Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review
Kavita Singh, Ambalam M Chandrasekaran, Soumyadeep Bhaumik, Kaushik Chattopadhyay, Anuji Upekshika Gamage, Padmal De Silva, Ambuj Roy, Dorairaj Prabhakaran, Nikhil Tandon
BMJ Open · 2018 · DOI: 10.1136/bmjopen-2017-017809
Countries: India, Bangladesh, Pakistan, Bhutan
What Was Studied
This systematic review searched 14 electronic databases and hand-searched the Disease Control Priorities Project 2 (DCPP2) and WHO-CHOICE registries for economic evaluations of interventions to control cardiovascular disease (CVD) and diabetes mellitus (DM) in South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka), published in English through August 2016. Of 2,949 records identified, 42 studies met full inclusion criteria after screening 85 full texts: 9 economic evaluations nested within observational studies, 12 within randomised controlled trials, and 21 based on decision models. Together, these studies evaluated 301 policy, clinical or behavioural interventions against no-intervention or active comparators, with methodological quality appraised using the Drummond, Evers and Philips checklists, and cost-effectiveness classified against each country's GDP-per-capita-per-QALY/DALY threshold.
What They Found
Of the 42 included studies, quality was rated excellent in 15, good in 18 and poor in 9; the evidence was heavily concentrated in India (37 studies), with only 3 from Bangladesh, 2 from Pakistan and 1 from Bhutan, and none from Nepal. Many primordial and primary prevention interventions were highly cost-effective (ICER below 1x GDP per capita per QALY/DALY): a tobacco tax increase alone (ICER US$207 per DALY averted), and tax increases combined with advertisement bans or clean indoor air laws (ICER US$366-529 per DALY averted); population-wide salt-reduction and dietary interventions ranged from US$40 to US$106 per DALY averted. A Bhutan modelling study found that the country's Package of Essential Non-communicable disease interventions (PEN) screening programme for diabetes and hypertension was cost-saving compared with no screening, with further cost savings from expanding to universal screening. By contrast, one Indian model found diabetes-only screening (without added risk factors such as hypertension) was not cost-effective (ICER US$11,671 per DALY averted, more than 3x GDP per capita). For secondary/tertiary prevention, multidrug treatment for CVD in high-risk groups (>35% ten-year cardiovascular risk) was cost-saving, and in the Indian Diabetes Prevention Programme trial, lifestyle modification plus metformin needed to treat 6.5 people to prevent one case of diabetes (ICER US$2,973, 1-3x GDP per capita). Diabetic retinopathy screening every 2-5 years was also found cost-effective, though not highly so (ICER 1-3x GDP per capita per QALY gained).
What This Means for Nepal
Nepal's 2026 health-system reform priorities explicitly include expanding WHO PEN at primary care and stocking essential NCD medicines within the Basic Health Service Package (BHSP) -- this review's strongest primordial/primary-prevention evidence (tobacco taxation, salt-reduction legislation, and Bhutan's cost-saving PEN-based diabetes/hypertension screening) directly supports that agenda, since Bhutan is the most comparable Himalayan LMIC setting reviewed. However, all cost-effectiveness estimates here use India's, Pakistan's or Bhutan's GDP-per-capita thresholds and health-system costs, not Nepal's -- before MoHP or the Department of Health Services (DoHS) scale up PEN screening nationally, they should commission a Nepal-specific costing study (replicating the Dukpa et al (2015) Bhutan model using Nepali price levels and public facility costs) rather than assume the Bhutan ICER transfers directly. Given that zero of the 42 studies in this review were conducted in Nepal, MoHP -- as the federal body constitutionally responsible for health policy and standards (Constitution Schedule 5) -- should also prioritise building standing health technology assessment (HTA) capacity, as the review itself recommends for South Asia broadly, to generate the local cost and effectiveness data needed to prioritise NCD investment within Nepal's constrained ~4.9%-of-budget health financing envelope.
Contextualisation
Nepal's NCD burden is severe -- cardiovascular disease and diabetes together drive an estimated 66-71% of all deaths, with adult hypertension at 24.5% and raised blood glucose at 5.8% (STEPS 2019) -- yet government health spending remains only about 4.9% of the national budget (FY2025/26) and out-of-pocket spending covers 54.2% of health costs. This systematic review compiles South Asian cost-effectiveness evidence directly relevant to Nepal's current reform priorities of expanding the WHO Package of Essential Non-communicable Disease interventions (PEN) at primary care and stocking essential NCD medicines in the Basic Health Service Package (BHSP), including a Bhutan modelling study that found the PEN-based diabetes and hypertension screening programme to be cost-saving compared with no screening at all. Critically, however, none of the review's 42 included studies were conducted in Nepal (37 were from India alone) -- an evidence gap that the Ministry of Health and Population (MoHP) and Department of Health Services (DoHS) should address as WHO PEN scale-up proceeds.