This document analyzes the costs and benefits of screening and treatment programs for four non-communicable diseases in Andhra Pradesh, India: cardiovascular disease, diabetes, cervical cancer, and breast cancer. It finds that adequately screening and treating these diseases can effectively reduce mortality rates in a cost-effective manner. While costs of the programs are substantial, the economic and health benefits of averted deaths are much greater, resulting in benefit-cost ratios above 1 for cardiovascular disease, diabetes, and cervical cancer screening and treatment. Key interventions like polypill treatment for cardiovascular disease and metformin treatment for diabetes show especially high benefits relative to their costs. Increased funding for primary care-based non-communicable disease programs could generate significant returns on investment.

1. A Benefit-Cost Analysis of Screening and
Treatment for Non-Communicable Disease
Shreelata Rao Seshadri, Vijayalakshmi Hebbare
© 2017 Copenhagen Consensus Center
(This work has been produced as a part of the Andhra Pradesh Priorities project under the larger,
India Consensus project. This project is undertaken in partnership with Tata Trusts.)

2. Communicable,
maternal,
perinatal and
nutritional
conditions
37%
Injuries
10% CVD
24%
Cancers
6%
Respiratory
diseases
11%
Other NCDs Diabetes
10% 2%
NCDs are estimated to account for 53% of all deaths.
NCD mortality
2008 estimates males females
Total NCD deaths (000s) 2967.6 2273.8
NCD deaths under age 60 38.0 32.1
(percent of all NCD deaths)
Age-standardized death rate per 100 000
All NCDs 781.7 571.0
Cancers 78.8 71.8
Chronic respiratory diseases 178.4 125.5
Cardiovascular diseases and diabetes 386.3 283.0
Why Non-Communicable Disease ?
Morbidity due to non-communicable disease (NCDs) increased
significantly
World Health Organization - NCD Country Profiles , 2011.

4. NCDs Targeted for Intervention
In line with the National Program for Prevention and
Control of Cancer, Diabetes, CVD and Stroke (NPCDCS)
- CVD:
- Diabetes:
- Cervical Cancer:
- Breast Cancer:
Four Interventions:

5. Burden in Andhra Pradesh - 4 interventions
1990 2016
CVD 4878.26 5960.02
Diabetes 1559 1859
Cervical Cancer 113.52 89.97
Breast Cancer 82.89 121.69
DALYs per100000
Interventions

6. 1. CVD: Secondary Prevention with
Multidrug Polypill
• Target: To screen 70% of all persons aged 30-69
for CVD
• Objective: To identify those who are at high risk of
CVD or with existing CVD
• Intervention: To treat identified persons with a
multidrug polypill, achieving 60% adherence to
treatment
• Outcome: Averting about 20% of CVD mortality

7. 2. Diabetes screening and treatment with
Metformin therapy
• Target: To screen all persons aged 30-
69 for diabetes
• Objective: To identify those who are at
high risk of diabetes
• Intervention: Achieve 50% coverage of
the target group annually, and 65%
adherence to Metformin treatment
• Outcome: Avoidance of diabetes in
about 30% of high risk individuals

8. 3. Cervical Cancer screening with VIA/VILI
• Target: To screen women in the age group 30-
69 one through VIA/VILI
• Objective: To identify women with lesions and
provide appropriate follow-up referral/treatment
• Intervention: To cover 30% of women in the
target group annually for the first 3-4 years, and
women entering the cohort in subsequent years
• Outcome: Averting about 35% of deaths through
screening and early detection

9. 4. Breast Cancer screening through CBE
• Target: Women in the age group 30-69
• Objective: To screen eligible women through
biennial Clinical Breast Exam (CBE)
• Intervention: To cover 50% of women in the target
group annually each year, eventually achieving
100% coverage of this age group
• Outcome: Averting about 16% of deaths through
screening and early detection

10. Estimation of Costs & Benefits
Specific Interventions

11. Cost Estimates
• Cost estimates based on secondary data sources
generated in similar contexts, extrapolated to
2018-2030
• The total costs include private costs of seeking
out-patient care, treatment costs and opportunity
costs of lost wages
• The aggregated costs were then applied to the
total target population and then discounted at 3%,
5% and 8%

12. Benefits
• Benefits were estimated based on the number of deaths
averted by the selected intervention, the estimated number
of years of life saved, multiplied by the value of one YLL
• Total deaths due to each selected disease for the specified
target population were estimated from the Global Burden of
Disease 2017
• Proportion of deaths possible to be averted were estimated
based on the available evidence in the literature

13. Intervention Costs
30-69 Population
70%
coverage
for CVD
Hypertensi
on
prevalence
Number
of cases
detected
60% adherence
to treatment
regimen
(Polypill)
Cost per
person
treated (Rs.)
Total cost 2017
(Rs.)
Male 9404990 6583493 0.164 1079693 647816 4107.7 2,661,032,679
Female 9036167 6325317 0.1 632532 379519 3958.7 1,502,401,944
10% screeing (Male) 5935677 292 1733217822
10% screeing (Female) 5945798 143 850249111
6,746,901,556
30-69
Populati
on
50%
screening
coverage
Diabetes
prevalence
Screening
cases
65%
Metoformin
treatment
Cost per
person
treated (Rs.)
Total cost 2017
(Rs.)
Male 9404990 4702495 0.157 738292 479890 2,103.03 1,009,222,288
Female 9036167 4518084 0.131 591869 384715 1,954.03 751,744,292
1,760,966,580
30% (OF 65% Metoformin treatment - Male) 143967 1,811.03 260,728,355
30% (OF 65% Metoformin treatment - Female) 115414 1,811.03 209,019,022
469,747,377
Intervention 1 - CVD
Intervention 2 - Diabetes
TOTAL
TOTAL
TOTAL

14. Intervention Costs
Screening one
time with
VIA/VILI
cost per
person 2017
(Rs.)
Total cost 2017
(Rs.)
Female 9036167 30% screening (3 yrs) 2710850 2813.1 7,625,892,536
5% next 10Yrs 451808 2813.1 1,270,982,089
Cryosurgery for 10% of women (Poli et al 2015)271085 2332.76 632,376,278
Cryosurgery for 3% of 5% 13554 2332.76 31,618,813
Total cost 1st 3years 8,258,268,814
From 4th Year 1,302,600,903
Female 9036167 50% coverage 4518084 550.13 2,485,533,314.79
Intervention 3 - Cervic Cancer
Intervention 4 - Breast Cancer
30-69 Population

15. Benefit – Cost Ratio
4 Specific Interventions

16. Total costs, total benefits and cost-benefit ratio
Intervention - CVD
Discount rate
3% 5% 8%
Benefit (Crs) 191,676 136,464 85,815
Cost (Crs) 5,020 4,399 3,664
BCR 38.2 31 23.4

17. Total costs, total benefits and cost-benefit ratio
Intervention - Diabetes
Discount rate
3% 5% 8%
Benefit (Crs) 15,061 10,723 6,743
Cost (Crs) 656 588 507
BCR 23 18.2 13.3

18. Total costs, total benefits and cost-benefit ratio
Intervention - Cervical Cancer
Discount rate
3% 5% 8%
Benefit (Crs) 7,176 5,039 3,118
Cost (Crs) 3,439 3,184 2,866
BCR 2.1 1.6 1.1

19. Total costs, total benefits and cost-benefit ratio
Intervention - Breast Cancer
Discount rate
3% 5% 8%
Benefit (Crs) 3,082 2,166 1,338
Cost (Crs) 6,408 5,615 4,677
BCR 0.5 0.4 0.3

20. Benefit – Cost Ratio - Interventions

21. Key Takeaways
• Adequate coverage of screening and treatment services at the
primary level can detect NCDs early and reduce treatment
costs
• It can also avert a large number of deaths in a cost-effective
manner
• Funding for NCD screening and treatment programs need to be
scaled-up substantially, and spent effectively at the primary
care level
• These findings could provide important inputs for the
decentralized health planning and monitoring recommended by
the National Health Policy 2017 and the NITI Aayog Action
Agenda 2017–2020.

22. Data Sources
1. Target population - India’s 2011 census age-specific data - Ministry of
Home Affairs website (data.gov.in).
2. Death and YLD numbers - Global Burden of Disease Study (2016) -
Institute for Health Metrics and Evaluation (IHME) University of
Washington, Seattle. http://www.hehalthdata.org/gbd/data
3. Data on burden of risk factors (hypertension, blood sugar levels) -
National Family Health Survey, NFHS -4
http://rchiips.org/NFHS/pdf/NFHS4/RJ_FactSheet.pdf.
4. Data on the private costs of health - National Sample Survey (NSS)
71st Round (2014) http://mospi.nic.in/.

23. Data Sources
Estimates of unit costs / deaths averted
a) Chow et al (Chow J, Darley S, Laxminarayan R. Cost-
effectiveness of disease interventions in India.
RFP DP 07-53, Resources for the Future, Washington DC;
2007).
(b) Nugent R. Benefits and costs of the NCD targets for the
post-2015 development agenda. Perspective paper,
Copenhagen Consensus Center (updated January 6, 2017);
(c) Gelband H, Jha P, Sankanarayanan R and Horton S. Cancer.
Disease Control Priorities Project – 3, 2016