, Trachoma Hearing loss H influenzae type B meningitis, Meningococcal 314 3,161 9.9 meningitis, Other meningitis, Otitis media, Pneumococcal meningitis Congenital heart anomalies Rubella 159 5,368 3 Dental caries Various 162 162 100 Infertility Chlamydial infection, Gonococcal infection, Maternal 15 75 20.5 sepsis and other maternal infections, Other sexually transmitted infections

Appendices Page 58 Non-communicable Disease or Long-term Infectious Cause Infection-attributable Total DALYs from NCDs Attributable Sequela DALYs (thousands) (thousands) Fraction (%) Other gynecological diseases (PID) Chlamydial infection, Gonococcal infection, Other 18 127 14.1 sexually transmitted infections

Urinary tract infections Various 584 584 100 All NCDs* Infectious Risks Quantified 15,126 150,413 10.1 *All NCDs includes YLDs from long-term sequelae of infectious disease for which burden is included in the GBD study as infectious burden (infertility, pelvic inflammatory disease, hearing loss, blindness and vision impairment, developmental intellectual disability, Guillain-Barre syndrome, and epilepsy). This impairment burden from infectious causes is then added to the total NCD burden to be included in the denominator for the attributable fraction column.

Table 12: Infectious risks for NCDIs

Appendices Page 59 Appendix 1.K. Disease-specific Health Adjusted Age at Death (HAAD)

First, we assessed population severity using Health-Adjusted Life Expectancy (HALE). HALE incorporates both morbidity and mortality into a life expectancy calculation by discounting years lived by the age-group-specific rate of Years Lived with Disability (YLDs). The metric, originally developed by Sullivan, is reported as part of the Global Burden of Disease studies. HALE in the poorest billion was low (52.2 years) compared with LICs (55.7 years) and high- income countries (69.4 years). 17,58

In addition to calculating HALE, we calculated a metric called disease-specific health-adjusted age at death (HAAD) that captures the distribution of expected total healthy years of life lived among people with a given disease. The full methods are described in detail elsewhere. 59 60 In brief, HAAD is calculated in two components: prior healthy years lived and expected future healthy years lived. The first step is to take a population of individuals with a specific incident disease, using the age-specific incidence estimated from the Global Burden of Disease. The average population YLD rate (essentially an average disability weight per person) is used to calculate healthy years lived up to the age of onset of the disease, by age of onset, by adding YLD rates from age 0 to the age of onset. Then, standard lifetable methods are used to calculate future expected years of healthy life from the age of onset using with-disease mortality risk and YLD rates. HAAD is the sum of healthy life lived to the age of onset and the expected HALE at the age of onset, given the additional risk of the disease. For some diseases, the with-disease mortality risk and morbidity used in the lifetable returns to baseline population levels after a certain length of time if the disease is not a long-term chronic disease. The future expected years of healthy life are added to the years of healthy life lived before onset to obtain a distribution of HAAD among the people with these incident cases. We summarize this distribution using the average HAAD, though it can be used to examine inequalities in the distribution as well (for example, comparing the percent of people who attain fewer than 20 years of healthy life between one disease and another). In addition to showing average HAAD, we calculate the shortfall in this average HAAD from 75 years to present healthy life lost rather than healthy life attainment on an increasing scale.

To show the transition in years of lifetime health associated with particular diseases in different settings, we accounted for differences in the background mortality risk and rates of morbidity between the poorest billion and high-income populations by using high-income background morbidity and mortality to calculate HAAD for both populations (see Figure 5). This isolated the effects of the morbidity and mortality from the disease, as well as the age of onset. Consistent with the concept of the “worse off” in terms of lifetime health, we were not quantifying the years of life taken away by the disease, but rather, we were quantifying the lifetime health that people with a given condition in the population would expect to have. 61

Appendices Page 60

Figure 5: The Average Health Loss Transition for NCDIs: Poorest Billion to High Income Populations

Appendices Page 61 Appendix 2.A. Equity Scoring

The WHO Consultative Group on Equity and Universal Health Coverage met between 2013 and 2014 to deliberate regarding what advice to give governments on making fair choices on the path to Universal Health Coverage.61 The Consultative Group found that three health-sector priority- setting principles are widely accepted in their general form.

(1) Cost-effectiveness has been the dominant concern in global health policy over the past 40 years. The Commission on Macroeconomics and Health established that most societies value a healthy year of life at around 3 times their per capita GDP. 62 Those interventions costing less than this amount were defined as cost-effective, and those interventions costing less than the per capita GDP were defined as highly cost-effective. Most effective interventions that have been evaluated in LMICs (apart from those requiring expensive patented medications) meet this standard. Recent estimates have suggested that the average cost-effectiveness of current health investments in LMICs is much better than previously appreciated: probably less than 50% of per capita GDP in these countries.63,64

(2) Equity, in the sense of priority to the worse off, can imply several different concerns.65-69 One of these concerns is priority to those who have been disadvantaged in ways other than their health, such as material poverty.70 Another concern is priority to those have had least health over their lifetime.67,71 A third concern is priority for those suffering from the most severe conditions at a particular point in time.72,73

(3) Financial risk protection is a concern in priority setting because health problems can be impoverishing. Public finance of health interventions aims to protect households from impoverishment particularly due to expensive treatments.74 As a reflection of this concern, benefits packages in many countries tend to emphasize inpatient care. On the other hand, expensive treatments may be simply out of reach for the poorest households.

Early on, this Commission identified two of the WHO criteria for priority setting as especially relevant: cost-effectiveness and equity. To assess equity, defined as priority to the worse off, the Commission developed a composite equity score through a modified Delphi process. Although the Commission did not achieve consensus, strong majorities of Commissioners thought it was important to consider: (1) priority to the poorest (100%); (2) priority to those conditions causing the most lifetime loss of health (92%); (3) priority to the interventions addressing the most severe conditions independent of age (67%); and (4) some priority to conditions that only affect women (92%). The Commission also emphasized that assessment of equity requires value judgements and should be conducted on a local basis as part of a multicriteria decision process that also includes cost-effectiveness and financial risk protection. We graded interventions on a scale of 1 to 4 (4 being the highest in terms of equity) for each of the first three equity dimensions we have described. Our composite equity index (also on a 1 to 4 scale) assigned to each interventions the highest value allotted for any of the first three equity dimensions, with an additional point for conditions uniquely affecting women, as illustrated in Table 13.

Appendices Page 62

Priority to Priority to Priority to conditions Priority to least severely uniquely Composite the lifetime disabling affecting equity Intervention poorest health conditions women score Treatment of type 1 diabetes 4 4 NA - 4 Screening for diabetes in 1 1 2 1 3 Management of diabetes in pregnancy 1 1 2 1 3 Treatment of Diabetic Ketoacidosis NA 4 4 - 4 Screening for diabetes among at-risk 1 1 2 - 2 adults Care and treatment of diabetes among adults, including management of blood 1 1 2 - 2 pressure and lipids, and consistent foot care Table 13: Examples of equity scoring To quantify priority to the poor, for each intervention, we calculated the percent difference between the associated cause-specific, age-standardized DALY rates for our modelled poorest billion population with the associated rate in high-income countries. We gave interventions addressing conditions with a DALY rate difference of 90% and higher a “4,” those with a rate difference between 90% and 80% a “3,” those with a rate difference between 80% and 50% a “2”, and those with a less than 50% difference in DALY rates a “1.”

To address concerns for those with the least lifetime health, we calculated a disease-specific, health-adjusted age at death (HAAD) for each of the causes for which data is available in the Global Burden of Disease Study. 59 Those interventions addressing a condition with an associated HAAD of less than 30 years were given a “4.” Those with an associated HAAD of 30- 40 years were given a “3;” those with an HAAD between 40 and 60, a “2,” and those with HAADs of greater than 60, a “1.” For those definitely therapeutic interventions (i.e. secondary or tertiary prevention) that were targeting exclusively children and young adults, we manually assigned an HAAD score.

To reflect concern for those with severely disabling conditions at any stage of life, we calculated the implied average disability weight (DW) for all the conditions associated with each intervention based on the ratio between the Years-of-Life with Disability (YLDs) and prevalence of the condition in LICs. For those interventions addressing a more specific health state, we assigned the relevant disability weight.75-77 For interventions for which the sequelae were specified, we used the associated disability weight from GBD. We assigned a score of “4” to those interventions that addressed a condition with a DW of greater than 0.3, a “3” to those addressing conditions with a disability weight between 0.3 and 0.1, a “2” for a DW between 0.1 and 0.05, and a “1” to those with a DW of less than 0.05.

Appendices Page 63 Appendix 2.B. Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by cause group

*CE = Cost-Effectiveness; “4” = less than $250 per DALY at market exchange rates; “3” = between $250 and $1300 per DALY; “2” = between $1301 and $4100 per DALY; “1” = less than $4100 per DALY; Equity scoring and methodology are detailed in Appendix 2.A: “4” = very high equity; “3” = high equity; “2” = moderate equity; “1” = low equity.

NA = Not Applicable; ND = No Data; † = not included in DCP3 essential UHC package

Non-communicable diseases

No. Cardiovascular diseases Equity CE*

Management of acute coronary syndromes with aspirin, unfractionated 1 heparin, and generic thrombolytics (when indicated) 4 2

2 Provision of aspirin for all cases of suspected acute 4 4

Management of atrial fibrillation patients at high risk of stroke requiring 3 warfarin 2 ND

4 Medical management of acute, decompensated, heart failure 4 4

Medical management of heart failure with diuretics, beta-blockers, ACEi, 5 and mineralocorticoid antagonists 4 4

Acute management of stroke with aspirin and blood pressure medications, 6 aspiration precautions 3 ND

Management of acute critical limb ischemia with amputation as a last 7 resort 4 3

8 Management of acute critical limb ischemia with unfractionated heparin 4 2

9 Management of post-valve replacement patients requiring warfarin 4 ND

10 Management of severe hypertension 2 ND

11 Management of venous thromboembolism requiring warfarin 2 ND

Long term management of ischemic heart disease, stroke, and peripheral vascular disease with aspirin, beta blockers, ACEi, and statins (as indicated) 12 to reduce risk of further events 2 3

Appendices Page 64 Long-term combination therapy for persons with multiple CVD risk factors, including screening for CVD in community settings using non-lab-based 13 tools to assess overall CVD risk 2 2

Opportunistic screening for hypertension for all adults and initiation of treatment 14 among individuals with severe hypertension and/or multiple risk factors 2 ND

Secondary prophylaxis with penicillin for rheumatic fever or established 15 rheumatic heart disease 4 4

16 Treatment of acute pharyngitis in children to prevent rheumatic fever 4 4

Initiation of treatment among individuals with severe hypertension and/or 17 multiple risk factors 2 4

Use of percutaneous coronary intervention for acute myocardial infarction 18 where resources permit 4 3

Management of acute critical limb ischemia with revascularization where 19 available 4 2

20 Balloon Mitral Valvuloplasty for Rheumatic Mitral Stenosis 4 ND

21 Cardiac surgery for children and young adults with rheumatic heart disease 4 ND

No. Chronic respiratory diseases Equity CE*

Exercise-based pulmonary rehabilitation for patients with obstructive lung 22 disease 2 ND

Inhaled corticosteroids and bronchodilators for severe, persistent asthma 23 and for selected patients with COPD 4 ND

Management of acute exacerbations of asthma using systemic steroids, ND 24 inhaled beta-agonists, and , if indicated, oxygen therapy 4

Management of acute ventilatory failure due to acute exacerbations of 25 asthma 4 ND

Management of acute exacerbations of COPD using systemic steroids, inhaled beta-agonists, and, if indicated, oral antibiotics and oxygen ND 26 therapy 4

Management of acute ventilatory failure due to acute exacerbations of 27 COPD 4 ND

Appendices Page 65 28 Low-dose inhaled corticosteroids and bronchodilators for asthma 2 2

Low-dose inhaled corticosteroids and bronchodilators for selected patients 29 with COPD 2 2

Annual flu vaccination and pneumococcal vaccine every five years for 30 individuals with underlying lung disease 2 ND

No. Cirrhosis and other chronic liver diseases Equity CE*

31 Childhood vaccination series (hepatitis B) 3 4

As resources permit, hepatitis B vaccination of high-risk populations, 32 including healthcare workers, IDU, MSM, household contacts, and persons 3 ND with multiple sex partners

Hepatitis B testing of individuals identified in the national testing policy 33 (i.e., based on endemicity and risk level), with appropriate referral of 3 1 positive individuals to trained providers

Hepatitis C testing of individuals identified in the national testing policy 34 (i.e., based on endemicity and risk level), with appropriate referral of 2 ND positive individuals to trained providers

No. Diabetes, urogenital, blood, and endocrine diseases Equity CE*

35 Peritoneal Dialysis for Acute Kidney Injury in Children and Young Adults† 4 ND

In settings where sickle cell disease is a public health concern, universal 36 4 4 newborn screening

In settings where specific single-gene disorders are a public health concern 37 (e.g., thalassemias), retrospective identification of carriers plus prospective 4 ND (premarital) screening and counseling to reduce rates of conception

38 Treatment of Diabetic Ketoacidosis† 4 ND

39 Management of Type 1 Diabetes† 4 4

40 Relief of urinary obstruction by catheterization or suprapubic cystostomy 4 4

Screening and management of albuminuric kidney disease with ACEi or 41 1 2 ARBs, including targeted screening among people with diabetes

Appendices Page 66 Care and treatment of diabetes among adults, including management of 42 2 4 blood pressure and lipids, and consistent foot care

Management of diabetes in pregnancy (gestational diabetes or preexisting 43 3 ND type 2 diabetes)

44 Screening for diabetes among at-risk adults 2 4

Screening for diabetes in pregnancy (gestational diabetes or preexisting 45 3 1 type 2 diabetes)

Prophylaxis against bacterial infections and malaria for those with sickle 46 4 4 cell disease

47 Kidney Biopsy† 2 ND

48 Renal transplantation for children and young adults† 4 ND

No. Digestive diseases Equity CE*

49 Appendectomy 4 4

50 Removal of gallbladder, including emergency surgery 4 4

51 Hernia repair, including emergency surgery 4 4

52 Colostomy 4 4

53 Management of bowel obstruction 4 4

Repair of perforations (e.g., perforated peptic ulcer, typhoid ileal 54 4 4 perforation)

For individuals testing positive for hepatitis B, assessment of treatment 55 eligibility by trained providers followed by initiation and monitoring of 3 1 antiviral treatment when indicated

For individuals testing positive for hepatitis C, assessment of treatment 56 eligibility by trained providers followed by initiation and monitoring of 2 ND antiviral treatment when indicated

Diagnosis and management of peptic ulcer disease - H. pylori testing and 57 3 ND treatment†

Appendices Page 67 Endoscopy to treat upper gastrointestinal bleeding due to esophageal 58 4 ND varices from schistosomiasis†

Endoscopy to treat upper gastrointestinal bleeding due to peptic 59 4 ND ulceration†

No. Mental and substance use disorders Equity CE*

Adherence support for high-risk individuals with chronic mental health 4 ND 60 conditions†

61 Life skills training in schools to build social and emotional competencies NA NA

Management of bipolar disorder using generic mood-stabilizing 3 2 62 medications and psychosocial treatment

Inpatient treatment of severe depression with suicidality with first 4 ND 63 generation antidepressants†

Inpatient treatment of acute psychosis with first generation antipsychotic 4 ND 64 medications†

Management of schizophrenia using generic anti-psychotic medications 4 2 65 and psychosocial treatment

66 Screening and brief intervention for alcohol use disorders 2 3

Psychological treatment for mood, anxiety, ADHD and disruptive behavior 2 ND 67 disorders in adolescents

68 Interventions to support caregivers of patients with dementia 3 ND

Management of depression and anxiety disorders with psychological and 3 3 69 generic antidepressant therapy

Provision of harm reduction services such as safe injection equipment and 4 4 70 opioid substitution therapy to people who inject drugs

71 Electroconvulsive therapy for severe or refractory depression† 4 ND

No. Musculoskeletal disorders Equity CE*

Management of osteomyelitis, including surgical debridement for 4 3 72 refractory cases

Appendices Page 68 73 Management of septic arthritis 2 3

Combination therapy, including low-dose corticosteroids and generic disease-modifying antirheumatic drugs (including methotrexate), for 4 4 74 individuals with moderate to severe rheumatoid arthritis

Basic management of musculoskeletal and neurological injuries and 3 ND 75 disorders, such as simple exercises prescription and sling/cast provision

No. Neoplasms Equity CE*

School based HPV vaccination for girls (In countries where cervical cancer 4 3 76 is a public health priority)

Adherence support for high-risk individuals with chronic NCD conditions (history of malignant hypertension, heart failure, needing anticoagulation, 4 ND 77 type 1 diabetes, malignancies)†

Early detection of breast cancer with ultrasound and breast biopsy in women presenting with breast complaints to health centers and first-level 4 ND 78 hospitals†

79 Management of stable breast cancer requiring tamoxifen† 4 ND

80 Biopsy and referral of stage 1 and 2 cervical cancer† 4 ND

81 Early detection and treatment of early-stage cervical cancer 4 3

Opportunistic screening for cervical cancer using visual inspection or HPV 3 3 82 DNA testing and treatment of precancerous lesions with cryotherapy

83 Management of CML requiring imatinib therapy† 3 ND

Expanded palliative care and pain control measures, including prevention 4 NA 84 and relief of all physical and psychological symptoms of suffering

Surgical Treatment of early stage breast cancer with curative intent, for cases that are detected by clinical examination at health centers and first- 4 4 85 level hospitals

Treatment of early stage breast cancer with generic chemotherapy, with curative intent, for cases that are detected by clinical examination at 4 4 86 health centers and first-level hospitals

Appendices Page 69 Treatment of early-stage childhood cancers (e.g., Burkitt and Hodgkin lymphoma, acute lymphoblastic leukemia) with curative intent in pediatric 4 2 87 cancer units or hospitals

88 Radical hysterectomy for Stage I and II cervical cancer† 4 ND

Surgical Treatment of early stage colorectal cancer for cases that are 3 3 89 detected by clinical examination at health centers and first-level hospitals

Treatment of early stage colorectal cancer with generic chemotherapy, with curative intent, for cases that are detected by clinical examination at 3 3 90 health centers and first-level hospitals

91 Surgical management of early stage head and neck cancer† 3 ND

92 Curative treatment of Hodgkin’s lymphoma in adults† 3 ND

93 Curative treatment of non-Hodgkin’s lymphoma in adults† 3 ND

Treatment of early-stage childhood cancers (Wilm's tumor and 4 2 94 retinoblastoma) with curative intent in pediatric cancer units or hospitals

No. Neurological disorders Equity CE*

95 Self-managed treatment of migraine† 4 ND

Training and retraining for disorders of speech, swallowing, 1 ND 96 communication, and cognition

97 Management of prolonged seizures or status epilepticus 4 ND

Management of epilepsy using generic anti-epileptic medications and 4 4 98 psychosocial treatment

99 Ventilatory support for Guillaine-Barré syndrome† 4 ND

No. Other non-communicable diseases Equity CE*

100 Childhood vaccination series (rubella) 3 4

101 Education of schoolchildren on oral health 2 ND

102 Vision prescreening by teachers 2 3

103 Universal newborn screening for congenital endocrine or metabolic 4 2 disorders (e.g., congenital hypothyroidism, phenylketonuria) that have

Appendices Page 70 high incidence rates and for which long-term treatment is feasible in limited resource settings

Assessment, provision and training in the use of assistive products, 3 1 104 including assistive devices for hearing

Retinopathy screening via telemedicine, followed by treatment using laser 2 3 105 photocoagulation

106 Management of severe psoriasis† 4 ND

107 Vision tests and provision of ready-made glasses on-site by eye specialists 2 3

Targeted screening for congenital hearing loss in high-risk children using 3 1 108 otoacoustic emissions testing

109 Treatment of caries 1 ND

110 Dental extraction 1 ND

111 Drainage of dental abscess 1 ND

Provide and folic acid supplementation to pregnant women, as well as food/caloric supplementation to pregnant women in food insecure 4 3 112 households

113 Drainage of superficial abscess 2 4

114 Cataract extraction and insertion of intraocular lens 3 4

115 Repair of cleft lip and cleft palate 3 4

116 Repair of club foot 3 4

Treatment of congenital hearing loss with deaf education and cochlear 3 ND 117 implantation

Cardiac surgery for children and young adults with correctable congenital 4 ND 118 heart disease†

Percutaneous Interventions for congenital heart disease in children and young adults (e.g. closure of patent ductus arteriosis, valvuloplasty for 4 ND 119 pulmonic stenosis)†

Appendices Page 71 Treatment of congenital endocrine or metabolic disorders (e.g., congenital hypothyroidism, phenylketonuria) that have high incidence rates and for 4 3 120 which management is feasible in limited resource settings

121 Treatment of diabetic retinopathy using laser photocoagulation 2 3

122 Surgical correction of gastroschisis† 4 ND

123 Repair of anorectal malformations and Hirschsprung's Disease 4 ND

124 Shunt for hydrocephalus 4 4

125 Surgery for trachomatous trichiasis 3 4

Injuries

No. Injuries Equity CE*

Pressure area prevention, and supportive seating interventions for 2 ND 126 wheelchair users

127 Mobilization activities following acute injury or illness 2 ND

128 Ventilatory Support for Head Trauma† 4 ND

In countries where it is a public health concern, prevention of FGM (may 4 ND 129 be for daughters of women of reproductive age)

130 Education campaigns for the prevention of gender-based violence 2 2

Parent training, including nurse home visitation for child maltreatment, for 1 1 131 high-risk families

Post gender-based violence care including, counseling, provision of emergency contraception, and rape-response referral (medical and 4 2 132 judicial)

133 Management of complications following FGM 2 ND

134 Burr hole to relieve acute elevated intracranial pressure 4 ND

Early identification of and counseling of families in 3 ND 135 remediation strategies for sources of environmental exposure

Appendices Page 72 136 Safer storage of pesticides in the community and farming households 3 ND

137 Basic skin grafting 3 4

138 Escharotomy/fasciotomy 3 ND

Management of intoxication/poisoning syndromes using widely available agents, e.g. activated charcoal, bicarbonate, atropine, calcium gluconate, 4 ND 139 benzodiazapines, naloxone

140 Antivenom for poisonous snake bite† 4 ND

Calcium and D supplementation for primary prevention of 1 ND 141 osteoporosis in high-risk individuals

Calcium and vitamin D supplementation for secondary prevention of 1 ND 142 osteoporosis

Basic outpatient rehabilitation services (priority to longitudinal care for 2 ND 143 individuals post injury)

144 Individualized environmental modifications (e.g., adaptations to a house) 2 ND

Provision and training in the use of basic assistive products (e.g., canes, braille displays, and other aides) and compensatory strategies needed to 2 ND 145 communicate and perform activities of daily living

Training, retraining, and exercise programs for musculoskeletal and 2 4 146 neurological injuries and disorders

Compression therapy for amputations, burns, and vascular or lymphatic 2 ND 147 disorders

Fabrication, fitting, and training in the use of prosthetics, orthotics, and 2 ND 148 splints

149 Management of non-displaced fractures 2 3

150 Fracture reduction 4 4

151 Irrigation and debridement of open fractures 4 4

152 Placement of external fixator and use of traction for fractures 4 4

Appendices Page 73 153 Tube thoracostomy 4 4

Resuscitation with advanced life support measures, including surgical 4 NA 154 airway

155 Resuscitation with basic life support measures 4 NA

156 Trauma laparotomy 4 4

157 Trauma-related amputations 4 4

158 Exercise programs for upper extremity injuries and disorders 2 ND

Review of prosthetics, orthotics, and splints, with referral to hospital if 2 ND 159 indicated

160 Suturing laceration 2 4

Elective surgical repair of common orthopedic injuries (e.g., meniscal and 3 ND 161 ligamentous tears) in individuals with severe functional limitation

Urgent, definitive surgical management of orthopedic injuries (e.g., by 3 3 162 open reduction and internal fixation)

163 Post-operative ventilatory support† 4 NA

No specific cause

No. Rehabilitation, Palliative Care, & Diagnostic Services Equity CE*

164 Early childhood development rehabilitation interventions, including NA NA motor, sensory, and language stimulation Initial assessment, and prescription, and provision of individualized interventions for musculoskeletal, cardiopulmonary, neurological, speech NA 3 and communication, and cognitive deficits, including training in 165 preparation for discharge

166 Functional interventions for self-care for individuals with disabilities NA 4

167 Management of pain and palliative care in the community 4 NA

Management of advanced malignancies and other end-stage NCDs with 4 NA 168 pain and palliative care

Appendices Page 74 Relief of refractory suffering and of acute pain related to serious, complex or life-limiting health problems including cirrhosis, advanced malignancies, 4 NA 169 advanced heart failure, and advanced chronic kidney disease

Essential palliative care and pain control measures, including oral 4 NA 170 immediate release morphine and medicines for associated symptoms

Psychosocial support and counseling services for individuals with serious, 4 NA 171 complex, or life-limiting health problems and their caregivers

172 End of life counselling and pain management 4 NA

173 Vital registration with verbal autopsy NA NA

174 First-level hospital pathology services NA NA

175 First-level hospital radiology services NA NA

176 Health center pathology services NA NA

177 Referral-level hospital pathology services NA NA

178 Specialty radiology services NA NA

No Specific Cause

No. No Specific Cause Equity CE*

179 School-based education on healthy lifestyles NA 2

180 School-based education on sexual health and nutrition NA 2

181 Cardiac and pulmonary rehabilitation programs 2 ND

182 Evaluation and acute management of swallowing dysfunction 2 ND

Tobacco cessation counseling, and use of nicotine replacement therapy in 2 3 183 certain circumstances

Table 14: Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by cause group

Appendices Page 75 Appendix 2.C. Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by health system platform and integrated care team (ICT)

Referral and Specialty Hospital ICTs

No. Gynecologic Surgical Team at Referral Hospital Equity CE*

88 Radical hysterectomy for Stage I and II cervical cancer 4 ND

No. Orthopedic Surgical Team at Referral Hospital Equity CE*

116 Repair of club foot 3 4

Elective surgical repair of common orthopedic injuries (e.g., meniscal and ligamentous tears) in individuals with severe functional 161 limitation 3 ND

Urgent, definitive surgical management of orthopedic injuries (e.g., 162 by open reduction and internal fixation) 3 3

No. Cardiothoracic Surgical Team at Referral Hospital Equity CE*

Cardiac surgery for children and young adults with rheumatic heart 4 ND 21 disease

Cardiac surgery for children and young adults with correctable 4 ND 118 congenital heart disease

No. Specialized Surgical Team at Referral Hospital Equity CE*

47 Kidney Biopsy 2 ND

48 Renal transplantation for children and young adults 4 ND

Surgical Treatment of early stage breast cancer with curative intent, for cases that are detected by clinical examination at health centers 85 and first-level hospitals 4 4

Appendices Page 76 Surgical Treatment of early stage colorectal cancer for cases that are detected by clinical examination at health centers and first-level 89 hospitals 3 3

91 Surgical management of early stage head and neck cancer 3 ND

Treatment of early-stage childhood cancers (Wilm's tumor and retinoblastoma) with curative intent in pediatric cancer units or 94 hospitals 4 2

115 Repair of cleft lip and cleft palate 3 4

Treatment of congenital hearing loss with deaf education and 117 cochlear implantation 3 ND

122 Surgical correction of gastroschisis 4 ND

123 Repair of anorectal malformations and Hirschsprung's Disease 4 ND

124 Shunt for hydrocephalus 4 4

No. Internal Medicine Inpatient Team at Referral Hospital Equity CE*

Endoscopy to treat upper gastrointestinal bleeding due to 58 esophageal varices from schistosomiasis 4 ND

Endoscopy to treat upper gastrointestinal bleeding due to peptic 59 ulceration 4 ND

71 Electroconvulsive therapy for severe or refractory depression 4 ND

Treatment of early stage breast cancer with generic chemotherapy, with curative intent, for cases that are detected by clinical 86 examination at health centers and first-level hospitals 4 4

Treatment of early stage colorectal cancer with generic chemotherapy, with curative intent, for cases that are detected by 90 clinical examination at health centers and first-level hospitals 3 3

92 Curative treatment of hodgkin's lymphoma in adults 3 ND

93 Curative treatment of non-hodgkin's lymphoma in adults 3 ND

No. Pediatric Inpatient Care Team at Referral Hospital Equity CE*

Appendices Page 77 Treatment of early-stage childhood cancers (e.g., Burkitt and Hodgkin lymphoma, acute lymphoblastic leukemia) with curative intent in 87 pediatric cancer units or hospitals 4 2

Treatment of congenital endocrine or metabolic disorders (e.g., congenital hypothyroidism, phenylketonuria) that have high incidence rates and for which management is feasible in limited 120 resource settings 4 3

No. Critical and Palliative Care Team at Referral Hospital Equity CE*

99 Ventilatory support for Guillane Barre syndrome 4 NA

128 Ventilatory Support for Head Trauma 4 NA

163 Post-operative ventilatory support 4 ND

172 End of life counselling and pain management 4 ND

No. Interventional Cardiology Team at Referral Hospital Equity CE*

Use of percutaneous coronary intervention for acute myocardial 18 infarction where resources permit 4 3

Management of acute critical limb ischemia with revascularization 19 where available 4 2

20 Balloon Mitral Valvuloplasty for Rheumatic Mitral Stenosis 4 ND

Percutaneous Interventions for congenital heart disease in children and young adults (e.g. closure of patent ductus arteriosis, 119 valvuloplasty for pulmonic stenosis) 4 ND

No. Ophthalmic Outpatient Care Unit at Referral Hospital Equity CE*

114 Cataract extraction and insertion of intraocular lens 3 4

121 Treatment of diabetic retinopathy using laser photocoagulation 2 3

125 Surgery for trachomatous trichiasis 3 4

No. Pathology Service Team at Referral Hospital Equity CE*

177 Referral-level hospital pathology services NA NA

No. Radiology Service Team at Referral Hospital Equity CE*

Appendices Page 78 178 Specialty radiology services NA NA

First-level Hospital Outpatient ICTs

No. Ophthalmic Outpatient Care Team at First-level Hospital Equity CE*

Retinopathy screening via telemedicine, followed by treatment using laser 105 photocoagulation 2 3

107 Vision tests and provision of ready-made glasses on-site by eye specialists 2 3

No. Severe Mental Health Outpatient Team at First-level Hospital Equity CE*

Management of bipolar disorder using generic mood-stabilizing 62 medications and psychosocial treatment 3 2

Management of schizophrenia using generic anti-psychotic medications 65 and psychosocial treatment 4 2

No. Severe NCD Outpatient Team at First-level Hospital Equity CE*

Management of atrial fibrillation patients at high risk of stroke requiring 3 warfarin 2 ND

Medical management of heart failure with diuretics, beta-blockers, ACEi, 5 and mineralocorticoid antagonists 4 4

9 Management of post-valve replacement patients requiring warfarin 4 ND

10 Management of severe hypertension 2 ND

11 Management of venous thromboembolism requiring warfarin 2 ND

Inhaled corticosteroids and bronchodilators for severe, persistent asthma 23 and for selected patients with COPD 4 ND

In settings where specific single-gene disorders are a public health concern (e.g., thalassemias), retrospective identification of carriers plus prospective 37 (premarital) screening and counseling to reduce rates of conception 4 ND

39 Management of Type 1 Diabetes 4 4

Appendices Page 79 For individuals testing positive for hepatitis C, assessment of treatment eligibility by trained providers followed by initiation and monitoring of ND 56 antiviral treatment when indicated 2

Combination therapy, including low-dose corticosteroids and generic disease-modifying antirheumatic drugs (including methotrexate), for 74 individuals with moderate to severe rheumatoid arthritis 4 4

79 Management of stable breast cancer requiring tamoxifen 4 ND

83 Management of CML requiring imatinib therapy 3 ND

106 Management of severe psoriasis 4 ND

Management of advanced malignancies and other end-stage NCDs with 168 pain and palliative care 4 NA

No. Women's Health Outpatient Team at First-level Hospital Equity CE*

Early detection of breast cancer with ultrasound and breast biopsy in women presenting with breast complaints to health centers and first-level 78 hospitals 4 ND

80 Biopsy and referral of stage 1 and 2 cervical cancer 4 ND

81 Early detection and treatment of early-stage cervical cancer 4 3

Opportunistic screening for cervical cancer using visual inspection or HPV 82 DNA testing and treatment of precancerous lesions with cryotherapy 3 3

First-level Hospital Inpatient ICTs

No. Adult Inpatient Care Team at First-level Hospital Equity CE*

Management of acute exacerbations of asthma using systemic steroids, 4 ND 24 inhaled beta-agonists, and , if indicated, oxygen therapy

Management of acute exacerbations of COPD using systemic steroids, inhaled beta-agonists, and, if indicated, oral antibiotics and oxygen 4 ND 26 therapy

Inpatient treatment of severe depression with suicidality with first 4 ND 63 generation antidepressants

Appendices Page 80 Inpatient treatment of acute pysychosis with first generation antipsychotic 4 ND 64 medications

Relief of refractory suffering and of acute pain related to serious, complex or life-limiting health problems including cirrhosis, advanced malignancies, 4 NA 169 advanced heart failure, and advanced chronic kidney disease

No. Emergency/High Dependency Team at First-level Hospital Equity CE*

Management of acute coronary syndromes with aspirin, unfractionated 1 heparin, and generic thrombolytics (when indicated) 4 2

2 Provision of aspirin for all cases of suspected acute myocardial infarction 4 4

4 Medical management of acute, decompensated, heart failure 4 4

Acute management of stroke with aspirin and blood pressure medications, 6 aspiration precautions 3 ND

8 Management of acute critical limb ischemia with unfractionated heparin 4 2

Management of acute ventilatory failure due to acute exacerbations of 25 asthma 4 ND

Management of acute ventilatory failure due to acute exacerbations of 27 COPD 4 ND

35 Peritoneal Dialysis for Acute Kidney Injury in Children and Young Adults 4 ND

38 Treatment of Diabetic Ketoacidosis 4 ND

97 Management of prolonged seizures or status epilepticus 4 ND

Management of intoxication/poisoning syndromes using widely available agents, e.g. activated charcoal, bicarbonate, atropine, calcium gluconate, 139 benzodiazapines, naloxone 4 ND

140 Antivenom for poisonous snake bite 4 ND

149 Management of non-displaced fractures 2 3

Resuscitation with advanced life support measures, including surgical 154 airway 4 NA

155 Resuscitation with basic life support measures 4 NA

Appendices Page 81 No. General Surgical Team at First-level Hospital Equity CE*

Management of acute critical limb ischemia with amputation as a last 7 resort 4 3

40 Relief of urinary obstruction by catheterization or suprapubic cystostomy 4 4

49 Appendectomy 4 4

50 Removal of gallbladder, including emergency surgery 4 4

51 Hernia repair, including emergency surgery 4 4

52 Colostomy 4 4

53 Management of bowel obstruction 4 4

Repair of perforations (e.g., perforated peptic ulcer, typhoid ileal 54 perforation) 4 4

Management of osteomyelitis, including surgical debridement for 72 refractory cases 4 3

73 Management of septic arthritis 2 3

134 Burr hole to relieve acute elevated intracranial pressure 4 ND

137 Basic skin grafting 3 4

138 Escharotomy/fasciotomy 3 ND

150 Fracture reduction 4 4

151 Irrigation and debridement of open fractures 4 4

152 Placement of external fixator and use of traction for fractures 4 4

153 Tube thoracostomy 4 4

156 Trauma laparotomy 4 4

157 Trauma-related amputations 4 4

No. Newborn Screening Team at First-level Hospital Equity CE*

Appendices Page 82 In settings where sickle cell disease is a public health concern, universal 4 4 36 newborn screening

Universal newborn screening for congenital endocrine or metabolic disorders (e.g., congenital hypothyroidism, phenylketonuria) that have 4 2 high incidence rates and for which long-term treatment is feasible in 103 limited resource settings

No. Laboratory Service Team at First-level Hospital Equity CE*

174 First-level hospital pathology services NA NA

No. Radiology Service Team at First-level Hospital Equity CE*

175 First-level hospital radiology services NA #NA

No. Rehabilitation Service Team at First-level Hospital Equity CE*

Assessment, provision and training in the use of assistive products, 104 including assistive devices for hearing 3 1

127 Mobilization activities following acute injury or illness 2 ND

Compression therapy for amputations, burns, and vascular or lymphatic 147 disorders 2 ND

Fabrication, fitting, and training in the use of prosthetics, orthotics, and 148 splints 2 ND

Initial assessment, and prescription, and provision of individualized interventions for musculoskeletal, cardiopulmonary, neurological, speech and communication, and cognitive deficits, including training in 165 preparation for discharge NA 3

166 Functional interventions for self-care for individuals with disabilities NA 4

182 Evaluation and acute management of swallowing dysfunction 2 ND

Health Center ICTs

No. Acute/Women's Care Team at Health Center Equity CE*

Appendices Page 83 Opportunistic screening for hypertension for all adults and initiation of treatment among individuals with severe hypertension and/or multiple 14 risk factors 2 ND

16 Treatment of acute pharyngitis in children to prevent rheumatic fever 4 4

As resources permit, hepatitis B vaccination of high-risk populations, including healthcare workers, IDU, MSM, household contacts, and persons 32 with multiple sex partners 3 ND

Screening for diabetes in pregnancy (gestational diabetes or preexisting 45 type 2 diabetes) 3 1

Diagnosis and management of peptic ulcer disease - H.pylori testing and 57 treatment. 3 ND

66 Screening and brief intervention for alcohol use disorders 2 3

Targeted screening for congenital hearing loss in high-risk children using 108 otoacoustic emissions testing 3 1

Provide iron and folic acid supplementation to pregnant women, as well as food/caloric supplementation to pregnant women in food insecure 112 households 4 3

113 Drainage of superficial abscess 2 4

Post gender-based violence care including, counseling, provision of emergency contraception, and rape-response referral (medical and 132 judicial) 4 2

133 Management of complications following FGM 2 ND

160 Suturing laceration 2 4

No. Chronic Care Team at Health Center Equity CE*

Long term management of ischemic heart disease, stroke, and peripheral vascular disease with aspirin, beta blockers, ACEi, and statins (as indicated) 12 to reduce risk of further events 2 3

Long-term combination therapy for persons with multiple CVD risk factors, including screening for CVD in community settings using non-lab-based 13 tools to assess overall CVD risk 2 2

Appendices Page 84 Secondary prophylaxis with penicillin for rheumatic fever or established 15 rheumatic heart disease 4 4

Initiation of treatment among individuals with severe hypertension and/or 17 multiple risk factors 2 4

28 Low-dose inhaled corticosteroids and bronchodilators for asthma 2 2

Low-dose inhaled corticosteroids and bronchodilators for selected patients 29 with COPD 2 2

Annual flu vaccination and pneumococcal vaccine every five years for 30 individuals with underlying lung disease 2 ND

Hepatitis B testing of individuals identified in the national testing policy (i.e., based on endemicity and risk level), with appropriate referral of 33 positive individuals to trained providers 3 1

Hepatitis C testing of individuals identified in the national testing policy (i.e., based on endemicity and risk level), with appropriate referral of ND 34 positive individuals to trained providers 2

Screening and management of albuminuric kidney disease with ACEi or 41 ARBs, including targeted screening among people with diabetes 1 2

Care and treatment of diabetes among adults, including management of 42 blood pressure and lipids, and consistent foot care 2 4

Management of diabetes in pregnancy (gestational diabetes or preexisting 43 type 2 diabetes) 3 ND

44 Screening for diabetes among at-risk adults 2 4

Prophylaxis against bacterial infections and malaria for those with sickle 46 cell disease 4 4

Psychological treatment for mood, anxiety, ADHD and disruptive behavior 67 disorders in adolescents 2 ND

68 Interventions to support caregivers of patients with dementia 3 ND

Management of depression and anxiety disorders with psychological and 69 generic antidepressant therapy 3 3

Appendices Page 85 Provision of harm reduction services such as safe injection equipment and 70 opioid substitution therapy to people who inject drugs 4 4

Basic management of musculoskeletal and neurological injuries and ND 75 disorders, such as simple exercises prescription and sling/cast provision 3

Expanded palliative care and pain control measures, including prevention 84 and relief of all physical and psychological symptoms of suffering 4 NA

Management of epilepsy using generic anti-epileptic medications and 98 psychosocial treatment 4 4

Calcium and vitamin D supplementation for primary prevention of 141 osteoporosis in high-risk individuals 1 ND

Calcium and vitamin D supplementation for secondary prevention of 142 osteoporosis 1 ND

158 Exercise programs for upper extremity injuries and disorders 2 ND

Review of prosthetics, orthotics, and splints, with referral to hospital if 159 indicated 2 ND

Essential palliative care and pain control measures, including oral 170 immediate release morphine and medicines for associated symptoms 4 NA

Psychosocial support and counseling services for individuals with serious, 171 complex, or life-limiting health problems and their caregivers 4 NA

No. Dental Team at Health Center Equity CE*

109 Treatment of caries 1 ND

110 Dental extraction 1 ND

111 Drainage of dental abscess 1 ND

No. Laboratory Service Unit at Health Center Equity CE*

176 Health center pathology services NA NA

Community ICTs

No. Community Acute Care and Prevention Team Equity CE*

Appendices Page 86 31 Childhood vaccination series (hepatitis B) 3 4

100 Childhood vaccination series (rubella) 3 4

In countries where it is a public health concern, prevention of FGM (may 129 be for daughters of women of reproductive age) 4 ND

130 Education campaigns for the prevention of gender-based violence 2 2

Parent training, including nurse home visitation for child maltreatment, for 131 high-risk families 1 1

Early identification of lead poisoning and counseling of families in 135 remediation strategies for sources of environmental exposure 3 ND

No. Community Chronic Care Team Equity CE*

Exercise-based pulmonary rehabilitation for patients with obstructive lung 22 disease 2 ND

Adherence support for high-risk individuals with chronic mental health 60 conditions 4 ND

Adherence support for high-risk individuals with chronic NCD conditions (history of malignant hypertension, heart failure, needing anticoagulation, 77 type 1 diabetes, malignancies) 4 ND

95 Self-managed treatment of migraine 4 ND

Training and retraining for disorders of speech, swallowing, 96 communication, and cognition 1 ND

Pressure area prevention, and supportive seating interventions for 126 wheelchair users 2 ND

136 Safer storage of pesticides in the community and farming households 3 ND

Basic outpatient rehabilitation services (priority to longitudinal care for 143 individuals post injury) 2 ND

144 Individualized environmental modifications (e.g., adaptations to a house) 2 ND

Provision and training in the use of basic assistive products (e.g., canes, braille displays, and other aides) and compensatory strategies needed to 145 communicate and perform activities of daily living 2 ND

Appendices Page 87 Training, retraining, and exercise programs for musculoskeletal and 146 neurological injuries and disorders 2 4

Early childhood development rehabilitation interventions, including 164 motor, sensory, and language stimulation NA NA

167 Management of pain and palliative care in the community 4 NA

173 Vital registration with verbal autopsy NA NA

181 Cardiac and pulmonary rehabilitation programs 2 ND

No. School-based Care Team Equity CE*

61 Life skills training in schools to build social and emotional competencies NA NA

School based HPV vaccination for girls (In countries where cervical cancer 76 is a public health priority) 4 3

101 Education of schoolchildren on oral health 2 ND

102 Vision prescreening by teachers 2 3

179 School-based education on healthy lifestyles NA 2

180 School-based education on sexual health and nutrition NA 2

Table 15: Health-sector NCDI Interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by health system platform and integrated care team (ICT)

Appendices Page 88 Appendix 2.D. Intersectoral NCDI Interventions from DCP3 Essential UHC Package

Interventions Addressing Behavioral Risks

Exercise: Take initial steps to develop infrastructure enabling pedestrians and bicyclists

Mass media messages concerning physical activity

Salt: Impose regulations to reduce salt in manufactured food products

Salt: provide consumer education against excess use, including product labeling

Sugar sweetened beverages: tax to discourage use

Sugar: provide consumer education against excess use, including product labeling

Trans fats: ban and replace with polyunsaturated fats

Mass media messages concerning healthy eating

Mass media messages concerning use of alcohol

Mass media messages concerning use of tobacco

Setting and enforcement of blood alcohol concentration limits

Smoking in public places: Ban smoking in public places

Substance use: Impose large excise taxes on alcohol, and other addictive substances

Substance use: Impose large excise taxes on tobacco

Substance use: Impose strict regulation of advertising, promotion, packaging and availability of alcohol, with enforcement

Substance use: Impose strict regulation of advertising, promotion, packaging and availability of tobacco, with enforcement

Interventions Addressing Environmental Risks

Measures to control non-emission sources of air pollution, including road and construction dust

Appendices Page 89 Measures to reduce diesel use, including engine retrofits and transition to compressed natural gas for fleets

Promotion of kitchen retrofits to reduce household air pollution

Regulations on building codes that ensure adequate ventilation

Relocation of brick kilns and retrofits for emission control when feasible

Setting and enforcement of occupational safety standards

Setting and enforcement of regulations on the use of personal protective equipment in hazardous occupations

Subsidies to promote the use of low emission household devices and fuels

Subsidies to renewable energy

Safer stove design to reduce risk of burns

Training in hazard recognition and control relevant to the work performed (for example, task- based training for hazardous tasks)

Occupational Safety and Health training in hazard recognition and control relevant to the work performed (e.g. task based training for hazardous tasks)

Ban on kerosene as a source of household fuel

Building and strengthening public transportation systems, including buses, rapid transit, and rail

Emissions: Regulate transport, industrial, and power generation emissions

Emissions: Tax emissions and/or auction off transferable emission permits

Enhance clean fuel distribution networks

Establish or strengthen municipal street cleaning and trash collection measures

Fines for non-emission sources of air pollution, including construction dust

Fines for residential trash burning

Fossil fuel emissions: Dismantle subsidies for and increase taxation of fossil fuels (except LPG)

Greenhouse gasses: Regulate CO2 and methane emissions (including cap and trade)

Appendices Page 90 Greenhouse gasses: Tax CO2 and methane emissions

Indoor air pollution: halt the use of unprocessed coal as a household fuel

Indoor air pollution: Subsidize clean alternatives to kerosene such as liquid propane gas (LPG), including transfer of subsidies to the poor when appropriate

Mass media for awareness on household air pollution health effects

Interventions Addressing Other Risks

Mass media messages concerning mental health for adolescents

Folic acid: fortify food

Hazardous waste: Legislation and enforcement of standards for hazardous waste disposal

Stricter licensing laws and reduced availability of firearms

Decriminalization of suicide

Increased visibility, areas for pedestrians separate from fast motorized traffic

Mandatory use of daytime running lights for motorcycles

Public transportation: Build and strengthen public transportation systems in urban areas

Social marketing to promote seatbelt use in vehicles and helmet use by child bicyclists

Traffic safety: Include traffic calming mechanisms into road construction

Traffic safety: Set and enforce speed limits on roads

Vehicle safety: enact legislation and enforce personal transport safety measures, including seatbelts in vehicles and helmets for motorcycle users

Legislation and enforcement of use of personal flotation devices for recreational and other high-risk boaters

Programs to prevent drowning in high-risk areas by supervising younger children and teaching older children how to swim

Swimming lessons for children in high risk areas for drowning

Pesticides: enact strict control and move to selective bans on highly hazardous pesticides

Appendices Page 91 Regulations on child-resistant containers for hazardous substances (e.g., paraffin, paracetamol, etc.)

Dispensing alcohol in plastic rather than glass that could be used as a weapon

Programs that ensure the supervision of children walking to and from school

Agricultural antibiotic use: Reduce and eventually phase-out subtherapeutic antibiotic use in agriculture

Arsenic: monitoring of groundwater supplies and provision of alternatives if needed

Asbestos: banning of import, export, mining, manufacture, and sale

Concessionary financing for remediation of worst cases of lead contamination

Engineering controls to decrease release of silica and other toxins

Established and enforced toxic element emissions limits for air and water

Lead exposure: take actions to reduce human exposure to lead, including bans on leaded fuels and phase-out of lead-based consumer products

Mercury: monitoring and reduction or elimination of use in artisanal mining, large-scale smelting, and cosmetics

Micro-finance combined with gender equity training

Notification of public of locations of contaminated sites

Restricted access to contaminated sites

School-based programs to address gender norms and attitudes

Subsidies to encourage use of public transportation systems

Table 16: Intersectoral NCDI Interventions from DCP3 Essential UHC Package

Appendices Page 92 Appendix 2.E. Cost-effectiveness and Equity of health sector interventions in the DCP3 Essential Universal Health Coverage Package (EUHC), plus additional interventions, organized by cause groups and by level of the health system

Figure 6: Cost-Effectiveness and Equity of NCDI Interventions; interventions are listed by number and by cause group in Appendix 2.B.

Appendices Page 93

Figure 7: Cost-Effectiveness and Equity of NCDI Interventions by Level of the Health System; interventions are listed by number and by level of the health system in Appendix 2.C.

Appendices Page 94 Appendix 2.F. Prototypical Staffing of Integrated Care Teams for NCDIs

Data Auxilliary Sub- Mid-level Specialist Clerks Integrated Care Team (ICT) CHWs Teachers clinical Specialist providers Physicians and other staff Physicians ancillary Referral and Specialty Hospital – 10 million population catchment area Cardiothoracic Surgical 24 3 3 Team Intervent. Cardiology Team 4 9 Specialized Surgical Team 14 10 6 8 Orthopedic Surgical Team 5 3 Critical and Pall. Care Team 20 4 Pathology Service Team at 4 2 Referral Hospital Radiology Service Team at Referral Hospital 4 2 First-level Hospital (Outpatient) – 250,000 population catchment area Severe Mental Health Outpatient Team 2 0.2 at First-level Hospital Severe NCD Outpatient 2 0.2 Team at First-level Hospital Women's Health Outpatient 4 0.2 Team at First-level Hospital First-level Hospital (Inpatient) – 250,000 population catchment area Emergency/High Dependency Team at First- 20 6 4 level Hospital General Surgical Team at 20 10 4 First-level Hospital Newborn Screening Team at First-level Hospital 2 2 2 Adult Inpatient Care Team at First-level Hospital 14 10 5 Rehabilitation Service Team at First-level Hospital 4 Radiology Service Team at First-level Hospital 4 Laboratory Service Team at First-level Hospital 4 Health Center – 25,000 population catchment area Acute/Women's Care Team at Health Center 6 Chronic Care Team at Health Center 3 Community – 10,000 population catchment area Community Chronic Care Team 10 School-based Care Team 2.5 Table 17: Prototypical Staffing of Integrated Care Teams for NCDI

Appendices Page 95 Appendix 2.G. Costing interventions grouped by integrated care teams (ICTs)

We have estimated the per-capita cost of selected ICTs as a fraction of total NCDI costs and essential UHC (EUHC) costs in DCP3 in low- and lower-middle income countries (see Appendix 2.I. relating to impact estimation). 78 To do this, we took the intervention-specific costs estimated from DCP3 in low-income countries (LICs) and lower-middle-income countries (LMI countries) and aggregated them by the prototype ICTs to which we assigned them. These selected ICTs account for 94% of total EUHC costs in LICs. We find that NCDIs account for the vast majority of the costs associated with ICTs at referral and first-level hospitals. NCDIs account for 63% of health-center ICT costs in LICs, rising to 75% in LMI countries. NCDIs account for a minority of community costs. The NCDI component of the chronic care unit at health centers accounts for 25% of all EUHC costs and 41% of NCDI costs in LICs, rising to 29% of EUHC costs in LMI countries.

Lower-middle income Low-income countries countries total ICT Fraction of NCDI cost Fraction of ICT % total cost per ICT cost per capita cost from NCDI cost capita from NCDIs NCDIs $6.9 $6.85 99.5% 10% 99.8% First-level Hospital (Outpatient) Severe Mental Health Outpatient Team $2.4 $2.35 100% 4.1% 100% at First-level Hospital Severe NCD Outpatient Team at First-level Hospital $3.6 100% $3.61 4.7% 100% Women's Health Outpatient Team at First-level Hospital $0.3 100% $0.25 0.4% 100% Ophthalmic Outpatient Care Team at First-level Hospital $0.7 95% $0.64 1% 98% First-level Hospital (Inpatient) $25.2 78% $19.66 28% 83% Emergency/High Dependency Team at First-level Hospital $6.4 93% $5.94 9.1% 97% General Surgical Team at First-level Hospital $5.6 85% $4.78 5.6% 91% Newborn Screening Team at First-level Hospital $0.5 100% $0.50 0.4% 100% Adult Inpatient Care Team at First-level Hospital $6.2 61% $3.79 4.7% 57% Rehabilitation Team at First-level Hospital $1.9 100% $1.93 3% 100% Radiology Team at First-level Hospital $2.6 74% $1.93 3% 78% Laboratory Team at First-level Hospital $1.7 74% $1.24 2% 78% Health Center $39.5 63% $24.87 47% 75% Acute/Women's Care Team at Health Center $2.9 20% $0.57 2.8% 21% Chronic Care Team at Health Center $34.4 77% $26.52 41% 91% Dental Team at Health Center $0.3 100% $0.25 0.2% 100% Laboratory Team at Health Center $2.3 63% $1.43 2.6% 75% $6.0 $1.45 24% 5.7% 30% Community Community Acute Care and Prevention Team $1.4 9% $0.13 1% 8% Community Chronic Care Team $2.0 70% $1.41 3% 80% School-based Care Team $1.6 92% $1.47 1.7% 95% Total 96% 63% $1.43 94% 73% Table 18: Cost of Integrated Care Teams as a Fraction of total essential Universal Health Coverage in DCP3

*LICs = Lower-income countries; ** LMI = Lower-middle income

Appendices Page 96 Appendix 2.H. Mapping “sentinel” NCDI conditions onto Integrated Care Teams

Integrated Care Teams Rheumatic Type 1 Pediatric Women’s Pediatric Sickle Severe Trauma (ICTs) Heart Diabetes Cancers Cancers Asthma Cell Mental Disease Disease Illness Referral and Specialty Hospital Platforms Cardiothoracic Surgical Team X Cardiology Team X Specialized Surgical Team X X X Orthopedic Surgical Team X Critical and Palliative Team X X X Pathology Service Team at X X X Referral Hospital Radiology Service Team at Referral Hospital X X X First-level Hospital Platforms (Outpatient) Severe Mental Health Outpatient Team X at First-level Hospital Severe NCD Outpatient Team X X X X X X at First-level Hospital Women's Health Outpatient X Team at First-level Hospital First-level Hospital Platforms (Inpatient) Emergency/High Dependency X X X X X X X X Team at First-level Hospital General Surgical Team at X First-level Hospital Newborn Screening Team at First-level Hospital X Adult Inpatient Care Team at First-level Hospital X X X X Pediatric Inpatient Care Team at First-level Hospital X X X X Rehabilitation Service Team at First-level Hospital X Radiology Service Team at First-level Hospital X X X X X X Laboratory Service Team at First-level Hospital X X X X X X Health Center Platforms Acute/Women's Care Team at Health Center X X X X X X X X Chronic Care Team at Health Center X X X X X X X Community Platforms Community Chronic Care Team X X X X X X X X School-based Care Team X X X X X X Table 19: Selected “sentinel” NCDIs and associated Integrated Care Teams (ICTs) at existing health system platforms

Appendices Page 97 Appendix 2.I. Impact estimation for implementation of DCP3 Essential Universal Health Coverage Package (EUHC) and injury prevention interventions

We estimated mortality impact and costs associated with scale-up of essential Universal Health Coverage (EUHC) interventions in the Disease Control Priorities, Third Edition. Full details of 79 the impact model are detailed elsewhere. Deaths averted in a particular year (Daverted) were calculated using the effect size of the intervention (Eff), initial coverage (Cov0), scaled-up coverage for the year (Cov1), adjustment for quality (Qual), and projected deaths (Dproj).

, (, ,) = [1 ( ) ,] We translated the effect sizes based on WHO disease classifications to those used in the Global Burden of Disease (GBD) to use GBD estimates of death rates from 2017. As the most recent estimates of mortality rates, we projected death numbers from 2020 to 2030 using these mortality rates. We found that the coverage necessary to reach a 30% reduction in deaths before the age of 70 from the projected 2030 levels (after accounting for a 20% reduction in effect sizes of the interventions for quality) was 98%. We estimated impact on mortality under two scenarios: scaling up coverage of interventions from current levels in 2020 to 98% in 2030; and scaling up coverage by 25 percentage points from 2020 to 2030. Current levels of coverage were based on the prior DCP3 estimates. 79

In addition, we quantified the effects of scaling up several sets of intersectoral interventions to address road injuries and drowning. A previous analysis of the Commission reviewed effectiveness of interventions for unintentional injuries and quantified the potential impact of implementing several interventions on road injuries and drowning deaths using Global Burden of Disease estimates.80 We implemented this step prior to estimating deaths averted through EUHC scale-up to account for prevention first. To combine multiple prevention interventions affecting the same conditions, we used the following equation, where interventions are represented by r and their effect sizes by E:

=1(1 ) This equation assumes that the interventions have independent effects; this was an assumption we had to make for lack of evidence regarding the combined effects of the interventions. 80 Similar to the EUHC impact estimates, we scaled the injury interventions’ impact using a 20% reduction for inefficiency in implementation and scaled the increases in coverage linearly from 2020 to 2030. As with the EUHC intervention scale-up, we compared to a 25 percentage point increase in coverage. We made these impact calculations for low- and lower-middle-income countries (LICs and LMICs).

To estimate impact in the poorest billion, we used the proportion of the population in the poorest billion by country, age, and sex, multiplied by projected populations, and found the proportion of

Appendices Page 98 the population in the poorest billion for LICs and LMICs from 2020 to 2030. We multiplied the deaths averted in each year by the age- and year-specific proportion of the population in the poorest billion to approximate the deaths averted in the poorest billion.

UNDER-40 TOTAL YEARS 40-69 YEARS Inter-sectoral Injury 150,000 100,000 50,000 25 PERCENTAGE Interventions POINT INCREASE IN EUHC Interventions 1,320,000 310,000 1,010,000 COVERAGE Total 1,470,000 415,000 1,060,000 Inter-sectoral Injury 590,000 400,000 195,000 Interventions 98% COVERAGE EUHC Interventions 3,980,000 925,000 3,055,000 Total 4,570,000 1,320,000 3,250,000 Table 20: Potential deaths averted in the poorest billion through scale-up of essential UHC NCDI interventions and intersectoral injury prevention interventions in low- and lower-middle-income countries, 2020-2030

UHC=Essential UHC Package of Interventions from Disease Control Priorities, Volume 3

Figure 8: Annual deaths averted in the poorest billion by injury prevention and essential UHC interventions scaled-up from 2020-2030, ages 0-69

Appendices Page 99 Appendix 3.A. Health financing and expenditures on NCDIs in low- and lower-middle-income countries

Data Source

All data discussed in this Appendix 3.A are taken from the 2018 WHO Global Health Expenditure Database (GHED). The GHED is the “global reference for health expenditure estimates in all WHO Member States.” Data are updated with publicly available data (e.g. national budget documents or available NHA data). When no public information is available, data are supplemented with WHO estimates. Regional WHO offices coordinate with Member States to develop data; WHO country focal points, together with development partners, validate data. All Member States are consulted on data before publication. Updates to the GHED take place annually, with a two-year lag. Thus, the 2018 update provides information on health expenditures in 2016. Since 2017, the GHED has applied the System of Health Accounts (SHA) framework.

Gaps in NCDI financing

In order to assess the gaps in available financing for NCDIs, we conducted an analysis of publicly available data from the GHED. We compiled estimates of domestic government health expenditures, out-of-pocket payments for health, and development assistance for health in the “poorest billion” countries. These estimates were summed and compared to the cost of the model benefits package for UHC, the essential UHC (EUHC) interventions, developed for and described by the Disease Control Priorities Project, Third Edition. 81

Inclusion Criteria: All countries from Appendix 1.B, Table 5 with available data were included in this analysis. Data was downloaded in December 2018.

Per Capita Domestic Spending on NCDIs in Low- and Middle-Income Countries

In order to assess the sufficiency of government spending on NCDIs, the working group conducted an analysis of publicly available National Health Accounts (NHA) data from the Global Health Expenditure Databased (GHED). We compiled estimates of domestic government spending on NCDIs, both in absolute dollars and as a percent of general government health expenditures, for each of the 36 countries for which information was available.

Inclusion Criteria: All countries with available information on 1) domestic government spending on NCDIs in 2016, and 2) general government health expenditure in the 2018 GHED were included in this analysis. Data was downloaded in December 2018.

Appendices Page 100 Low-income countries Lower-middle-income countries Upper-middle-income countries Benin * Cabo Verde, Republic of Gabon Burkina Faso * Congo * Mauritius

Burundi * Côte d'Ivoire * Namibia

Democratic Republic of the Gambia * Armenia Congo *

Ethiopia * Ghana * Bosnia and Herzegovina

Guinea * Kenya * Samoa

Liberia* Mauritania *

Malawi * Nigeria* Mali * Sao Tome and Principe

Niger * Zambia * Togo * Tunisia Uganda * Kyrgyzstan

United Republic of Tanzania * Bhutan *

Tajikistan Sri Lanka

Cambodia *

Lao People's Democratic Republic*

* = Poorest Billion

Table 21: Countries included in the analysis of government spending on NCDIs

Appendices Page 101 Appendix 3.B. Modelling catastrophic expenditure due to NCDIs among the Poorest Billion

To estimate the prevalence of catastrophic health spending on NCDIs, we used data from 37 World Health Surveys (WHS) conducted between 2002 and 2004 that captured information on total household expenditure, health expenditure, and multidimensional indices of poverty. Health spending was classified as catastrophic if it was greater than 40% of a household’s capacity-to- pay (total household expenditure minus subsistence expenditure). The condition-specific cause of catastrophic health expenditure was classified according to the most recent reason for health care utilization on the survey. Reasons for care presented in WHS included: fever, cough and ; maternal and child; heart disease; asthma; arthritis; dental complaints; minor surgery; injuries; and other. To obtain a proportion of the overall prevalence of catastrophic health expenditure due to NCDIs, we aggregated all the specific, non-infectious causes together with a range (30% to 80%) of the “other” expenditure not tied to one of the specific options presented in the WHS. To predict the fraction and absolute amount of catastrophic expenditure due to NCDIs among the poorest billion specifically, we calculated the fraction of total catastrophic expenditure in WHS that occurred in households that were among the world’s poorest billion by multidimensional indices, as well as the fraction of catastrophic expenditure in the poorest households that was due to NCDIs. We then applied these estimates to the total quantity of catastrophic expenditure in low- and lower-middle-income countries.82,83

Appendices Page 102 Appendix 3.C. Development Assistance for Health targeted to NCDs in the Poorest Countries

The share of developmental assistance for health (DAH) targeted to NCDs has been low compared to that for other diseases, including after adjustment for disease burden. For instance, previous analyses have estimated that $0.78 of donor funding per DALY goes to NCDs as compared with $23.90 for HIV, tuberculosis, and malaria. 84 We used the Financing Global Health database from IHME and disease burden estimates from the Global Burden of Disease 2017 to estimate development assistance per DALY for NCDs and Group 1 conditions (communicable, maternal, neonatal, and nutritional diseases). These has also been evidence that donor financing tends to prioritize burden occurring at young ages 85 The targeting of development assistance cannot be disaggregated by age group to calculate funding per DALY for specific conditions. However, it is likely that such a donor financing gap exists in young ages as well and may be even wider. We calculated funding per DALY for all ages (total DAH per all- age DALYs) and with a hypothetical targeting of the funding to burden under age 40 (total DAH per under-40 DALYs) for both LMICs generally and the set of 55 countries with a high proportion of population in the Poorest Billion (see Table 22). The differences in funding per DALY between NCDs and Group 1 conditions were high in both sets of countries and larger if the funding were targeted to under-40 burden.

Country-allocable Development Assistance for Health per DALY* Communicable, Maternal, Neonatal, NCDs and nutritional diseases DALYs from all ages, LMICS** $0.1 $24.4 DALYs under age 40, LMICs $0.5 $31.1 DALYs from all ages, 55 “Poorest Billion Countries” $0.1 $26.3 DALYs under age 40, 55 “Poorest Billion Countries” $0.4 $32.6 * DALY = Disability-adjusted Life Year; ** LMIC = Low-and Middle-Income Country Table 22: Development Assistance for Health per Disability-adjusted Life Year by disease category Some DAH from the IHME database could not be allocated to specific countries. For NCDs, this amount was a relatively large proportion of total NCD DAH. We calculated the DAH per DALY for NCDs and Group 1 conditions using the total DAH for all countries in the database and the burden from all of these countries under age 40. NCDs received $2.67 per DALY, while Group 1 conditions received $54.80 per DALY.

Previous work on Development Assistance for Health (DAH) has analyzed the main funding streams for all conditions based on a variety of data sources, including the OECD Development Assistance Committee (OECD DAC), WHO, the World Bank, and the Foundation Center. 86 DAH has been analyzed for NCDs relative to total DAH and other priority conditions, and was thought to constitute around 2% of DAH between 2010 and 2014.84,87 This Commission wanted to determine how much of the meagre DAH available for NCDIs was plausibly reaching the world’s poorest people. We first conducted a more comprehensive review of data sources and gathered more detailed information about the nature of the funded projects for 2010 to 2014, the countries receiving the funding, and the degree to which the poor were explicitly targeted. In order to estimate the fraction of DAH for NCDs going to the poorest billion, we analyzed the

Appendices Page 103 proportion of DAH that was traceable to specific recipient countries, and within that funding, what proportion was allocated to one of 55 countries that contained 98% of the world’s poorest people. We estimated $10 million as the lower bound and $68 million as the upper bound of NCDI DAH focused on the poorest in 2014.

Our review was based on searching national, international and organizational databases to identify external funding (coming exclusively or primarily from rich countries into LMICs) for a broad range of NCD-related programs from 2010-2014. There currently is no NCD-specific tracking codes were initiated in 2018 for the OECD DAH database (Creditor Reporting System (CRS) of the Development Assistance Committee (DAC)), which serves as the primary source of longitudinal and consistent development assistance information. The new set of codes that will include NCDs are expected to produce NCD-specific data on donor funding in 2019.

The quantitative data are complemented and validated through key informant interviews with the major funding organizations. Funds tracked include spending in and for LMICs on projects that a) deliver and improve NCD services, including through integrated programs, b) carry out health promotion or disease prevention actions, c) strengthen health systems for purposes of NCD care in LMICs, and d) support activities within and outside of the health sector that provide care or other services for populations living with an NCD.

Only 10% of NCDI projects in poorest billion countries explicitly target the poorest

Of the 434 donor projects for NCDIs in the countries representing the poorest billion in 2014, only 44, or approximately 10%, explicitly targeted poor populations. Funding for these 44 projects amounted to $9.2 million (USD 2015) from donors for NCDIs of the poorest. Out of these 44 projects, 25 funded poor populations in general, 10 funded populations in remote areas, 8 focused on poor children, and 5 targeted injuries, particularly supporting people with disabilities arising from injuries. Two projects addressed multi-dimensional aspects of poverty, such as occupational risks of child labor and the effects of social capital on discrimination of people with disabilities.

Of the projects focused on the poorest, the majority targeted sense organs, multiple NCDs, and mental health disease categories. Overall, they aimed to improve social integration of marginalized and underserved communities, to improve access to healthcare, provide training and capacity development for healthcare staff working with vulnerable populations, and facilitate healthcare research. Donor leaders in pro-poor targeting were Canada, Impact Foundation, EU Institutions, Finland, Germany, Norway and Sweden.

To elicit the reasoning behind the donor priorities suggested by the quantitative numbers, the NCDI Commission conducted structured interviews with 10 key informants knowledgeable about donor priorities and NCDIs. Only 3 out of 10 interviewed organizations (UNICEF, GiZ, OSF) claimed to prioritize interventions for the poorest populations. All of them mentioned multi-dimensional aspects of poverty, focusing on marginalized populations, ethnic and religious minorities, undocumented populations and the urban poor. However, they did not explicitly frame NCDIs as diseases of poverty.

Appendices Page 104 Most funders agreed that equity dimensions should underpin NCDI interventions, and six organizations emphasized that their ability to influence prioritization of funding is constricted by national priorities and donor interests. They indicated that governments of LMIC countries often do not see NCDIs as diseases affecting the poor, while donors tend to be concerned more with health security aspects of communicable diseases.

Representatives from the three development banks (IADB, ADB, WB) emphasized that they work with Ministries of Health, implying that governments direct the money to subsidized care in line with the UHC framework and thus indirectly target the poor. However, the funders themselves do not explicitly prioritize the poorest within recipient countries.

Appendices Page 105 Appendix 3.D. Projected health financing capacity in low- and lower-middle-income countries, 2017-2030

In order to assess the anticipated fiscal space for spending on NCDI into the coming years, we developed projections of health spending through the year 2030 for low- and lower-middle- income “poorest billion” countries in the absence of additional development assistance for health.

Inclusion Criteria: All low- and lower-middle-income countries for which data was available were included in this analysis. In total, this includes a total of 52 countries: 27 LICs and 25 L- MICs. Data were downloaded in January 2019.

Methods: Six scenarios were projected based on GDP growth and allocation of GDP for health. Specifically, for per capita GDP growth rates of 3%, 4%, and 6%, respectively, we calculated the available government spending on health given either 1) status quo allocation: e.g., no change in either total revenue collection or the prioritization of health in the overall government budget, or 2) maximum hypothesized revenue; i.e., increasing government revenue generation to the country’s estimated taxation potential, as defined by the Overseas Development Institute (ODI) and increasing prioritization of health within the government budget (in this case, revenue) up to the 15% goal established by the Abuja Declaration. 86,87 Development assistance for health was kept at 2017 levels for all projections.

To illustrate this method, Table 23 indicates the projected aggregated government and external per capita spending on health in low-income countries in the year 2024, approximately half-way through the projection period.

Per Capita Spending on Health, projected at 2024 GDP growth per year 3% 4% 6% Revenue generation remains at current levels; $21.46 $22.29 $24.10 Government expenditures on health as a proportion of total government budget: Unchanged. Revenue as a proportion of GDP linearly increases to $26.79 $27.90 $30.51 estimated taxation potential by 2030; Government expenditures on health as a proportion of total government budget linearly increases to 15% by 2030. Table 23: Projected per capita spending on health in low-income countries for the year 2024, according to each of the 6 projections

Appendices Page 106 SHORTFALL IN DOMESTIC PLUS EXTERNAL FINANCING FOR HEALTH IN LOW- AND LOWER-MIDDLE- INCOME COUNTRIES IN 2030

COMPARED TO EUHC COST ($84 LIC, $120 LMIC) IN 2016 USD Increase in government revenue to ODI estimate of No increase in government revenue as proportion of potential revenue as proportion of GDP; Increase of GDP or in proportion of revenue spent on health proportion of government revenue spent on health to 15%

COUNTRY World Bank 2016 3% Annual Per 4% Annual Per 6% Annual Per 3% Annual Per 4% Annual Per 6% Annual Per Classification Shortfall Capita GDP Capita GDP Capita GDP Capita GDP Capita GDP Capita GDP Growth Growth Growth Growth Growth Growth AFGHANISTAN LIC 71.1 69.6 68.9 67.4 56.2 53.6 47.3 BENIN LIC 68.5 65.3 63.9 60.6 39.0 33.8 21.3 BURKINA FASO LIC 58.0 49.6 46.0 37.3 44.9 40.6 30.3 BURUNDI LIC 71.5 68.7 67.6 64.7 65.9 64.3 60.4 CENTRAL AFRICAN REPUBLIC LIC 74.9 73.6 73.1 71.8 68.6 67.4 64.3 CHAD LIC 73.4 70.3 69.0 65.9 63.1 60.8 55.1 COMOROS LIC 69.1 64.7 62.8 58.2 44.2 39.4 27.7 DEMOCRATIC REPUBLIC OF THE LIC 72.6 71.3 70.7 69.4 60.0 57.8 52.5 CONGO ETHIOPIA LIC 72.2 68.3 66.6 62.6 47.4 42.7 31.4 GUINEA LIC 69.2 66.8 65.8 63.4 41.5 36.9 25.6 GUINEA-BISSAU LIC 58.8 49.9 46.1 37.0 42.4 37.6 25.8 HAITI LIC 63.7 60.8 59.5 56.4 42.8 39.0 29.6 LIBERIA LIC 53.7 48.7 46.6 41.4 36.5 32.7 23.3 MADAGASCAR LIC 66.5 60.6 58.1 52.0 51.9 48.1 39.0 MALAWI LIC 59.8 55.5 53.7 49.3 50.0 47.3 41.0 MALI LIC 65.0 60.2 58.1 53.1 44.3 40.0 29.5 MOZAMBIQUE LIC 66.4 61.2 58.9 53.5 53.3 49.9 41.7 NEPAL LIC 70.2 65.9 64.1 59.6 40.6 35.1 21.8 NIGER LIC 75.6 72.7 71.5 68.6 63.5 61.0 54.9 RWANDA LIC 43.4 35.0 31.5 22.8 27.4 22.7 11.4 SENEGAL LIC 62.6 53.2 49.3 39.6 28.9 21.4 3.2 SIERRA LEONE LIC 39.0 34.0 31.9 26.8 32.6 30.3 24.6 TANZANIA LIC 56.7 49.3 46.1 38.5 43.2 39.2 29.4

Appendices Page 107 THE GAMBIA LIC 70.9 68.9 68.1 66.0 51.2 47.8 39.6 TOGO LIC 68.2 64.2 62.5 58.4 44.6 40.0 29.0 UGANDA LIC 62.6 59.4 58.0 54.7 46.4 43.2 35.4 ZIMBABWE LIC 16.4 0.0 0.0 0.0 0.0 0.0 0.0 BANGLADESH LMIC 111.2 108.1 106.8 103.5 74.2 68.0 52.9 BHUTAN LMIC 48.1 13.5 0.0 0.0 0.0 0.0 0.0 BOLIVIA LMIC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 CAMBODIA LMIC 88.3 79.7 75.9 67.0 50.5 42.6 23.5 CAMEROON LMIC 105.4 101.0 99.1 94.5 48.5 39.0 16.1 CONGO LMIC 87.9 72.7 66.2 50.4 0.0 0.0 0.0 COTE D'IVOIRE LMIC 92.4 83.5 79.7 70.5 29.8 18.2 0.0 DJIBOUTI LMIC 68.3 51.9 44.8 27.8 0.0 0.0 0.0 GHANA LMIC 85.5 72.2 66.5 52.8 42.5 32.5 8.4 INDIA LMIC 103.4 95.2 91.7 83.3 18.0 3.4 0.0 INDONESIA LMIC 69.6 44.0 33.1 6.7 0.0 0.0 0.0 KENYA LMIC 83.2 70.9 65.6 53.0 44.1 34.9 12.9 LAOS LMIC 92.1 82.9 79.0 69.5 0.0 0.0 0.0 LESOTHO LMIC 50.6 22.7 10.7 0.0 0.0 0.0 0.0 MAURITANIA LMIC 99.0 90.2 86.5 77.4 38.7 27.4 0.3 MONGOLIA LMIC 34.8 0.0 0.0 0.0 0.0 0.0 0.0 MYANMAR LMIC 103.8 97.4 94.7 88.1 62.1 54.2 35.2 NICARAGUA LMIC 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NIGERIA LMIC 101.9 96.6 94.3 88.8 28.3 16.1 0.0 PAKISTAN LMIC 107.3 101.7 99.3 93.4 59.5 50.9 30.3 SUDAN LMIC 87.0 71.8 65.3 49.7 29.0 16.3 0.0 TIMOR-LESTE LMIC 50.2 27.3 17.6 0.0 0.0 0.0 0.0 VANUATU LMIC 22.8 0.0 0.0 0.0 0.0 0.0 0.0 ZAMBIA LMIC 74.3 63.2 58.5 47.0 38.7 30.4 10.3 Table 24: Projected shortfall in available health financing from an essential UHC target for low-income and lower-middle-income countries in 2030 under varied assumptions

Appendices Page 108 Appendix 4.A. NCDs and the Poorest Billion on two separate tracks: 1948-2015

As a starting point for our investigation of governance for NCDI Poverty, we undertook a historical assessment of how the NCD category was constructed and the NCD agenda took shape at the World Health Organization since 1948, as the intergovernmental institution mandated with formulating and coordinating global health policies and strategies. To understand how this agenda diverged from efforts to improve the health of the poorest billion, we also examined the parallel history of health and poverty reduction initiatives in LMICs at both WHO and the World Bank – which has become the largest provider of country-allocable aid within the UN system as part of its mission “to end extreme poverty and to promote shared prosperity.”

To track the evolution of NCDI framing and policies at WHO, we examined approximately 500 documents from the WHO archives, as well as more than 450 published WHO documents, including official histories and technical report series. Finally, we conducted semi-structured interviews with four of the living directors of the Noncommunicable Disease units at WHO. We also reviewed policy documents and assessments of the World Bank’s engagement with global health over the same period.

Appendices Page 109 Appendix 4.B. Review of Global Governance Documents

Objectives In order to assess how NCDIs are included and framed within global development institutions, the working group conducted a policy review of the most recent, publicly available, NCD, health, and institutional strategy documents of multilateral health and development organizations, bilateral funders, and corporate and family foundations that play an outsized role in development assistance for health. Specifically, the team conducted a content review of any language within the documents that mentions NCDIs, chronic conditions, and their associated risk factors (see Table 25). Additionally, mentions of which populations the institutions are prioritizing were also reviewed, with particular attention to actionable language targeting the poorest populations.

Methods Design: The working team conducted a framework analysis using a conceptual framework to structure data collection. 88 The conceptual framework was developed to answer the following questions:

1. How are NCDI health outcomes mentioned?

2. How are NCDI risk factors mentioned?

3. How are populations being served described in the policy?

Exact quotes were collected and recorded in Excel. The extracted quotes were analyzed for their descriptions of NCDI health outcomes, NCDI risk factors and the population being served according to the policy. The documents were then mapped according to the diseases, risk factors and populations being served that were described. The rows of the matrix reflected national documents, while the columns of the matrix indicated the question being answered.

Mapping The following two dimensions were used to map how the documents reviewed align with the “4 x 4” framework or an expanded “NCDI Poverty” agenda addressing other conditions and risk factors; and to determine which populations and communities the institutions prioritize. The resulting figure displays where the institutions selected map onto the following two dimensions:

NCDI Framing: Expanded NCD view addressing NCDI Poverty: includes explicit mentions of additional conditions and risk factors beyond the four main disease categories and risk factors included in the Global Action Plan and Global Monitoring Framework.

Dominant 4x4 NCD View: explicit mention and structuring around the conditions and risk factors of the Global Monitoring Framework and targets, without mention of additional conditions or risk factors.

Priority to the Poverty Eradication and the poorest:

Appendices Page 110 Explicit Focus on poverty eradication in LMICs: In addressing economic and social development in LMICs, the institution specifically focuses on eradication of extreme poverty and recognizes that the poorest populations face additional obstacles with regards to development and health.

General Focus on Economic Development in LMICs: The institution focuses broadly on economic and social development in low- and middle-income countries or in geographical regions but without specific focus on poverty eradication or the poorest populations.

Focus mainly on middle-income countries: The institution focuses mainly on populations in middle-income countries without any specific emphasis on the poorest populations.

Institution Selection The 35 chosen institutions were identified due to their outsized role in development assistance for health. All WHO Regional Offices were included. In addition, associated regional entities and banks from the African, South-East Asian and Caribbean regions were selected given their regional representation of the poorest billion.

The multilaterals selected included the World Bank; the UN InterAgency Task Force for NCDs (UNIATF) as the representing body across all UN institutions for NCDs; UNICEF and UNDP due to their focus and influential role on general development assistance, including health; and health-specific multilaterals Global Fund and GAVI were selected due to their role in shaping global health policy and funding DAH.

The bilateral institutions identified were the top 10 donor nations listed by GBD, in addition to the European Commission. Of the foundations reviewed, five were identified by Working Group 3 as the top funders of NCDs among the poorest billion population, in addition to the Gates Foundation that was included given it’s outsized and influential role in establishing global health policy.

Document Selection All documents included in the review were taken from their respective institutional websites. The preliminary search identified all NCD-specific documents. When NCD-focused documents did not exist, health-specific documents were used. In cases where neither existed, general institutional strategy documents were reviewed. A complete list of the 92 documents from 35 institutions included in the review is provided in Table 25 below.

Data Extraction Using the conceptual framework described above, two researchers reviewed and extracted data from each document. Cases of discordance in data entry were jointly reviewed and discussed by the two researchers for reconciliation. When agreement could not be reached, a third reviewer was called to provide a final judgement.

Appendices Page 111

# Institution Document Date WHO Regional Offices

1 WHO AFRO Regional Office Report on the Status of Major Health Risk 2015 Factors for NCDs: AFRO Brazzaville Declaration 2011

Multisectoral Action for a Life Course 2016 Approach to Healthy Aging: Implementation Framework for the African Region Health in the 2030 Agenda for Sustainable 2017 Development Budget Framework 2016

The Africa Health Transformation Programme 2015 2015- 2020: A vision for UHC 22 WHO EMRO Regional Office NCDs in EMRO 2016

Assessing National Capacity of Preventing 2015 and Controlling of NCDs Regional Framework for action to implement 2012 the UN Political Declaration on NCDs. Annex to Resolution EM/RC29/R.2 16 WHO EURO Regional Office Action Plan for implementation of the 2012 European Strategy for the Prevention and Control of Noncommunicable Diseases (2012-2016) Gaining health. The European Strategy for 2006 the Prevention and Control of Noncommunicable Diseases

Appendices Page 112 # Institution Document Date

23 WHO PAHO Regional Office Plan of Action for the Prevention and Control 2014 of Noncommunicable Diseases in the Americas (2013-2020) Plan of Action on Mental Health (2015 – 2015 2020) 2 WHO SEARO Regional Office Action plan for the Prevention and Control of 2013 NCDs in South-East Asia (2013-2020) Approaches to establishing country-level, 2015 multisectoral coordination mechanisms for the prevention and control of NCDs Health & Development Challenges of NCDs in 2011 the South East Asia Region 10 WHO WPRO Regional Office Western Pacific Regional Action Plan for the 2014 Prevention & Control of NCDs (2014-2020)

Western Pacific Regional Action Plan for the 2009 Prevention & Control of NCDs (2008-2013)

Multilateral organizations

6 World Bank Public Policy and the Challenge of Chronic 2007 Noncommunicable Diseases Effective Responses to NCDs: Embracing 2011 Action Beyond the Health Sector Chronic Emergency: Why NCDs matter 2011

The Challenge of NCDs and Road Traffic 2013 Injuries in Sub-Saharan Africa The Growing Dangers of NCDs: Acting now to 2011 Reverse Course Health in All policies as a Strategic policy 2014 response to NCDs Setting the stage to Address Dual Challenge 2014 of MDGs and NCDs World Bank’s financing, priorities, and lending 2017 structures for global health 17 United Nations Inter-Agency Global Baseline for integrating NCDs in 2015 Taskforce on NCDs UNDAF Sectoral Briefs: What government ministries 2016 need to know about NCDs Work Plan for the taskforce 2016- 2017 29 UNDP UNDP Strategic Plan (2014-2017) 2013

Strategy Note: HIV, Health & Development 2016 (2016-2021)

Appendices Page 113 # Institution Document Date

Issue Brief: Preventing & Controlling NCDs 2016

7 UNICEF The UNICEF Strategic Plan (2014-2017) 2014

Regional NCD Outcome and Risk Factor 2016 Profiles UNICEF’s Strategy for Health (2016-2030) 2015

18 Global Fund The Global Fund Strategy: Investing to end 2016 epidemics (2017-2022) 19 GAVI GAVI Phase IV: 2016 - 2020 Strategy 2014

Regional Banks 20 Inter-American Development Bank Updated Institutional Strategy (2010-2020) 2015

Health Sector Strategic Framework 2016

Action Plan for the implementation of the 2015 Update to the Institutional Strategy

27 African Development Bank AfDB Strategy: At the Center of Africa's 2013 Transformation (2013-2022) Annual Report 2016 2017

Health in Africa over the next 50 years 2013

Bank Group Regional Integration Policy & 2014 Strategy (2014-2023) 28 Asian Development Bank The Long-Term Strategic Framework of the 2008 Asian Development Bank (2008-2020)

Operational Plan for Regional Cooperation 2016 and Integration (2016-2020)

Health in Asia & the Pacific: A focused 2015 approach to address the health needs of ADB Development Member Countries (2015-2020) Monitoring UHC in the Western Pacific: 2016 Framework, Indicators and Dashboard ADB Health Investor Brief 2017

Road to 2030: Asian Development Bank's 2017 New Strategy (Draft) Regional Entities

5 African Union The impact of NCDs and NTD on 2013 Development in Africa. Conference Concept Note The African Union Commission Strategic Plan 2013 2014-2017

Appendices Page 114 # Institution Document Date

African Health Strategy 2016-2030 2016

21 Association of Southeast Asian ASEAN Post-2015 Health Development 2017 Nations Agenda Regional Action Plan on Healthy ASEAN 2017 Lifestyles 15 Caribbean Community (CARICOM) CARICOM Strategic Plan 2015-2019 2014

Bilaterals

8 USAID Department of State & USAID Strategic Plan 2014 2014-2018 USAID's Global Health Strategic Framework 2012 2012-2016 USAID's Vision for Health Systems 2015 Strengthening 2015-2019 24 DFID 2010 to 2015 government policy: health in 2015 developing countries Health is Global: An Outcomes Framework for 2015 Global Health 2011-2015 Economic Development Strategy: Prosperity, 2017 Poverty & Meeting Global Challenges 31 DANIDA Denmark's strategy for development 2017 cooperation and humanitarian action 2017- 2030 Danish Government's priorities for Danish 2016 Development Cooperation 2017: Overview of the Development Cooperation Budget 2017- 2020 Action Plan for Policy Coherence for 2014 Development The Government's priorities for the Danish 2015 Development Cooperation 2016: Overview of the Development Budget 2016-2019 32 SIDA Results strategy for global action on socially 2014 sustainable development 2014 – 2017 Swedish Strategy for Multilateral 2007 Development Cooperation 33 NORAD Global Health in Foreign and Development 2011 Policy NORAD: White paper: Global Health in 2012 Foreign Development Norway's Follow up of Agenda 2030 and the 2016 SDGs 2015-2030 4 GIZ Towards Health for All 2016

Appendices Page 115 # Institution Document Date

The BACKUP Model in German Development 2014 Cooperation 9 ADF Santé & Protection Sociale 2015-2019 2015

La Stratégie de la France pour la coopération 2012 internationale dans le domaine de la santé Position française sur le concept "One 2011 Health/Une seule Santé" 25 Canada Global Affairs Canada, Report on Plans & 2016- Priorities 2017 26 JICA JICA's Operation in Health Sector: Present & 2013 Future 34 Australia Development for All 2015 -2020: Strategy for 2015 strengthening disability-inclusive development in Australia's Aid Program Health for Development Strategy 2015-2020 2015

35 European Union European Commission Health General 2014 Guidelines Increasing the impact of EU Development 2011 Policy: an Agenda for Change The EU Role in Global Health 2010

The New European Consensus on 2017 Development ‘Our World, Our Dignity, Our Future”

Foundations

30 Bill and Melinda Gates Foundation Gates Family Foundation Strategic Plan 2016 2017-2021 Gates Family Foundation Annual Report 2017

3 Bloomberg Foundation Bloomberg Foundation Annual Report 2015

Bloomberg Foundation Annual Report 2017

11 Project Orbis Foundation Project Orbis Foundation 2014 Annual Report 2014

12 Helen Keller Foundation Helen Keller Foundation 2015 Annual Report 2015

13 Cure International 2016 Calendar Year Executive Summary 2016

14 Sightsavers Foundation USA Annual Report 2015

Table 25: Documents included in the global institutional policy review

Appendices Page 116 Appendix 4.C. Review of National NCD Strategic Plans

Objectives

In order to assess the way that NCDIs are included and framed within national policy frameworks of low-income countries, the working group conducted a policy review of the most recently available national NCD Strategic Plans (NCDSPs) for 32 countries identified as having high proportions of populations in the poorest billion. Specifically, the team conducted a content review of the national framing discussions (e.g., national situation assessments) and Monitoring and Evaluation (M&E) frameworks that were included in the documents (see Figure 9).

Methods

Design: The working team conducted a framework analysis using a conceptual framework to structure data collection. 88 The conceptual framework was developed to reflect anticipated priority disease and risk factors and monitoring indicators and was modeled on the 183 noncommunicable disease categories included in the most detailed level of the GBD 2017 Cause Hierarchy as well as the 54 lowest-level risk factors associated with these conditions in the GBD. The specificity of GBD cause levels varies by condition. For example, “Diabetes” is classified as Level 3, while Diabetes Type 1 and Diabetes Type 2 are both Level 4. By contrast, “Cancer” is classified as Level 2, while Breast Cancer is Level 3 and is the most specific cause available. For each condition of interest, the team selected the most specific cause available, which were a combination of Level 3 and Level 4 conditions. A matrix framework was developed wherein columns indicate the source document, while the rows of the matrix indicate the key relevant information.

Document Selection: NCDSPs were collected from known repositories of strategic plans, namely: the WHO Country Planning Cycle Database (http://www.nationalplanningcycles.org), the WHO NCD Document Repository (https://extranet.who.int/ncdccs/documents/), and the International Cancer Control Partnership (ICCP) (https://www.iccp-portal.org/map). Each of these repositories was last reviewed for NCDSPs in January 2019. All English- or French- language documents for “Poorest Billion” countries were downloaded and reviewed quickly to determine whether they qualified as strategic plans. Documents other than strategic plans were excluded from the complete review. For countries with multiple strategic plans, only the most recent document was reviewed. A complete list of the 32 documents available and included in the review is provided in Table 26 below.

Data Extraction: Using the conceptual framework described above, two researchers reviewed and extracted data from each strategic plan. Information from the national situation analysis and the M&E framework sections was captured separately, with reviewers first scanning documents and agreeing upon relevant sections for detailed review. In total, 31 documents were found to contain a framing of the national NCD burden and 22 documents were found to contain an M&E plan (Table 26); 21 documents had both framing of the national burden and an M&E plan and are the focus of the information provided in this report.

Appendices Page 117 In extracting data for the national framing, reviewers indicated when the national strategic plan identified a given condition or risk factor as a specific concern within the country’s context. Descriptions of the global or regional disease contexts were not considered, nor were definitional listings of disease categories. Risk factors were noted when a risk factor was locally contextualized; global statements on a causal relationship between a risk factor and a condition were not considered. Additional indicators were added when the original framework was found to be missing relevant information. Cases of discordance in data entry were jointly reviewed and discussed by the two researchers for reconciliation. When agreement could not be reached, a third reviewer was called to provide a final judgement. See Table 27 for a summary of data collected from the 21 strategic plans containing both a national framing and an M&E plan.

Appendices Page 118

Figure 9: NCDI conditions and risk factors included in NCDSPs of poorest billion countries – references in background narratives compared with implementation monitoring frameworks

Appendices Page 119

Country Percent Name Date Narrative M&E Poverty Review

Afghanistan 25% National Strategy for Prevention and Control of 2015-2020 Noncommunicable Diseases (NCDs)

Bangladesh 25% Strategic Plan for Surveillance and Prevention of 2011-2015 Non-Communicable Diseases in Bangladesh

Benin 45% Programme National De Lutte Contre Les 2014–2018 Maladies Non Transmissibles

Burkina 65% Plan Strategique Integre de Lutte Contre les 2016-2020 Faso Maladies Non-Transmissibles

Burundi 73% Plan Strategique Integre de Lutte Contre les 2011-2015 Maladies Chroniques Non-Transmissibles

Cambodia 13% National Strategic Plan for the Prevention and 2013-2020 Control of Noncommunicable Diseases: , Cancer, Chronic Respiratory Disease and Diabetes

Central 76% Plan Pour La Lutte Contre Les Maladies Non 2015-2021 African Transmissibles Republic

Chad Plan Multisectoriel de Lutte et de Contrôle des 2017-2021 Maladies Non Transmissibles

Comoros 23% Document de Stratégie National de Prévention et 2012-2015 de Lutte Contre Les Maladies Non Transmissibles

Republic of 30% Plan National Integre de Lutte Contre Les 2013-2017 Congo Malades Non-Transmissibles au Congo

Cote D'Ivoire 30% Plan Strategigiqu Integre de Prevention et de 2015-2019 Prise en Charge des Malades Non Transmissibles en Cote D'Ivoire

Ethiopia 82% National Strategic Action Plan (NSAP) For 2014-2016 Prevention & Control of Non-Communicable Diseases in Ethiopia

Ghana 12% Strategy for the Management, Prevention and 2012-2016 Control of Chronic Non- Communicable Diseases in Ghana

Guinea 55% Programme National Integre de Prevention et de 2010 Controle des Maladies Non Transmissibles

India 14% National Action Plan and Monitoring Framework 2012-2013 for Prevention and Control of Non Communicable Diseases in India

Appendices Page 120 Country Percent Name Date Narrative M&E Poverty Review

Kenya 40% Kenya National Strategy for the Prevention and 2015-2020 control of Non Communicable Diseases

Laos 17% National Multisectoral Action Plan for the 2014-2020 Prevention and Control of Noncommunicable Disease

Lesotho 26% National Multisectoral Integrated Strategic Plan for 2014-2020 the Prevention and Control of Non-Communicable Diseases (NCDs)

Malawi 49% National Action Plan for Prevention and 2012-2016 Management of Non Communicable Diseases in Malawi

Mali 59% Plan Stategique National de Lutte Contre Les 2015-2019 Maladies Non Transmissibles

Nepal 13% Multisectoral Action Plan for the Prevention and 2014-2020 Control of NCDs in Nepal

Niger 79% Plan Stratégique National de Prévention et de 2012 Lutte contre les MNT

Nigeria 34% National Policy & Strategic Plan of Action on 2013 NCDs

Pakistan 16% National Action Plan for Prevention and Control of 2004 Non-Communicable Diseases and Health Promotion in Pakistan

Rwanda 50% Rwanda Non- communicable Diseases and 2014-2019 Injuries National Strategic Plan

Sierra Leone 63% National Non-Communicable Diseases 2013-2017 STRATEGIC PLAN

Sudan 45% Non-communicable Disease National Strategic 2010-2015 Plan

Tanzania 57% Strategic Plan And Action Plan For The 2016-2020 Prevention And Control Of Non Communicable Diseases In Tanzania

Timor Leste 52% National Strategy for Prevention and Control of 2014-2018 Noncommunicable Diseases (NCDs), Injuries, Disabilities, and Care of the Elderly & NCD National Action Plan

Togo 32% Politique et Plan Strategique Intregre De Lutte 2012-2015 Contre Les Maladies Non Transmissibles (PSIMNT)

Vanuatu 28% Non Communicable Disease Policy and Strategic 2016-2020 Plan

Appendices Page 121 Country Percent Name Date Narrative M&E Poverty Review

Zambia 48% Zambian Strategic Plan Non Communicable 2013-2016 Diseases and Their Risk Factors

Table 26: Documents included in the national NCD Strategic Plan policy review

Appendices Page 122

Appendices Page 123

Table 27: Summary Content of Narrative Framing and M&E for 13 countries with complete information. Gray shading indicates that a given indicator was not present in the Strategic Plan. (Descriptions of the global or regional disease contexts were not considered, nor were definitional listings of disease categories.)

Appendices Page 124 Appendix 4.D. Review of Poverty Reduction Strategic Papers

Objectives

In order to assess the way that NCDIs are included and framed within Poverty Reduction Strategy Papers (PRSPs) of low-income countries, the working group conducted a policy review of the most recently published full PRSPs for 29 countries identified as having large proportions of population in the poorest billion (see Table 28). Specifically, the team conducted a content review of any language within the strategy documents that describes NCDI conditions and their associated risk factors.

Methods

Design: The working team conducted a framework analysis using a conceptual framework to structure data collection. 88 The conceptual framework was developed to answer the following questions:

1. How are NCDI health outcomes mentioned?

2. How are NCDI risk factors mentioned?

Exact quotes were collected and recorded in Excel. The content of the quotes was analyzed for their description of NCDI health outcomes and their associated risk factors. The rows of the matrix reflected national documents, while the columns of the matrix indicated the question being answered.

Document Selection:. All documents were collected from the International Monetary Fund Database of PRSPs (https://www.imf.org/external/np/prsp/prsp.aspx). For countries with multiple strategic plans, only the most recent document was reviewed. Interim reports were not included in the documents reviewed. A complete list of the strategy documents reviewed from each of the 29 countries is listed below in Table 28.

Data Extraction: Using the conceptual framework described above, two researchers reviewed and extracted data from each document. Cases of discordance in data entry were jointly reviewed and discussed by the two researchers for reconciliation. When agreement could not be reached, a third reviewer was called to provide a final judgement. Of the 14 PRSP’s that pre-dated 2011, only three contained references to NCDs. For the 15 that were published in 2011 or later, 11 referenced NCDs.

Country Document Date

Afghanistan Afghanistan National Development Strategy 2008

Bangladesh Sixth Five Year Plan FY2011-FY2015 Accelerating Growth and Reducing 2013 Poverty

Benin Growth Strategy for Poverty Reduction 2011-15 2011

Appendices Page 125 Burkina Poverty Reduction Strategy Paper 2005 Faso

Burundi Poverty Reduction Strategy Paper II 2012

Cambodia National Strategic Development Plan 2006-2010 2006

Comoros Poverty Reduction and Growth Strategy Paper (Updated Interim Paper) 2005

Congo Growth, Employment, and Poverty Reduction Strategy Paper (2012-2016) 2012

Cote D’Ivoire Stratégie de Relance du Développement et de Réduction de la Pauvreté 2009

Ethiopia Growth and Transformation Plan 2010/11-2014/15 2011

Ghana Ghana Shared Growth and Development Agenda 2012

Guinea Poverty Reduction Strategy Paper III (2013-2015) 2013

Haiti Three-Year Investment Program and Its Framework -- to Achieve Accelerated, 2013 Balanced Economic Growth and Reduce Poverty 2014-2016

Kenya Kenya Vision 2030 First Medium Term Plan Update 2011

Liberia Poverty Reduction Strategy 2008

Madagascar Madagascar Action Plan 2007-2012 A Bold and Exciting Plan for Rapid 2007 Development

Malawi Malawi Growth and Development Strategy II 2011 – 2016 2012

Mali Plan for the Sustainable Recovery of Mali 2013-2014 2013

Mozambique Poverty Reduction Action Plan 2011-2014 2007

Nepal The 10th Plan (Poverty Reduction Strategy Paper) 2002-2007 2003

Niger Poverty Reduction Strategy Paper 2012-2015 2012

Nigeria Meeting Everyone's Needs – National Economic Empowerment and 2004 Development Strategy

Pakistan Accelerating Economic Growth and Reducing Poverty: The Road Ahead 2004

Rwanda Economic Development and Poverty Reduction Strategy 2013-2018 2013

Sierra Leone Poverty Reduction Strategy Pape: A National Programme for Food Security, 2005 Job Creation and Good Governance (2005-2007)

Sudan Interim Poverty Reduction Strategy Paper 2012

Appendices Page 126 Tanzania National Strategy for Growth and Reduction of Poverty II 2010

Togo Full Poverty Reduction Strategy Paper 2009-2011 2009

Zambia Fifth National Development Plan 2006-2010 2006 Table 28: Documents included in the Poverty Reduction Strategy Paper (PRSP) policy review

Appendices Page 127 Appendix 4.E. Composition, current status, and examples of country-level impacts of NCDI Poverty Commissions, Groups, and Consortia established since 2016

Completed National NCDI Poverty Commission reports can be accessed online at http://www.ncdipoverty.org/national-commission-reports.

Country Members Co-Chair Composition Status Examples of Country-level Impacts

Afghanistan 17 Ministry of Public Health Report in Draft Core support of the NCD Division at the Ministry of Public Health; coordination and mobilization of key stakeholders

Ethiopia 15 Federal Ministry of Completed: Recommendations included in essential health Health Launched services update and NCD strategic plan; November 2018 commission endorsed to serve as national technical working group (TWG) for NCDs; community awareness creation through mass media (newspapers, television); planning of facility-based NCDI service delivery assessment

Haiti 11 Ministry of Public Health Completed: To Commission endorsed to serve as national TWG and Population, Haitian be launched for NCDs; operational planning for scale-up of Foundation of Diabetes second quarter integrated NCDI service delivery at first-referral and Cardiovascular 2019 level hospitals Disease, Partners In Health

India 11 Institute of Economic Research Literature reviews and academic publications in Growth, Jan Swasthya initiatives in process under the India NCDI Poverty Research Sahyog, Tata Institute process consortium of Social Sciences University

Kenya 24 Ministry of Health, Completed: Recommendations included in health sector African Institute for Launched strategic planning and essential health services Health and March 2018 package update Development

Liberia 19 Ministry of Health, Completed: Core support for the NCD Division of the Ministry Partners In Health Launched of Health; coordination and mobilization of November 2018 stakeholders; operational planning for scale-up of integrated NCDI service delivery at first-referral level hospitals; contributions to global policy resolutions; planning convening for western Africa sub-regional NCDI implementation network

Malawi 26 Ministry of Health, Completed: Commission endorsed to serve as national TWG Partners In Health Launched for NCDs; seeding of research and August 2018 implementation collaborations amongst stakeholders; inclusion of socioeconomic indicators and mental health conditions and epilepsy in national STEPS survey, operational planning for scale-up of integrated NCDI service delivery at first-referral level hospitals

Mozambique 14 Mozambique Institute Completed: Coordination and mobilization of key for Health Education Launched June stakeholders; convening of southern African sub-

Appendices Page 128 and Research 2018 regional NCDI implementation network

Nepal 20 Ministry of Health, Completed: Recommendations included in design of national Tribhuvan University Launched health insurance coverage package; commission March 2018 endorsed to serve as national TWG for NCDs; contributed to global NCDI policy resolutions; community awareness creation through mass media (newspapers, television); planning of facility based NCDI service delivery assessment

Rwanda 16 Ministry of Health Analysis in Convening of eastern African sub-regional NCDI process implementation network, operational planning for scale-up of integrated NCDI service delivery at first-referral level hospitals

Tanzania 6 Ministry of Health, Report in draft Coordination and mobilization of key Community stakeholders; findings presented at national health Development, Gender, research conference Elderly, and Children; National Institute for Medical Research

Sierra Leone Commission newly established as of January 2019.

Uganda Commission newly established as of January 2019.

Zambia Commission newly established as of January 2019.

Zimbabwe Commission newly established as of January 2019.

Table 29: Composition, current status, and examples of country-level impacts of NCDI Poverty Commissions, Groups, and Consortia established since 2016

Appendices Page 129 Appendix 5.A. Voices of NCDI Poverty

VOICES of NCDI Poverty

Fede Francky, Haiti Spinal cord injury, 22 years old

Enock Maloya Phiri, Malawi Fortuna Messaye, Ethiopia Psychosis, 23 years old Leukemia, 14 years old

Estifanos Balcha, Ethiopia Pabitra Manandhar, Nepal Type 1 diabetes, 20 years old Chronic kidney disease, 26 years old

Gracia Vanel, Haiti Dipesh Rai, Nepal Sickle cell disease, 23 years old Rheumatic heart disease, 17 years old

Appendices Page 130 VOICES of NCDI Poverty

Fede Francky, Haiti Spinal cord injury, 22 years old

“The accident happened one day when I went to cut down a tree with my dad to make charcoal. As I was cutting the tree, it accidentally fell on me. Since then, things have been very di!cult. I am young and I used to be in school, even though my parents did not have a lot of "nancial means. But with the accident, our "nancial situation has gotten worse. And since then, I have been like this.“

Since the tree fell on him when he was 17, Fede • Falls, burns, and other unintentional Francky has been con!ned to a wheelchair and to the injuries account for 18% of the ramshackle house where he lives with his parents. burden of NCDIs under the age of 40 His family has taken him to six di"erent hospitals and spent all of their limited resources in the quest for among the poorest billion – more treatment that would allow him to walk again. But than cardiovascular disease, cancer, doctors have told him that he would need to go to the diabetes, and chronic respiratory United States or Cuba to !nd the kind of surgical care disease combined. that could make his dream come true.

“When I compare my life before and after the accident, it traumatizes me. Because before the accident, I used to go to school, and that gave me hope of a better future. But ever since, I lost all the opportunities that I could have had in life. Because the government does not look after people who are disabled. The way that I see disabled people can help their country is for the government to create professional schools for the disabled so they can also build their lives. If I could go to a professional school, I could help my family. Because I can still learn. This would help my family in the future. Because it is only physically that we are impaired. In spirit, we are just like everyone else.”

“The government needs to support and educate the youth, because the reason my situation has not gotten better "ve years later is that there are no neurosurgeons in Haiti. I would like the government to build schools for the youth of Haiti, so Haiti can have neurosurgeons just like any other country.”

Appendices Page 131 VOICES of NCDI Poverty

Gracia Vanel, Haiti Sickle cell disease, 23 years old “I was eight years old. I walked like a normal kid. I had a lot energy. Then I started feeling pain all over my body and inside my bones. My parents brought me to the hospital. Doctors did a range of tests and determined that I had sickle cell . After that I started to feel sick again. I went back to the hospital, where I stayed for four years.”

After his !rst long stay in the hospital, Gracia went back home and back to school. But he su"ered • Approximately 1,000 children are born repeated bouts of pain and fever and repeated trips to with sickle cell disease every day in the hospital. “Stress and infection can cause the pain. Africa, more than half of whom will Or if you don’t eat or hydrate well, it can cause the die before they reach the age of !ve.1 symptoms to get worse.” Then, when he was 22, both his parents died and his condition deteriorated.

“I couldn’t move my legs; I couldn’t move my toes. They became sti#. It did not happen all at once. First, I found that I lost sensation and strength in my knees. At "rst I just needed help getting up. It took years before I "nally had become paralyzed to the point where I could no longer walk. ”

Since he became paralyzed from the waist down, • More than 90 percent of children born Gracia has been con!ned to a wheelchair and to the with sickle cell disease in resource- isolated home in rural Haiti where his siblings have cared for him. He is able to go from his bedroom to a poor countries do not survive to 2 dirt courtyard without assistance, but no further. adulthood.

“It hurts me that I am not able to be more active. I was getting ready to graduate from high school. It’s painful to see my classmates graduating while I am not able to do much. I can move around the house. But if I want to leave the house or use the bathroom, I need to "nd someone to help me. Get up, eat, go outside, sit outside by myself – I don’t do much.”

“I still have hope that one day I can get up and walk again if I receive good care. There could be another medication that comes out one day that I can be treated with that will help me walk again. I had a dream to learn something that would be useful for society and my family – to see if I could help them too. I haven’t lost hope, as long as I have care. I hope to go back to school one day and realize my dreams.” 1. Modell B and Darlison M. Global epidemiology of haemoglobiin disorders and derived service indicators. Bull World Health Organ. 2008;86(6):480-487. 2. Grosse SD et al. Sickle cell disease in Africa: A neglected cause of early childhood mortality. Am J Prev Med 2011; 41(4): S398-405.

Appendices Page 132 VOICES of NCDI Poverty

Enock Maloya Phiri, Malawi Psychosis, 23 years old “From time to time I would have an attack. Fear would just strike me, and I would take o# running very fast. At that time, everyone was afraid of me. People would mock me shouting, “Crazy man! Crazy man!” People would beat me. Some threw rocks at me. Others tied me up, saying I should be killed... “

Enock Maloya was 19 years old and thriving in 2013. • Mental health and substance abuse Trained as a tailor by a development program, he was disorders account for nearly a third married and had a good job in the city, working for a (30%) of NCDI YLDs (years lived with former cabinet minister. Then “some things started disability) for adolescents and young happening.” He lost his job, separated from his wife, and #ed back to his home village. adults in the poorest billion.

“I never knew that a mentally ill person could get well. Because I have seen my friends who didn’t go to the hospital and sought help from traditional healers instead. Even now, they are still disturbed. Their illness hasn’t left them. But after I ran to the hospital, I got well. I feel "ne and healthy and energetic in a good way. I take my medicine at the proper time, and yeah, that’s the way.”

Since his uncle convinced him to go to the hospital, • In low- and middle-income countries, Enock has been taking his medications and has more than three-quarters (76% - bene!ted from regular visits from clinicians and 85%) of cases of severe mental illness community health workers. He has reunited with his go untreated.1 wife and children and resumed his career as a tailor.

“People are nice to me now. They bring their clothes for me to sew sometimes. Kids can get close to me now. In the past, they would shout, ‘Enock is coming!’ and all the kids would hide indoors. Now, my relationship with the community is great. Now, they call, ‘Mr. Phiri, Mr. Phiri.’ Yeah, I am a happy person. I can feel free, yeah.”

1. The WHO World Mental Health Survey Consortium. Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys. JAMA. 2004;291:2581-2590.

Appendices Page 133 VOICES of NCDI Poverty

Dipesh Rai, 17 years old, Nepal Rheumatic heart disease “The "rst time it happened, I had gone to a temple and fell ill after coming back that evening. I used to get headaches and a fever, and my feet felt numb. After I was sick for about two weeks, we took help from a shaman. They cut a chicken, but it didn’t help. After that I went to the hospital.” Dipesh Rai lives with his parents, two younger siblings, and his grandmother in rural Nepal. The family’s home was destroyed in the • Rheumatic heart disease a"ects devastating 2015 earthquake, and they have been forced to mortgage their small plot of land to pay for over 33 million people worldwide medical expenses. “I have no education and no work and causes more than 320,000 or job,” his father says. “We had hoped to educate the deaths each year. More than 99% of children so that they would be capable. But he has a prevalent cases and 82% of deaths heart ailment.” occur in LMICs where RHD is endemic.1 “The doctor said my valve is damaged and it needed an operation. But I came back home without doing the operation, because we didn’t have any money to pay for it. So we didn’t operate, and later as time went by, it became more di!cult to breathe. Now two of my valves are damaged, one of which is more severe. It needs to be replaced.“ Dipesh’s family has struggled to save and borrow money to pay for hospital bills, transportation costs, and the surgery they now understand he needs. “If we could cure him and educate • In low- and lower-middle income him, he would be able to clear the debts,” his mother countries, RHD is responsible for one explains. “But he is in this condition. He cannot work or third to half of all cardiac admissions earn. The little work we do is just enough to buy us food. to hospitals. Of 9-year-old children But the children fall sick and their grandmother cannot surviving acute rheumatic fever, 20% survive without medicines for high blood pressure and will be dead by the age of 15 and asthma. Life has always been hard. There has never been a happy day, not a single day.” more than 70% before the age of 25.# “I don’t feel good [about living in Kathmandu to be closer to treatment]. It does not feel like home. I think of my parents a lot. I want to educate myself so I can take care of them. They are very humble. They always agree to what other people say. I want to study Japanese so I can go to Japan to study and work. I will go to Japan, make money, and clear the loans. That’s my plan.” Months after this interview was conducted, Dipesh underwent successful surgery to replace two valves in his heart free of charge – shortly after Nepal expanded its pioneering public cardiac surgery program to fully subsidize all costs for RHD treatment, including surgery. 1. Watkins D et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. NEJM 2017; 377(8): 713-722. 2. Hewitson J and Zilla P. Children’s heart disease in sub-Saharan Africa. SA Heart J 2010; 7(1): 18-29.

Appendices Page 134 VOICES of NCDI Poverty Pabitra Manandhar, Nepal Chronic kidney disease, 26 years old “Life used to be good. I had a very beautiful family. We were four of us. I was pursuing my higher secondary education. I attended my classes regularly, and I also used to work in a "nance company. Suddenly my head started to hurt. I was unable to do the regular chores and missed a lot of working days. So I decided to go to the clinic. They told me my blood pressure was too high for someone my age. They prescribed medication and asked me to come back in a week. After a week, they suspected some issues with my kidney and sent me to a bigger hospital. The doctors told me that my condition wasn’t good.” Since Pabitra Manandhar was diagnosed with chronic kidney disease in 2010, life has become di$cult for her • An estimated 1.5 million people and her family. Pabitra had been the !rst member of her in South Asia su"er from chronic family to learn to read, and start a professional job. But kidney disease and between 190,000 she is no longer able to work, and her family has been and 380,000 from end stage renal forced to sell o" their land and go into debt to pay for disease.$ the dialysis treatment that keeps her alive. “I had to pay 2,500 rupees (US$25) for every dialysis. Neither I nor my family had enough money to pay for it. It was a very di!cult time. I had no money for dialysis. I felt hopeless. My dad o#ered to sell the land he owned. We all agreed as my life was more valuable than a piece of land.” Pabitra’s father is also in poor health. Soon after Pabitra fell ill, his eyesight began to fail and • In Southeast Asia, dialysis costs are construction contractors stopped hiring him as a more than 10 times the annual per laborer. More recently he was diagnosed with cancer. capita income, and health insurance Her brother. who had hoped to donate a kidney if they coverage for dialysis and CKD could ever a"ord transplant surgery, died by suicide. treatment is low or non-existent.$ Her mother, who works as a farm laborer, is now the sole breadwinner for the family. “I got my mother tested because she was willing to donate her kidney to me. With the loss of my brother, I saw my mother su#ering. Her health was deteriorating as she began losing weight. I decided not to take her kidney, because I cannot a#ord to lose her. Life will be worthless without her. We are bankrupt. The earthquake destroyed our house and we are living in this makeshift shelter. If only I had a piece of land, I could sell it for the treatment, build a house, and give my parents a good life.”

1. Nugent R, Fathim SF, Feigl AB, Chyung D. The Burden of Chronic Kidney Disease on Developing Nations: A 21st Century Challenge in Global Health. Nephron Clin Pract 2011;118:c269–c277.

Appendices Page 135 VOICES of NCDI Poverty

Estifanos Balcha, Ethiopia Type 1 diabetes, 20 years old “I have type 1 diabetes, the kind you need insulin for. From the age of 6 to 13, I lived on the street. Getting food was di!cult at times. When my sugar used to drop, I used to steal soda to get it up. On top of that, I didn’t have anywhere to put my medicine. So I used the refrigerator in various stores. I didn’t always take my medicine appropriately. I used to mess up the time, and sometimes I just didn’t care.” At the age of six, Estifanos Balcha was forced to fend • In much of sub-Saharan Africa, life for himself on the streets of Addis Ababa. His parents expectancy for children with type 1 had separated and neither of them wanted to take diabetes is less than one year after responsibility for a child with type 1 diabetes – a disease that is costly to treat and usually fatal for diagnosis.$ children in low-resource settings. “When I turned 16, I started to work. I looked for odd jobs so that I could earn money to pay for transportation to the doctor. But it was tough, so I tried to leave and go to Kenya. That didn’t work, so I tried to leave for Sudan. I wasn’t able to leave the country. But that’s OK. Those experiences got me here.”

The “here” Estifanos refers to is the Ethiopian Diabetes • In many countries in Africa, care for Association, where Misrak Tarekegn serves as Project Director. The Association provides treatment and a person with diabetes can cost from education for Estifanos and over 200 other children half to two-thirds of average yearly with Type 1 diabetes. As Misrak explains: “The fact that income, of which about half is the cost diabetes and other NCDs have not gotten the same of insulin.$ prioritization [as HIV, TB, and malaria] will always be an obstacle for our work. So what we want to tell the government is, even if their numbers are only 10 or 5 percent, each life has value.” Estifanos has his own message for the government and for the world: “The government must get involved with this issue. Let them get involved. Let them say, ‘We are here,’ so that we can have hope. I really ... I really ... I really have to pass this message on.”

1. Beran D and Yudkin JS. Diabetes care in sub-Saharan Africa. Lancet 2006; 368: 1689–95.

Appendices Page 136 VOICES of NCDI Poverty

Fortuna Messaye, Ethiopia Leukemia, 14 years old “My illness started when I was 10 years old. In the beginning, I felt sleepy when I went to school. I couldn’t learn; each time I sat down, I would fall asleep. They told me I had to come to Addis Ababa because they didn’t have the necessary equipment [in the village where her family lives]. My mother brought me here. At Black Lion Hospital, they took a bone marrow biopsy. It took 15 days for the results to be ready. Then they told me it was cancer. I went back to Black Lion Hospital and took a lot of chemo.”

Since she was diagnosed with leukemia, Fortuna • It is estimated that 100,000 children has lived in Addis Ababa, where she can receive die unnecessarily from cancer each chemotherapy and treatment for opportunistic infections. First her mother and then her grandmother year in low- and middle-income stayed with her. But both of them fell ill themselves countries. In Africa, on average, only and moved back to their village. And other relatives 5% of childhood cancers are cured, complained, “What’s the point of helping her, since compared to an 80% cure rate in the she will not live?” Since then, Fortuna has lived high-income countries.$ with the Mathios Wondu Ethiopian Cancer Society (MWECS), a community-based organization founded by the parents of a child who died of leukemia. “Now I am not going to school. I want to go to school here. I don’t have anyone in the village. If I go to the village, the kids who help my grandmother complain. They say, “How can we help two people?” Also, when I go there, I get very sick. I got really sick there two times.” Fortuna’s chemotherapy cost more than $8,000 over • A study at a cancer center in rural three years – 25 times the average per capita income Rwanda found that two common in Ethiopia. Fortuna would not have been able to a"ord her treatment without the support of MWECS. pediatric cancers (nephroblastoma and “We give services here for women and children from Hodgkin lymphoma) can be cured for rural areas who have cancer, “ explained Berhanu, less than $2,100 per patient for a full a nurse and social worker. “We give them food, course of treatment and follow-up.# transport, access to health care, and pay for medicine.” Fortuna’s goal is to become a doctor so that she can help make quality treatment available to others who need it: “The reason I want to be a doctor is to take care of people in my community and all others, to help them heal. Those who are sick have to know they can be cured. And they have to teach others that it’s possible. That’s what I think.”

1. Kerr D, Milburn A, Arbuthnott J. Building sustainable cancer capacity in Africa: prevention, treatment and palliation. AFROX 2007. http://www.afrox.org/uploads/ asset_!le/London Report.pdf (accessed March 21, 2019). 2. Neal C et al. Cost of treating pediatric cancer at the Butaro Cancer Center of Excellence in Rwanda. Journal of Global Oncology 2018; 4: 1-7.

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