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WHO Discussion Paper (version dated 25 July 2016) Draft Updated Appendix 3 of the WHO Global NCD Action Plan 2013-2020

MANDATE

1.
Resolution WHA69.6 noted "the process to update, in 2016, Appendix 3" and requested DG "to submit an updated Appendix 3 of the global action plan for the prevention and control of
noncommunicable diseases 2013–2020, through the Executive Board, to the Seventieth World
Health Assembly in 2017, in accordance with the timeline contained in Annex 2 of document
A69/10"1. This WHO Discussion paper is prepared pursuant to this resolution.

BACKGROUND

2.
In the Director General's report to the 68th World Health Assembly in May 20152, the WHO Secretariat committed to update Appendix 3 of thto consider new scientific evidence since
the initial list was prepared.
3.
Appendix 3 consists of a menu of policy options to support the implementation of the 6 objectives of the Global NCD Action Plan. These 81 recommendations include 14 interventions which are classified as "very cost-effective and affordable interventions for all Member States"3 (previously referred to as the "best buys"), as well as other cost-effective interventions (previously referred to as "good buys"). The purpose is to assist Member States in implementing, as appropriate, for national context, (without prejudice to the sovereign rights of nations to determine taxation among other policies), actions to achieve the nine voluntary global targets for NCD prevention and control. The list of interventions is not exhaustive but is intended to provide information and guidance on effectiveness and cost-effectiveness of population-based and individual interventions based on current evidence, and to act as the basis for future work to develop and expand the evidence base. 4. The main reasons for updating Appendix 3 are firstly, to take into consideration the emergence of new evidence of cost-effectiveness or new WHO recommendations since the adoption of the WHO Global NCD Action Plan 2013-2020, and secondly, to refine the existing formulation of some interventions based on lessons learnt from the use of the first version. The area of Appendix 3 where this is most relevant is under Objective 3 (risk factors) and Objective 4 (health systems). All of 1 http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R6-en.pdf 2 Paragraph 21 in http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_11-en.pdf 3 Generate an extra year of healthy life for a cost that falls below the average annual income or GDP per person Page 1 of 26
the "very cost-effective and affordable interventions for all Member States" interventions in the
original Appendix were listed under Objectives 3 and 4, and this remains the case in the updated
version. The Global Action Plan for the prevention and control of noncommunicable diseases ends
in 2020, and once the updated Appendix 3 is presented to the World Health Assembly in 2017, any
future updates will be considered as part of the development of any subsequent global strategies for
noncommunicable diseases.

PROCESS FOLLOWED BY THE SECRETARIAT TO UPDATE APPENDIX 3

5.
The Secretariat has convened two technical consultations to seek expert advice on the approach to this work. The first technical consultation was held on 22-23 June 20154, to advise the WHO Secretariat on a suitable methodology for conducting the update of Appendix 3. This methodology was presented to Member States at the Executive Board in January 2016, and endorsed at the World Health Assembly in May 20165. Following the process endorsed by Member States, the Secretariat identified a revised list of 119 potential interventions, including 53 with updated economic data analysed through WHO-CHOICE. 6. A second technical consultation was held in Geneva, 27-28 June 20166, to review the updated economic analyses and discuss the criteria for determining the "very cost-effective & affordable interventions" from the updated list of interventions, and advise on how to structure and present the broad range of policy interventions (some which are suited to economic analysis and some which are not) in a user-friendly way to support implementation of the Global Action Plan in Member States. 7. Through both technical consultations, it was acknowledged that there are inherent challenges in identifying a core list of interventions whilst being comprehensive enough to meet the needs of Member States. The limitations of considering cost-effectiveness in isolation were also recognised, together with the absence of objective criteria for incorporating non-financial considerations into recommendations. Acknowledging these challenges, the Secretariat was urged to be as clear and specific as possible regarding the methodology and source/nature of evidence, while clearly communicating the limitations of economic modelling and not creating false sense of confidence in the precision of any economic values. The Secretariat was also advised to retain familiarity and consistency with the existing Appendix 3 and previously agreed global strategies, to maintain momentum and progress underway in Member States.This update of Appendix 3 is accompanied by a technical annex. This annex provides more detailed information about the methodology used to identify and analyse interventions, and includes the assumptions used in the WHO-CHOICE economic modelling7. The technical annex also presents more detailed economic analyses for each intervention, structured in a variety of ways to provide more information for decision-makers. This includes presenting the results of the economic analysis separately for low and lower-middle income, and upper-middle and high income countries. The Secretariat will also consider the utility of providing this information in an interactive web-tool, to enable users to compare and rank the information according to their own needs once the updated Appendix 3 is finalized. 6 7 http://www.who.int/choice/cost-effectiveness/en/ Page 2 of 26
PROPOSED UPDATED APPENDIX 3

8.
Annex 1 outlines the proposed structure and content of the updated Appendix 3. This includes: – A proposed preamble text to the Appendix 3 – The updated list of interventions for the main Appendix 3, and – An annotated outline of the proposed technical Annex, which would include more details about the economic analysis, and methodological information. This would be accompanied at a later stage by an interactive web-based version of the economic analysis, so that users could structure the tables according to their own needs. TIMELINE AND NEXT STEPS

9.
As per the approach shared with Members States, the timeframe and next steps for finalising the updated Appendix 3 is as follows:
Dates
Activity
22 July 2016 until The Secretariat will hold a web-based consultation on a WHO Discussion 1 September 2016 Paper which will contain a preliminary updated Appendix 3. The WHO Discussion Paper will be published in English first, and versions in the other five languages will follow shortly. The web-based consultation will be open to Member States, organizations of the UN System, and non-State actors. All contributions received will be published on WHO's website. The Secretariat will convene an informal consultation of Member States in the Executive Board Room on the WHO Discussion Paper. Interpretation will be provided in all six languages. The Secretariat will convene informal hearings with non-State actors in the Executive Board Room on the WHO Discussion Paper. The Secretariat will submit a final draft of the updated Appendix 3 to WHO's Governing Bodies for processing and translation, which will enable Member States to access the EB140 report containing the updated Appendix 3 in November 2016 in preparation for EB140 in January 2017. EB140 will consider the draft updated Appendix 3. Pending discussions at EB140, the final draft of the updated Appendix 3 will be submitted to WHA70 for consideration by Member States. Page 3 of 26
Annex 1. Proposed updated Appendix 3 of the Global Action Plan for the
prevention and control of noncommunicable diseases 2013-2020
What is Appendix 3?

Provided at the request of Member States, Appendix 3 is a menu of policy options and cost-effective
interventions for prevention and control of major noncommunicable diseases. The purpose is to
assist Member States in implementing, as appropriate, for national context, (without prejudice to
the sovereign rights of nations to determine taxation among other policies), actions to achieve the
nine voluntary global targets for NCD prevention and control through the six objectives of the NCD
Global Action Plan 2013-2020. The list of interventions is not exhaustive but is intended to provide
information and guidance on effectiveness and cost-effectiveness of population-based and individual
interventions based on current evidence, and to act as the basis for future work to develop and
expand the evidence base.
Why update Appendix 3?

The main reasons for updating Appendix 3 are firstly, to take into consideration the emergence of
new evidence of cost-effectiveness or new WHO recommendations since the adoption of the Global
Action Plan for the prevention and control of noncommunicable diseases 2013, and secondly, to
refine the existing formulation of some interventions based on lessons learnt from the use of the
first version. The area of Appendix 3 where this is most relevant is under Objective 3 (risk factors)
and Objective 4 (health systems). All of the "very cost-effective and affordable interventions for all
Member States" interventions in the original Appendix were listed under Objectives 3 and 4, and this
remains the case in the updated version. The Global Action Plan for the prevention and control of
noncommunicable diseases ends in 2020, and once the updated Appendix 3 is presented to the
World Health Assembly in 2017, any future updates will be considered as part of the development of
any subsequent global strategies for noncommunicable diseases.
What has changed?

The menu of options listed for Objectives 1 (raising the priority of NCDs), 2 (strengthening leadership
& governance), 5 (research) and 6 (monitoring & evaluation) are process-related recommendations
and have not changed.
Within Objectives 3 (risk factors) and 4 (health systems), in the updated Appendix 3, there are a now
a total of 88 interventions and overarching/enabling actions, representing an expansion from the
original list of 62. This increase is due to the availability of scientific evidence as proposed by WHO
technical units or expert groups, as well as the need to disaggregate some previous interventions
into more defined, implementable options. As in the first Appendix, a select number of those
interventions which are considered most cost-effective and feasible for implementation are
identified in bold. In the updated Appendix, there are now 15 bolded interventions with an average
cost-effectiveness ratio of ≤I$8100/DALY averted in low and lower middle income countries and 19
interventions with a cost-effectiveness ratio >I$100/DALY. In addition 30 interventions without CEA
but are part of WHO guidance are also provided.
8 The International dollar is a hypothetical unit of currency that has the samethat thehad in theat a given point in time. Page 4 of 26
Technical annex

Based on feedback from experts and Member States, this update of Appendix 3 is accompanied by a
technical annex. This annex provides more detailed information about the methodology used to
identify and analyse interventions, and includes the assumptions used in the WHO-CHOICE economic
modelling. The technical Annex also presents more detailed economic analyses for each
intervention, structured in a variety of ways to provide more information for decision-makers. This
includes presenting the results of the economic analysis separately for low and lower-middle income,
and upper-middle and high income countries. The Secretariat may also provide this information in
an interactive web-tool, to enable users to compare and rank the information according to their own
needs.
How to use this information

The economic analyses in the technical annex, upon which this list is based, give an assessment of
cost-effectiveness ratio, health impact and the economic cost of implementation. These economic
results present a set of parameters for consideration by Member States, but it must be emphasised
that such global analyses should be accompanied by analyses in the local context. Other tools, such
as the One Health Tool are available to help individual countries cost specific interventions in their
national context.
When considering interventions for prevention and control of noncommunicable diseases, emphasis
should be given to both economic and non-economic criteria, as both will affect the implementation
and impact of interventions. Non-economic implementation considerations such as acceptability,
sustainability, scalability, equity, ethics, multisectoral actions and monitoring are essential in
preparing to achieve the targets of the global action plan and should be considered before the
decision to implement items in Appendix 3.
Page 5 of 26
Objective 1: To raise the priority accorded to the prevention and control of
noncommunicable diseases in global, regional and national agendas and
internationally agreed development goals, through strengthened
international cooperation and advocacy
Overarching/enabling actions
 Raise public and political awareness, understanding and practice about prevention and control
 Integrate NCDs into the social and development agenda and poverty alleviation strategies  Strengthen international cooperation for resource mobilization, capacity-building, health workforce training and exchange of information on lessons learnt and best practices Engage and mobilize civil society and the private sector as appropriate and strengthen international cooperation to support implementation of the action plan at global, regional and national levels Implement other policy options in objective 1
Objective 2: To strengthen national capacity, leadership, governance,
multisectoral action and partnerships to accelerate country response for the
prevention and control of noncommunicable diseases
Overarching/enabling actions
 Prioritize and increase, as needed, budgetary allocations for prevention and control of NCDs
without prejudice to the sovereign right of nations to determine taxation and other policies  Assess national capacity for prevention and control of NCDs  Develop and implement a national multisectoral policy and plan for the prevention of control of NCDs through multi-stakeholder engagement Implement other policy options in objective 2 to strengthen national capacity including human and institutional capacity, leadership, governance, multisectoral action and partnerships for prevention and control of noncommunicable diseases Page 6 of 26
Objective 3: To reduce modifiable risk factors for noncommunicable diseases
and underlying social determinants through creation of health-promoting
environments
Tobacco Use

Overarching/enabling actions
 Strengthen the effective implementation of the WHO Framework Convention on Tobacco
 Establish and operationalize national mechanisms for coordination of the FCTC implementation as part of national strategy with specific mandate, responsibilities and resources
Specific interventions with WHO-CHOICE analysis9
Non-financial
considerations
Strengthen the implementation of tax policy and administrative
measures to reduce the demand for tobacco products
Comprehensive ban of tobacco advertising, promotion and sponsorship, Requires capacity for
including cross-border advertising and on modern means of
implementing and enforcing regulations Implementation of plain/standard packaging and/or large graphic
health warnings on all tobacco packages
Elimination of exposure to second-hand tobacco smoke in all indoor
workplaces, public places, public transport, and in all outdoor mass-
gathering places
Provision of cost-covered, effective and population-wide support Requires sufficient, (including brief advice, national toll-free quit line services and trained providers and mCessation) for tobacco cessation to all those who want to quit a better functioning health system
Other interventions from WHO Guidance (without WHO-CHOICE analysis)

Implement measures to minimize illicit trade in tobacco products 9 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low and lower middle income countries. Page 7 of 26
Harmful Use of Alcohol

Overarching/enabling actions
 Implement the WHO global strategy to reduce harmful use of alcohol through actions in the
recommended target areas including:  Strengthen awareness of alcohol-attributable burden; leadership and political commitment to reduce the harmful use of alcohol  Provide prevention and treatment interventions for those at risk of or affected by alcohol use disorders and associated conditions  Support communities in adopting effective approaches and interventions to prevent and reduce the harmful use of alcohol  Implement effective drink-driving policies and countermeasures  Regulate commercial and public availability of alcohol  Restrict or ban alcohol advertising and promotion  Use price policies such as excise tax increases on alcoholic beverages  Reduce the negative consequences of drinking and alcohol intoxication, including by regulating the drinking context and providing consumer information  Reduce the public health impact of illicit alcohol and informally produced alcohol by implementing efficient control and enforcement systems Develop sustainable national monitoring and surveillance systems using indicators, definitions and data collection procedures compatible with WHO's global and regional information systems on alcohol and health
Specific interventions with WHO-CHOICE analysis10
Non-financial
considerations
Increase in excise taxes on alcoholic beverages
Levying taxes should be combined with other price measures, such as bans on discounts or promotions Enforcement of bans or comprehensive restrictions on alcohol
Requires capacity for advertising (across multiple types of media)
implementing and Enforcement of restrictions on the physical availability of retailed
enforcing regulations alcohol (via reduced density of retail outlets and reduced hours of
Enforcement of drink-driving laws and blood alcohol concentration limits via sobriety checkpoints Provision of brief psychosocial intervention for persons with Requires trained hazardous and harmful alcohol use providers at all levels of health care 10 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low and lower middle income countries. Page 8 of 26
Unhealthy Diet
Overarching/enabling actions
 Implement the WHO Global Strategy on Diet, Physical Activity and Health
 Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to

Specific interventions with WHO-CHOICE analysis11
Non-financial
considerations
Reduce salt intake by engaging the industry in a voluntary
Requires multisectoral reformulation process
actions with relevant Reduce salt intake through establishment of a supportive
ministries and support environment in public institutions such as hospitals, schools and
by civil society nursing homes to enable low sodium meals to be provided
Reduce salt intake through a behaviour change communication mass
media campaign
Reduce salt intake through implementation of front-of-pack labelling Regulatory capacity
along with multisectoral Complete elimination of industrial trans fats through the development action is needed of legislation banning their use in the food chain
Other interventions from WHO Guidance (without WHO-CHOICE analysis)

Promote and support exclusive breastfeeding for the first 6 months of life, including promotion of breast feeding Implement subsidies to increase the intake of fruits and vegetables Replace trans fats and saturated fats with unsaturated fats through reformulation, labelling and fiscal and agricultural policies Reduce sugar consumption through taxation on sugar sweetened beverages Limiting portion size to reduce energy intake and the risk of childhood overweight/obesity Implementing nutrition education and counselling in different settings (i.e. schools, workplaces, hospitals etc) to increase the intake of fruits and vegetables Nutrition labelling to improve macronutrient intake, and reduce total energy intake (kcal) Nutrition labelling in educational settings to improve dietary intake Implement mass media campaign on healthy diets, including social marketing to reduce the intake of total fat, fibre and salt, and promote the intake of fruits and vegetables 11 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low and lower middle income countries. Page 9 of 26
Physical Inactivity

Overarching/enabling actions
 Implement the WHO Global Strategy on Diet, Physical Activity and Health

Specific interventions with WHO-CHOICE analysis
Non-financial
considerations
Provide physical activity counselling as part of routine primary Requires sufficient, health care services through the use of a brief intervention trained capacity in primary care
Other interventions from WHO Guidance (without WHO-CHOICE analysis)

Ensure macro-level urban design incorporates the core elements of residential density, connected street networks, easy access to a diversity of destinations and access to public transport Implement public awareness and motivation programmes for physical activity, including mass media campaign for the behavioral change of physical activity levels Ensure that adequate facilities are available on school premises to support recreational physical activity for all children Provide safe and adequate infrastructure to support walking and cycling Implement multi-component workplace physical activity programmes Page 10 of 26
Objective 4: To strengthen and orient health systems to address the
prevention and control of noncommunicable diseases and the underlying
social determinants through people-centred primary health care and
universal health coverage
Overarching/enabling actions
 Integrate very cost-effective noncommunicable disease interventions into the basic primary
health care package with referral systems to all levels of care to advance the universal health coverage agenda  Explore viable health financing mechanisms and innovative economic tools supported by  Scale up early detection and coverage, prioritizing very cost-effective high-impact interventions including cost-effective interventions to address behavioural risk factors  Train health workforce and strengthen capacity of health system particularly at primary care level to address the prevention and control of noncommunicable diseases  Improve availability of affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases, in both public and private facilities  Implement other cost-effective interventions and policy options in objective 4 to strengthen and orient health systems to address noncommunicable diseases and risk factors through people-centred health care and universal health coverage  Develop and implement a palliative care policy, including access to opioids analgesics for pain relief, together with training for health workers  Expand the use of digital technologies to increase health service access, efficacy and equity for NCD prevention, and to reduce the costs in health care delivery Page 11 of 26
Cardiovascular Disease and Diabetes

Specific interventions with WHO-CHOICE analysis12
Non-financial
considerations
Drug therapy (including glycaemic control for diabetes mellitus and
control of hypertension using a total risk approach)and counselling to
resource settings, individuals who have had a heart attack or stroke and to persons with
including by non- high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the
physician health next 10 years
Drug therapy (including glycaemic control for diabetes mellitus and
Applying lower risk control of hypertension using a total risk approach)and counselling to
threshold increases individuals who have had a heart attack or stroke and to persons with
health gain but also moderate to high risk (≥ 20%) of a fatal and non-fatal cardiovascular
event in the next 10 years
implementation cost Treatment of new cases of acute myocardial infarction with either: Selection of option acetylsalicylic acid, or acetylsalicylic acid and clopidogrel, or depends on health thrombolysis, or primary percutaneous coronary interventions (PCI) Primary prevention of rheumatic fever and rheumatic heart diseases by increasing treatment of pharyngitis at the primary care level prevalence in specific countries or sub-populations Secondary prevention of rheumatic fever and rheumatic heart disease (by developing a register of patients who then receive regular prevalence in specific prophylactic penicillin) countries or sub-populations
Other interventions from WHO Guidance (without WHO-CHOICE analysis)
Treatment of congestive cardiac failure with ACE inhibitor, beta-blocker and diuretic Cardiac rehabilitation post myocardial infarction Anticoagulation for medium-and high-risk non-valvular atrial fibrillation and for mitral stenosis with atrial fibrillation Low-dose acetylsalicylic acid for ischemic stroke Care of acute stroke and rehabilitation in stroke units 12 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in low and lower middle income countries. Page 12 of 26
Diabetes*
*Note that diabetes interventions are also covered in the previous section on cardiovascular disease
& diabetes
Specific interventions with WHO-CHOICE analysis
Non-financial
considerations
Preventive foot care for people with diabetes (including educational Requires systems programmes, access to appropriate footwear, multidisciplinary clinics) for patient recall Diabetic retinopathy screening for all diabetes patients and laser photocoagulation for prevention of blindness Effective glycaemic control for people with diabetes, along with standard home glucose monitoring to reduce diabetes complications
Other interventions from WHO Guidance (without WHO-CHOICE analysis)
No
Lifestyle interventions for preventing type 2 diabetes Influenza vaccination for patients with diabetes Preconception care among women of reproductive age including patient education and intensive glucose management Screening of people with diabetes for proteinuria and treatment with ACE-inhibitor for the prevention and delay of renal disease Page 13 of 26
Cancer

Specific interventions with WHO-CHOICE analysis13
Non-financial
considerations
HPV vaccination (2 doses) of 9-13 year old girls
Prevention of cervical cancer through screening women aged 30-
VIA is feasible in low 49, either through:
resource settings,  VIA (visual inspection with acetic acid) linked with timely including with non-
treatment of pre-cancerous lesions
physician health  Pap smear (cervical cytology) every 3-5 years linked with workers. Pap smear
timely treatment of pre-cancerous lesions
 HPV test every 5 years linked with timely treatment of
pre-cancerous lesions
capacity. Requires systems for organised, population-based screening Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy Treatment of breast cancer stages I and II with surgery +/- systemic therapy Screening with mammography (once every 2 years for women Requires systems for aged 50-69 years) linked with timely diagnosis and treatment of population-based screening Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy Basic palliative care for cancer: home-based and hospital care with Requires access to multi-disciplinary team and access to opiates and essential controlled medicines supportive medicines
Other interventions from WHO Guidance (without WHO-CHOICE analysis)
No
Prevention of liver cancer through hepatitis B immunization Oral cancer screening in high-risk groups (eg tobacco users, betel-nut chewers) linked with timely treatment Population-based colorectal cancer screening, including through a faecal occult blood test, as appropriate, at age >50, linked with timely treatment

13 Interventions in bold fonts are those with an average cost-effectiveness ratio of ≤ I$100/DALY averted in
low and lower middle income countries.
Page 14 of 26
Chronic Respiratory Diseases

Specific interventions with WHO-CHOICE analysis
Non-financial
considerations
Treatment of chronic obstructive pulmonary disease with inhaled Treatment of asthma with oral prednisolone, theophylline and high dose inhaled beclomethasone Treatment of asthma using low dose inhaled becalmethasone and short acting beta agonist

Other interventions from WHO Guidance (without WHO-CHOICE analysis)
No
Access to improved stoves and cleaner fuels to reduce indoor air pollution Cost-effective interventions to prevent occupational lung diseases, eg from exposure to silica, asbestos Influenza vaccination for patients with chronic obstructive pulmonary disease Page 15 of 26
Objective 5: To promote and support national capacity for high-quality
research and development for the prevention and control of
noncommunicable diseases
Overarching/enabling actions
 Develop and implement a prioritized national research agenda for noncommunicable diseases
 Prioritize budgetary allocation for research on noncommunicable disease prevention and control
 Strengthen human resources and institutional capacity for research
 Strengthen research capacity through cooperation with foreign and domestic research institutes

Implement other policy options in objective 5 to promote and support national capacity for high-quality research, development and innovation
Objective 6: To monitor the trends and determinants of noncommunicable
diseases and evaluate progress in their prevention and control
Overarching/enabling actions
 Develop national targets and indicators based on global monitoring framework and linked with a
multisectoral policy and plan  Strengthen human resources and institutional capacity for surveillance and monitoring and  Establish and or strengthen a comprehensive noncommunicable disease surveillance system, including reliable registration of deaths by cause, cancer registration, periodic data collection on risk factors and monitoring national response  Integrate noncommunicable disease surveillance and monitoring into national health information Implement other policy options in objective 6 to monitor trends and determinants of noncommunicable diseases and evaluate progress in their prevention and control Page 16 of 26
Technical annex to Appendix 3: proposed table of contents
This technical annex will be designed to provide further information for those interested in decisions and methods adopted in the development process of the updated Appendix 3. Proposed contents of this Annex include: 1. Detailed methodological information a. This will include more detailed explanation of the methodological approach and process used to update Appendix 3, including the selection of interventions, and consultation process. b. Explanation of Generalized Cost Effectiveness and WHO-CHOICE methodology c. References to the evidence source and assumptions used in the economic modelling for specific interventions 2. The background results of the WHO-CHOICE economic analyses for interventions included in a. The summary table will be complemented later by an interactive web tool which will enable users to manipulate the data for their own purposes. Section 1: Detailed methodological information
Identification of interventions
A transparent, unified approach for the identifications was taken after the first consultation on
updating Appendix 3, 2015.14 From the consultation, the following effectiveness criteria were used
for identifying interventions:
An intervention must have a demonstrated and quantifiable effect size, from at least one published study in a peer reviewed journal An intervention must have a clear link to one of the global NCD targets Using the above criteria, additional interventions were considered. The intervention list for the updated Appendix 3 comprises interventions which have been unchanged from the original version, interventions which have been re-worded or revised to reflect updates in WHO policy or scientific evidence and new interventions. Choice of economic parameters
Economic parameters were identified at the first technical consultation in June 2015 and are listed
below:
1. Cost-effectiveness ratio: as analysed using WHO-CHOICE methodology (see below) and
presented as a ratio of international dollars (I$) per disability adjusted life year (DALY). a. Cost-effectiveness ratios are presented in bands, ranging from < I$100/DALY to >I $10,000/DALY15. The decision to band cost-effectiveness was based on the consensus that the data represent global estimates, therefore banding cost-effectiveness emphasises the relative magnitude of cost-effectiveness rather than a specific amount. 14 http://who.int/nmh/events/meeting-report-consultation-on-appendix-3-final.pdf?ua=1 15 Cost-effectiveness bands (in I$) are: <100, 100-$500, 500-1,000, 1,000-5,000, 5,000-10,000, >10,000 Page 17 of 26
2. Size of health gain: the expected size of population health impact for each intervention was calculated based on total DALY averted in a standardized16 population of 1 million people. 3. Economic cost of implementation: The total cost required to implement each intervention was estimated, based on cost in I$ millions to implement in a standardized population of 1 million people (i.e. I$ per capita) Country selection
Economic parameters were assessed for two country income groups: Low and lower middle income
countries and upper middle and high income countries were taken as the second group. Recognizing
the need for generalizability, applicability and comprehensiveness, countries were selected so that a
significant proportion of the total population and health burden would be represented. We also
recognized the importance of representation from countries in different regional settings.
Resultantly, twenty countries were compiled and listed below. For most interventions, ten countries
were analysed from low and lower-middle income settings, and ten from upper-middle and high
income settings. Combined, they represent 63% of the total population and 65% of the global
burden of disease. For some types of interventions, (eg for cancer) analysis was based on a smaller
subset of countries.
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries

Iran (Islamic Republic of) Russian Federation United States of America WHO-CHOICE: A brief methodological overview
Value for money and efficiency are fundamental considerations guiding investment in health, and
WHO-CHOICE provides a way to measure them. This is true in settings where lack of finance is no
longer the greatest barrier to achieving better health outcomes; it is also true in less well-resourced
settings, where inefficiency is measured in lives lost and human suffering.
Cost-effectiveness analysis supports priority setting by defining areas of action where the greatest
health gains can be achieved.
Generalized cost-effectiveness analysis (WHO-CHOICE) also allows the definition of an optimal set of
interventions, taking into account setting-specific factors such as the burden of disease, health
system practice, and economic conditions. Tools to facilitate country-level cost-effectiveness
analysis of a wide range of health activities are available. In parallel, WHO-CHOICE publishes and
disseminates online a knowledge base of regional-level cost-effectiveness information.
16 Standardized over the total population of the analysed countries per income grouping Page 18 of 26
The use of cost-effectiveness analysis within decision making processes in health is increasingly common globally. However, a series of methodological shortcomings may limit the practical application of cost-effectiveness analysis results. Two examples of this are methodological differences between studies that limit comparability, and use of the current practice as a comparator, which implicitly assumes current resource use is efficient. Generalized Cost-Effectiveness Analysis (GCEA) was developed to overcome such shortcomings of traditional cost-effectiveness analysis. The GCEA approach enables both existing and new interventions to be evaluated simultaneously. The comparator used in GCEA is a hypothetical "null" scenario, where the impacts of all currently implemented interventions are removed. Uniquely, this method allows existing and new interventions to be analysed at the same time. Previous cost-effectiveness analyses have been restricted to assessing the efficiency of adding a single new intervention to the existing set, or replacing one existing intervention with an alternative. Using WHO-CHOICE, the analyst is no longer constrained by what is already being done, and policymakers can revisit and revise past choices if necessary and feasible. They will have a rational basis for deciding to reallocate resources between interventions to achieve social objectives. WHO-CHOICE: Uses a standardized method for cost-effectiveness analysis that can be applied to all interventions in different settings Costs and effectiveness of a wide range of health interventions at the WHO subregional level are calculated to ensure comparability across different interventions All interventions are evaluated compared to the "null", a scenario in which we model the absence of health care interventions Impact models are developed using a population based approach, and healthy life years gained due to an intervention are calculated over a 100 year time frame Costs for each intervention are developed using an ingredients based economic costing methodology. Costs are calculated over a 100 year time frame and discounted at 3% per year All interventions are evaluated at 50%, 80% and 95% coverage. For the appendix 3, 95% coverage results are used Page 19 of 26
Section 2. Summary tables of WHO-CHOICE economic analyses for interventions for NCD prevention and control
Notes:
1. The tables below list all interventions for which WHO-CHOICE economic analysis is available. In this example, separate tables are provided for each of
the four main risk factors and four main diseases covered by Objectives 3 and 4 of the Global NCD Action Plan. Interventions are listed in descending order of cost-effectiveness in low and lower-middle income countries. The intervention name contains more exact detail about the intervention that was modelled -note that these may differ slightly from the wording of the WHO recommended interventions. This Annex is provided for background scientific information only and should not be used as a specific menu for implementation. Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Economic Cost of Average cost- Economic Cost of effectiveness implementation (I$ in effectiveness implementation ratio (I$/DALY millions per 1 million) ratio (I$/DALY (I$ in millions per 1 averted per averted per 1 million) 1 million) Tobacco Use
Strengthen the implementation of tax policy and administrative measures to reduce the demand for tobacco products (price increase of 25% through excise tax) Comprehensive ban of tobacco advertising, promotion and sponsorship, including cross-border advertising and on modern means of communication at 95% coverage Implementation of plain/standard packaging and/or large graphic health warnings on all tobacco packages at 95% Elimination of exposure to second-hand tobacco smoke in all indoor workplaces, public places, public transport, and in all outdoor mass-gathering places at 95% coverage Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services and mCessation) for tobacco cessation to all those who want to quit, provided at 95% coverage Page 20 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Economic Cost of Average cost- Economic Cost of effectiveness implementation (I$ in effectiveness implementation ratio (I$/DALY millions per 1 million) ratio (I$/DALY (I$ in millions per 1 averted per averted per 1 million) 1 million) Harmful use of alcohol
Increase in excise taxes on alcoholic beverages (current rate Enforcement of bans or comprehensive restrictions on alcohol advertising (across multiple types of media including television, radio, print media and billboards) at 95% coverage Enforcement of restrictions on the physical availability of retailed alcohol (via reduced density of retail outlets and reduced hours of sale) at 95% coverage. Enforcement of drink-driving laws and blood alcohol concentration limits via sobriety checkpoints at 95% coverage. Provision of brief psychosocial intervention (3 visits) for persons with hazardous and harmful alcohol use at 50% coverage. Page 21 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Economic Cost of Average cost- Economic Cost of effectiveness implementation (I$ in effectiveness implementation ratio (I$/DALY millions per 1 million) ratio (I$/DALY (I$ in millions per 1 averted per averted per 1 million) 1 million) Unhealthy diet
Reduce salt intake by engaging the industry in a voluntary reformulation process Reduce salt intake through establishment of a supportive environment in public institutions such as hospitals, schools and nursing homes to enable low sodium meals to be provided Reduce salt intake through a behaviour change communication mass media campaign Reduce salt intake through implementation of front-of-pack Complete elimination of industrial trans fats through the development of legislation banning their use in the food Physical Inactivity
Provide physical activity counselling as part of routine primary health care services through the use of a brief intervention consisting of 2 minutes of physician time Page 22 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Economic Cost of Average cost- Economic Cost of effectiveness implementation effectiveness implementation ratio (I$/DALY (I$ in millions per ratio (I$/DALY (I$ in millions per 1 averted per 1 million) averted per 1 million) 1 million) Cardiovascular Disease & Diabetes
CV1a
Drug therapy including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling to persons with high risk (≥ 30%) of a fatal and non-fatal cardiovascular event in the next 10 years, carried out through primary health care facilities at a 95% coverage rate Drug therapy including glycaemic control for diabetes mellitus and control of hypertension using a total risk approach)and counselling to persons with high risk (≥ 20%) of a fatal and non-fatal cardiovascular event in the next 10 years, carried out through primary health care facilities at a 95% coverage rate Treatment of new cases of acute myocardial infarction with aspirin and clopidogrel, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate Treatment new cases of acute myocardial infarction with aspirin, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate Treatment of new cases of acute myocardial infarction with aspirin and thrombolysis, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate Treatment of new cases of myocardial infarction with primary percutaneous coronary interventions (PCI), aspirin and clopidogrel, initially treated in a hospital setting with follow up carried out through primary health care facilities at a 95% coverage rate Primary prevention of rheumatic fever and rheumatic heart diseases by increasing treatment of pharyngitis at the primary care Secondary prevention of rheumatic fever and rheumatic heart disease by developing a register of ARF or RHD patients who then receive regular prophylactic penicillin Page 23 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Health Impact Economic Cost of Average cost- Economic Cost of effectiveness (DALY averted implementation effectiveness implementation ratio (I$/DALY per 1 million) (I$ in millions per ratio (I$/DALY (I$ in millions per 1 1 million) averted per 1 million) Neuropathy screening for all diabetes patients each year and preventive foot care through wound debridement and protective insoles Diabetic retinopathy screening for all diabetes patients each year and laser photocoagulation for prevention of blindness Standard glycaemic control at 95% coverage using glibenclamide, metformin and insulin for type 1 diabetes, along with standard home glucose monitoring to reduce diabetes complications Intensive glycaemic control at 95% coverage using glibenclamide, metformin and insulin and intensive home glucose monitoring to reduce diabetes complications Page 24 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Health Impact Economic Cost of Average cost- Economic Cost of effectiveness (DALY averted implementation effectiveness implementation ratio (I$/DALY per 1 million) (I$ in millions per 1 ratio (I$/DALY (I$ in millions per 1 averted per 1 million) HPV vaccination (2 doses) of 9 – 13 year old girls with coverage Prevention of cervical cancer through screening women aged 30-49 years, either through: VIA (visual inspection with acetic acid) linked with timely treatment of pre-cancerous lesions with cryotherapy at coverage rate of 95% Pap smear (cervical cytology) every 3-5 years linked with timely treatment of pre-cancerous lesions with cryotherapy or LEEP at coverage rate of 95% HPV test every 5 years followed by VIA then linked with timely treatment of pre-cancerous lesions with cryotherapy or LEEP at coverage rate of 95% Treatment of cervical cancer stages I and II with either surgery or radiotherapy +/- chemotherapy, including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95% Treatment of breast cancer stages I and II with surgery +/- systemic therapy (endocrine therapy or chemotherapy), including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95% Screening with mammography (once every 2 years for women aged 50-69 years) linked with timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment related toxicities 17 Economic data for upper middle and high income countries are not available. Page 25 of 26
Low and Lower-Middle Income Countries
Upper-Middle and High Income Countries
Average cost- Health Impact Economic Cost of Average cost- Economic Cost of effectiveness (DALY averted implementation effectiveness implementation ratio (I$/DALY per 1 million) (I$ in millions per 1 ratio (I$/DALY (I$ in millions per 1 averted per 1 million) Treatment of colorectal cancer stages I and II with surgery in select high risk patients, +/- radiotherapy in select rectal cancer patients, including diagnosis with pathology, staging and management of treatment related toxicities, at coverage rate of 95% Basic palliative care for cancer: home-based and hospital care with multi-disciplinary team and access to opiates and essential supportive medicines at coverage rate of 95%18 Chronic Respiratory Diseases
Treatment of COPD with inhaled salbutamol at 95% coverage Asthma: Oral prednisolone + Theophylline and high dose inhaled beclomethasone at 95% coverage Treatment of asthma using low dose inhaled beclomethasone and short acting beta agonist at 95% coverage 18 Impact model not available for palliative care Page 26 of 26

Source: http://www.focuswine.net/media/1944/who-global-action-plan_appendix.pdf