Introduction

Adults living today are most likely to die from a cardiovascular, respiratory, or related disorders (CVRDs). The World Health Organization (WHO) data for 2012indicate that 44 percent of overall deaths and 52 percent of adult deaths globally were due to CVRDs (WHO 2012). The relative contribution of each disorder differs, but in every region except Sub-Saharan Africa, these closely related disorders are the leading causes of death.

Most of these disorders are preventable or, if they occur, can be medically treated to improve longevity and reduce disability. Optimal prevention and treatment—which require resources, certainly, but also consistent and persistent therapeutic compliance—remain a challenge even in high-income countries (HICs). Additionally, in low- and middle-income countries (LMICs), the limited capacity to detect these silent diseases and provide early treatment contributes to the rapid emergence of advanced complications and premature death.

Cardiovascular, Respiratory, and Related Disorders, volume 5 of the third edition of Disease Control Priorities (DCP3), covers three of the four major noncommunicable diseases (NCDs) prioritized by the United Nations’ (UN) high-level meeting on health in 2011:

• Cardiovascular diseases (ischemic heart disease and its risk factors, such as obesity, physical inactivity, tobacco use, high blood pressure and abnormal lipids, stroke, peripheral artery disease, structural heart disease, and congestive heart failure)
• Respiratory diseases
• Diabetes (United Nations 2011).

In addition, we include kidney disease as a related condition; cancers and mental health (also typically grouped among NCDs) are covered in other volumes of DCP3 (box 1.1). These CVRDs are closely related precursors or sequelae for the others, and they share many risk factors and therefore similar prevention and control measures. Box 1.2 summarizes the key messages from DCP3’s volume 5 and provides a framework for systematically addressing CVRDs in LMICs. We present several evidence-based strategies for prevention of CVRDs. We also address the reality that the burden of many arguably preventable disorders is likely to remain high in the coming decades, and that health care systems in LMICs will need to identify viable approaches to treat them. Furthermore, implementing treatment strategies for the aforementioned diseases prevents downstream, highly morbid complications such as heart failure, blindness, or end-stage kidney disease as well as premature mortality among those with preexisting disorders.

Box 1.1

History of the Disease Control Priorities Initiative.

Box 1.2

Key Messages Regarding Cardiovascular, Respiratory, and Related Disorders.

In this review, we discuss the overarching burden of CVRDs, including reasons why LMICs face disproportionately high premature mortality. We summarize the effectiveness and cost-effectiveness evidence and propose 36 essential interventions (see tables 1.1 and 1.2) that are feasible for LMICs to pursue that can either reduce the incidence of new disease or delay complications among persons who have developed CVRDs. We also present estimates of the cost of this package in typical low- and lower-middle-income country settings and discuss various aspects of package implementation.

Table 1.1

Essential Package of Interventions: Interventions Targeted Toward the Prevention or Management of Shared Risk Factors for Cardiovascular and Respiratory Disease.

Table 1.2

Essential Package of Interventions: Disease-Specific Interventions.

High Risk for Death, Disability, and Impoverishment

The world’s population is aging. Persons older than age 65 years now constitute 10 percent of the world’s population and are expected to constitute more than 15 percent by 2030, whereas for most of the twentieth century, 5 percent or fewer persons reached age 65 years (WHO 2011b). Combined with population growth, population aging has led to an overall increase in the number of persons dying from CVRDs, because, although the propensity for these diseases may start in utero, their substantive effects are seen in adulthood. From 2000 to 2012, the absolute number of deaths from CVRDs increased 16 percent globally (figure 1.1), although the age-standardized mortality rate for most disorders is declining (WHO 2012).

Figure 1.1

Share of All Deaths Caused by Cardiovascular, Respiratory, and Related Disorders, and Other Noncommunicable Diseases, by Country Income, 2015.

However, with implementation of population-level risk-reduction measures and advances in acute and chronic care, age-specific mortality has declined to the extent that it counterbalances the absolute increase in number of deaths from population growth and aging (Roth and others 2015; WHO 2012). Thus, age-standardized mortality rates for cardiovascular diseases (CVDs) and respiratory diseases are declining, whereas rates for diabetes and kidney diseases (including kidney disease that is due to diabetes) are unchanged or increasing (Roth and others 2015). In comparison with HICs, LMICs have experienced smaller declines; therefore, inequalities in outcomes are worsening (see annex 1A). For CVD—by far the most common cause of death among the CVRDs—the decline has ranged from 5 percent in low-income countries to 19 percent in upper-middle-income countries versus 28 percent in HICs (figure 1.2). Absolute rates of morbidity and premature mortality, captured in the summary metric of disability-adjusted life-years (DALYs), are increasing rapidly in the poorest regions. From 2000 through 2015, DALYs from CVD and diabetes increased 33 and 72 percent, respectively, in South Asia and 26 and 56 percent, respectively, in Sub-Saharan Africa (GBD 2015 DALYs and HALE Collaborators 2016).

Figure 1.2

Trends in Age-Standardized Mortality Rates from Cardiovascular Disease for Both Genders, by Country Income Group, 2000–15.

On an individual level, where a person with CVD lives predicts his or her risk for death (Yusuf and others 2014) as strongly as if he or she were overweight (Manson and others 1995) or had hypertension (van den Hoogen and others 2000) (figure 1.3). Residence in a LMIC also predicts higher likelihood of a serious event—for example, myocardial infarction (Yusuf and others 2004) or stroke (Sposato and Saposnik 2012)—at a younger age than in HICs. Acute hospitalizations are expensive and dramatically increase the likelihood of families’ falling into poverty (Jaspers and others 2015). More than half of the persons hospitalized for stroke, myocardial infarction, or peripheral artery disease in China, India, or Tanzania experienced catastrophic health spending in the process of receiving care (Huffman and others 2011). Even without acute complications, paying for routine use of generic medications such as atenolol in the Philippines would impoverish more than 5 percent of the population—and more than 20 percent of the population if brand-name atenolol were used (Niens and others 2010).

Figure 1.3

Relative Risk for Mortality from Cardiovascular and Respiratory Disease in LMICs versus HICs, by Age Group, 2015.

Why have LMICs not benefited from advances in CVRD prevention and care? The reasons are many and vary by region, but here we highlight the following: (a) the lack of population-wide strategies to tackle behavioral risk factors, (b) missed opportunities to identify and treat disease in early stages, and (c) inability to provide quality care for advanced complications.

Costs and Cost-Effectiveness of Prevention and Treatment Interventions for CVRDS

We reviewed the costs and cost-effectiveness of various CVRD clinical interventions and policies with the goal of creating a suggested package of interventions that LMICs could adopt to address CVRDs (Gaziano and others 2017). We performed a review of the published literature on the costs of providing preventive care and treatment for cardiovascular and metabolic diseases in LMICs (Brouwer and others 2015), as well as the cost-effectiveness of CVRD interventions in LMICs. We extracted cost and cost-effectiveness data from English-language literature published after 2000 through a bibliometric search, adjusted all reported results to the same currency and year, and ranked the cost and cost-effectiveness outcomes (Gaziano and others 2017). Where necessary to assess priority interventions when evidence from LMICs was lacking, we refer to evidence from HICs. Box 1.3 summarizes use of economic evaluation in DCP3.

Box 1.3

Economic Evaluation of Investments in Cardiovascular, Respiratory, and Related Disorder Control.

Overall affordability of individual interventions is an important consideration for country decision making. We found that interventions to prevent and treat conditions at early stages were much less expensive than interventions to treat diseases at advanced stages. Prevention interventions at the population and community levels were the cheapest (less than US$1 per capita in 2012 U.S. dollars), while treatment of end-stage kidney disease was among the most expensive (Gaziano and others 2017). However, affordability is only one measure for policy makers to consider. Preventive treatments or health promotion activities may not have the same efficacy on an individual basis as, for example, appropriate treatment of acute myocardial infarction. Between both population and individual measures, and preventive and treatment measures, policy makers should scrutinize which have the best evidence for being both effective and cost-effective.

Some fairly recent systematic reviews have taken stock of the evidence of cost-effectiveness of interventions to tackle CVD in LMICs specifically (Shroufi and others 2013; Suhrcke, Boluarte, and Niessen 2012). These reviews showed that, while the cost-effectiveness evidence on CVD interventions in LMICs remains modest in comparison to the evidence in HICs, it has been growing. The reviews also noted that a substantially larger number of publications assess pharmaceutical interventions, compared with population-level interventions.

Among the most cost-effective ways to reduce CVRD mortality are prevention-oriented population policies. The leading types of population policies involve tobacco control, including public smoking bans that are cost-saving/highly cost-effective; for example, taxation that is cost-saving (Vietnam) and highly cost-effective (US$140 per DALY) (Mexico); public smoking bans that cost US$2.4 to US$136 per life-year saved (India); advertising bans that cost US$2,800 per DALY averted (Mexico); and mass media campaigns that range from cost saving to US$3,200 per DALY averted (Gaziano and others 2017). Evidence is growing for the cost-effectiveness of sugar-sweetened beverage (SSB) taxes but is still inconclusive as to the health effects (Colchero and others 2016; Nakhimovsky and others 2016). The strongest evidence to date comes from Mexico, where an SSB tax reduced consumption of sugary beverages and increased water consumption, especially among the poor (Colchero and others 2016). Longer-term data on changes in obesity, diabetes, and other CVRDs have not yet been reported. Population-level salt reduction strategies range from cost saving (Argentina) to up to US$15,000 per life-year gained (Gaziano and others 2017). Salt reformulation by the food industry appears to be the most cost-effective approach, and salt reduction campaigns to promote health are the least cost-effective (Gaziano and others 2017).

Many important disease prevention or health promotion programs have not been assessed for cost-effectiveness, especially as they might apply to LMICs. Increasing physical activity can, in principle, reduce mortality and improve population health. Governments in many countries have recognized this opportunity, but the evidence on what works best to promote physical activity, let alone what is the best value for the money, remains scarce and largely concentrated on HICs (Ding and others 2016). A study from China shows that combining physical activity with a nutrition program is more effective than either intervention alone (Meng and others 2013), while a review by Laine and others (2014) found that the most efficient interventions to increase physical activity were community rail-trails (US$0.006 per metabolic equivalent hours [MET-h]), pedometers (US$0.014 per MET-h), and school health education programs (US$0.056 per MET-h). How generalizable these findings are to LMIC contexts is unclear.

Screening and pharmacological treatment of hypertension to prevent stroke and ischemic heart disease have been shown to range from cost saving (China) to cost-effective at US$700–US$5,000 per DALY averted or quality-adjusted life year (QALY) gained in South Africa and Argentina (Gaziano and others 2017). Cost-effectiveness of strategies using lipid-lowering therapies have had slightly higher ratios, ranging from as low as US$1,200 per QALY in most large LMICs when part of a multidrug regimen to as much as US$22,000 per DALY in the Philippines (Gaziano and others 2017). The range in cost-effectiveness is wider because the number of generic statins is more limited than the number of blood pressure medications. With more statins coming off patent, the price of statins has dropped, and lipid-lowering therapy is becoming more cost-effective.

Opportunistic screening for prediabetes and diabetes in a high-risk population is more cost-effective than screening for diabetes alone, since prevention of diabetes among those with prediabetes is highly cost-effective or cost saving (Ali and others 2017). Once diagnosed, structured diabetes self-management education programs are cost-effective (Diaz de Leon-Castaneda and others 2012), but self-monitoring of blood glucose among persons not on insulin or an oral hypoglycemic is not (Ali and others 2017). One randomized controlled trial from a HIC supports comprehensive management (for example, attention to blood glucose, blood pressure, and lipids) as being cost-effective (Gaede and others 2008). Similarly, another large randomized trial conducted in India and Pakistan supports comprehensive management delivered through care coordinators enabled with an electronic decision support system (Ali and others 2016). Evidence from both HIC and LMIC settings supports screening for complications of diabetes once diagnosed; screening for foot ulcers is among the most cost-effective (Habib and others 2010). A study in India (Rachapelle and others 2013) suggests that screening for retinopathy via telemedicine ranges from US$1,200 to US$2,400 per QALY gained.

Management of acute ischemic heart disease and stroke can be divided into the prehospital phase and the hospital phase. Prehospital phase management requires an established emergency transport system with trained staff and equipment. When available, prehospital thrombolysis was shown to be cost saving. The use of electrocardiogram machines in primary health centers to triage patients appropriately was shown to be cost-effective in India at US$12 per QALY gained (Gaziano and others 2017). The use of aspirin and beta-blockers is about US$10–US$20 per DALY averted. Streptokinase costs about US$700 per QALY gained, and the use of more fibrin-specific thrombolytics (such as tissue plasminogen activators) costs about US$15,000 per QALY. More advanced treatment includes the use of percutaneous coronary interventions (PCIs), including stents. In China, the availability of PCIs or streptokinase for acute myocardial infarction costs between US$9,000 and US$25,000 per QALY gained. Management of persons undergoing PCI with antiplatelet agents such as prasugrel and clopidogrel is also cost-effective in advanced centers where PCI is conducted. Data on cost-effectiveness of acute ischemic stroke management with a thrombolytic agent are sparse in LMICs, but one study recommends home-based rehabilitation (Sritipsukho and others 2010).

Management of heart failure with oral agents such as ACE inhibitors, beta-blockers, and aldosterone antagonists is cost saving or highly cost-effective (Gaziano and others 2017). Advanced therapy with implantable defibrillators and resynchronization therapy could be cost-effective in advanced centers in middle-income countries, with cost-effectiveness ratios of US$17,000–US$35,000 per QALY gained. The use of low-dose inhaled corticosteroids for mild asthma is an attractive intervention, as it addresses a large disease burden and is cost-effective in lower-middle-income countries (Gaziano and others 2017).

Acknowledging that cost- and cost-effectiveness data rarely translate directly across settings and that each country would need to individually assess its disease burdens and priorities (box 1.3), our review of cost-effectiveness has identified multiple cost-effective and even cost-saving interventions for CVRDs in LMICs, particularly for population-level interventions. Many highly effective clinical interventions—for example, treatment of hypertension or hyperlipidemia—are also cost-effective in some LMICs, whereas others requiring greater technology and specialized care are only cost-effective in MICs.

Pathways to Addressing CVRDS in LMICS

After the 2011 UN General Assembly high-level meeting on NCDs highlighted the growing and detrimental impact of NCDs on the health and wealth of nations, the WHO produced a Global Action Plan for the Prevention and Control of NCDs (WHO 2013). Of the eight voluntary targets set to help countries reduce NCD mortality, six focus on prevention and highlight interventions that improve diet and reduce smoking, obesity, and physical inactivity, helping individuals to live longer, healthier lives. To assist countries in meeting those targets, we offer here a set of policies and interventions that form an essential package of prevention actions, primarily delivered at the population level (table 1.1). Further, acknowledging the reality that LMICs continue to struggle with a spectrum of early to advanced cases of these diseases, we propose a set of disease-specific individual-level services appropriate for low-resource settings (table 1.2). These policies and interventions were selected from those deemed most effective and cost-effective by DCP3 Volume 5 chapter author teams, each using a literature review combined with expert judgment to prioritize among those with the strongest evidence. Interventions included in the essential package were shown to be cost-effective in at least one LMIC setting, or had strong evidence to suggest LMIC cost-effectiveness. This essential package goes beyond the WHO NCD “best buys” (WHO 2011a), but it has a high degree of overlap with priority interventions in the recent revision of appendix 3 of the WHO Global Action Plan (WHO 2013).

Individually and collectively, the 36 actions contained in the essential package can address a large portion of the health burden of these diseases, are proven to be effective, and are expected to be feasible to implement in low-resource settings. Cost-effectiveness is suggested, either by studies from low-income settings or reasonable extrapolation of existing estimates from well-resourced settings. The essential package of recommended interventions is organized by delivery level (or platform).

While all of the interventions in the essential package meet these criteria, not every country can or should implement all of them, and some countries will take years to build a health system that can implement even some of them. As countries expand and scale up their health benefits, the highest-priority interventions are controlling tobacco consumption (especially through tobacco taxation); improving dietary intake; and (when a health system has the capacity to support it) preventing or treating hypertension and promoting health. In addition, LICs with high disease burden (such as Sub-Saharan African countries) may want to consider starting with a suite of cost-effective interventions for endemic CVRDs such as rheumatic heart disease, chronic kidney disease, chronic obstructive pulmonary disease, and heart failure resulting from nonischemic etiologies. The menu chosen must be appropriate for a country’s disease burden and feasible given its health system capacity.

Central Role for Primary Care Centers

Stronger and better-equipped primary care centers are needed to manage the current and growing burden of CVRDs. Health systems in LMICs do not need to be replicas of health systems in HICs. Perhaps more than any other set of diseases, CVRDs require screening, long-term follow-up, and reliable medication delivery (table 1.2). The approach in a majority of HICs (that is, individualized interval screening performed by primary care physicians followed by highly specialized, referral-based care) is unlikely to be viable in most LMICs for a multitude of reasons. Financial and human resource constraints certainly come into play; in addition, the cultural approach to health may be different. For example, LMIC populations may be more amenable to peer counseling or community-based health promotion activities. Therefore, a majority of the medical management interventions (table 1.1) recommended in the essential package can be delivered at the community or primary health care level.

Primary health care clinics could be responsible primarily for delivering and titrating medications. The WHO Health Systems Framework provides a comprehensive approach to their strengthening (WHO 2010a). In addition to ensuring availability of key medications, governments can enable these centers to deliver care effectively by developing national guidelines and targets for specific conditions (table 1.3), which could, in turn, encourage reliance on the available generic medications and standardize follow-up intervals. Structured guidelines for referral to specialized systems could improve efficiency at both the primary and specialized care level. Further, if primary health care centers are the first point of contact in an acute situation (for example, chest pain in a patient likely to be experiencing myocardial infarction), available basic therapy (for example, rapid administration of aspirin), though limited, could be lifesaving. Primary care centers could be empowered to deliver such therapy prior to facilitating transfer to a first-level hospital.

Table 1.3

Recommendations for Health Systems Improvements That Enable Implementation of the Recommended Interventions.

Acute myocardial infarction and stroke are two conditions for which timely intervention is essential. Diagnosis and thrombolytic management of myocardial infarction require a simple electrocardiogram machine; ischemic stroke also benefits from thrombolytic therapy but requires use of computed tomography and on-site radiology to differentiate from hemorrhagic stroke. If built from the ground up to serve only stroke, such approach is unaffordable. However, many first-level hospitals in middle-income countries may have access to these facilities and require the implementation of a stroke algorithm to help prioritize their timely use in patients presenting within the appropriate time frame.

When specialized centers are used for conditions that are rare or costly to treat, two potential strategies merit consideration: (1) choosing and scaling up one effective treatment from the roster of potential therapies, or (2) creating high-volume centers that specialize in specific diseases. For example, end-stage kidney disease can be treated with relatively equivalent efficacy using either hemodialysis or peritoneal dialysis. After a careful analysis taking into account cost, cultural opinion, and ethics, Thailand has chosen to pay for and scale up the peritoneal form of dialysis (Teerawattananon, Mugford, and Tangcharoensathien 2007); we await long-term outcomes from this strategy, but preliminary data indicate an increase in the availability of treatment with patient survival similar to that in HICs relying mostly on hemodialysis, albeit at quite high cost (Praditpornsilpa and others 2011; Tantivess and others 2013). In children with congenital heart disease that is amenable to a highly technical but relatively effective surgical procedure (such as ventricular septal defect), creating centers especially designed to serve these patients may be a viable approach to treatment (Reddy and others 2015). Similarly, we know that high-volume kidney transplant centers can achieve good outcomes (Axelrod and others 2004; Medina-Pestana 2006).

The essential package does include a few examples of effective specialized care that is potentially immediately feasible and affordable in low-income settings but that is not widespread. Other effective tertiary care services are considered neither feasible nor affordable in low- and most middle-income settings. Advanced treatments such as implantable cardioverter defibrillators or cardiac synchronization therapy are potentially cost-effective in some places (Brazil, for example) but expensive (Ribeiro and others 2010). As costs drop and skilled providers are trained, additional capacity should become available in specialized facilities to diagnose and manage more complex chronic respiratory diseases that are not amenable to treatment using the simple algorithm. Equipment such as continuous positive airway pressure, nebulizers, Doppler ultrasound, and other tools may all be desired depending on the respiratory disease burden.

Costs of Implementing the Package

We estimated the potential cost of implementing the essential package of interventions in stylized low-income and lower-middle-income country settings, reflecting typical costs, demographic and epidemiological characteristics, and coverage gaps in CVRD care (table 1.4). Supplementary annex 1A contains more detail on costing methods and results. We estimated the annual incremental cost of the essential package to be US$21 in a typical low-income country (3.8 percent of current gross national income [GNI] per capita) and US$24 in a typical lower-middle-income country (1.3 percent of current GNI per capita).

Table 1.4

Potential Costs of the Essential Package in a Stylized Typical Low- and Lower-Middle-Income Country.

Most (60 percent) of the additional investments would need to be in primary health centers that offer preventive services and manage chronic disease. Low-income countries that are particularly resource constrained could focus on achieving full implementation of the bolded interventions in tables 1.1 and 1.2, which we have deemed likely to provide the best value for money in these settings. This high-priority subpackage would only cost an additional US$11 per capita, or 20 percent of current income. This costing exercise suggests that all countries—regardless of resource levels—can begin to put in place at least a few highly effective CVRD interventions at a reasonable cost as they move toward universal health coverage (UHC).

Measuring the Benefits from Universal Health Care for CVRDS

In considering whether to expend strained resources on CVRDs, countries can take into account not only the benefits to individual health but also the benefits to outcomes relevant to societal well-being, such as poverty aversion, financial risk protection, and equity. Extended cost-effectiveness analyses (ECEA), developed as part of the Disease Control Priorities effort, attempt to capture some of these outcomes and provide evidence that CVRD care, in particular, offers substantial financial risk protection. Three ECEAs relevant to CVRDs—assessing tobacco taxation in China (Verguet, Gauvreau, and others 2015), salt reduction in processed foods in South Africa (Watkins and others 2016), and treatment of hypertension in Ethiopia (Verguet, Olson, and others 2015)—not only support the cost-effectiveness of these policies but also demonstrate that they could avert thousands of cases of poverty annually.

Treatment of hypertension in Ethiopia illustrates two specific features of universal public finance for CVRD care in LMICs: (1) treatment of CVRDs may be more expensive than interventions in other domains (such as maternal and child health), but (2) because these health policies and interventions protect wage-earning adults from disability or death, universal coverage could reduce financial risk to a greater degree. Further, poor families spend a much larger portion of their household income on hospitalizations or medications for CVRDs than wealthier families, so they could benefit more (Kankeu and others 2013).

For cases of advanced disease, when universal coverage for treatment is not yet affordable or sustainable (that is, complex congenital heart defects, advanced heart failure, or end-stage kidney disease), countries could consider expanding palliative care services. In addition to easing the emotional and physical burden of disease, palliative care may offer a form of financial risk protection, allowing families to care for their loved ones without exhausting their financial resources on ultimately unsustainable treatments.

Conclusions

We offer a range of effective and cost-effective policies and interventions to reduce the high and mounting global health burden from the constellation of CVRD. We reviewed the evidence for CVRD interventions to assemble an essential package of the most effective policies and services that could be implemented in LMICs. Modeled studies suggest that countries can expect a high return on investment from prevention and control of CVRD, especially from implementing population prevention policies that cost relatively little (Nugent, Kelly, and Narula 2012). Countries have effective and cost-effective choices available to them. By relying heavily on population-level policies and on services that can be delivered at the community and primary health levels—and by using an effective referral system for the few specialized interventions that meet the essential package criteria—countries may obtain significant health gains at reasonable cost.

Many important issues remain uncertain, especially given the scarcity of LMIC economic evidence. Research in areas likely to produce high public benefit—such as further evaluation of the health gains from taxes on SSBs, agricultural and trade policies to improve fruit and vegetable intake, intersectoral policies to increase physical activity, use of cheaper or faster surveillance techniques, and methods of ensuring a reliable supply of generic medications, including of fixed-dose combination therapy—could be a specific priority in LMICs. New technologies, medications, and delivery platforms on the horizon have the potential to disrupt and shift management paradigms. These issues warrant development of strong priority-setting institutions in LMICs to develop a research agenda and to evaluate new technologies as well as changing disease epidemiology and health system constraints.

Nonetheless, the health benefits of individual medical interventions are clear, and HICs have achieved huge reductions in mortality by making medical treatment widely available. These gains must be extended to LMICs in order for global goals to be achieved. A strong global framework is now in place. Since the 2011 UN high-level meeting on NCDs, a Global Plan of Action for NCD Prevention and Control has been put in place, and the 2015 SDGs have recognized NCDs as a serious threat to development. The DCP3 essential package provides a pathway to achieving substantial reduction in death, disability, and impoverishment from CVRD in LMICs using evidence-based cost-effective interventions.

Acknowledgments

The DCP3 volume 5 author group consists of the following: Alma Adler, Ashkan Afshin, Vamadevan S. Ajay, Mohammed K. Ali, Eric Bateman, Janet Bettger, Robert O. Bonow, Elizabeth Brouwer, Gene Bukhman, Fiona Bull, Peter Burney, Simon Capewell, Juliana Chan, Eeshwar K. Chandrasekar, Jie Chen, Michael H. Criqui, John Dirks, Sagar B. Dugani, Michael Engelgau, Meguid El Nahas, Caroline H. D. Fall, Valery Feigin, F. Gerald R. Fowkes, Amanda Glassman, Shifalika Goenka, Rajeev Gupta, Babar Hasan, Fred Hersch, Frank Hu, Mark D. Huffman, Samer Jabbour, Deborah Jarvis, Panniyammakal Jeemon, Rohina Joshi, Jemima H. Kamano, Andre Pascal Kengne, Preeti Kudesia, R. Krishna Kumar, Kalyanaraman Kumaran, Estelle V. Lambert, Edward S. Lee, Chaoyun Li, Rong Luo, Matthew Magee, Vasanti S. Malik, J. Antonio Marin-Neto, Guy Marks, Bongani Mayosi, Helen McGuire, Renata Micha, J. Jaime Miranda, Pablo Aschner Montoya, Andrew E. Moran, Dariush Mozaffarian, Saraladevi Naicker, Nadraj G. Naidoo, K. M. Venkat Narayan, Irina Nikolic, Martin O’Donnell, Churchill Onen, Clive Osmond, Anushka Patel, Rogelio Perez-Padilla, Neil Poulter, Michael Pratt, Miriam Rabkin, Vikram Rajan, Anis Rassi, Anis Rassi Jr., Ishita Rawal, Giuseppe Remuzzi, Miguel Riella, Greg A. Roth, Ambuj Roy, Adolfo Rubinstein, Yuna Sakuma, Uchechukwu K. A. Sampson, Karen R. Siegel, Karen Sliwa, Marc Suhrcke, Nikhil Tandon, Bernadette Thomas, Claudia Vaca, Rajesh Vedanthan, Stéphane Verguet, Michael Webb, Mary Beth Weber, Laurie Whitsel, Gary Wong, Lijing L. Yan, Clyde W. Yancy, Ping Zhang, Dong Zhao, and Yishan Zhu.

The authors would like to acknowledge Jinyuan Qi for her assistance in preparing the essential package cost estimates, Dean T. Jamison for thoughtful review and guidance, Kristen Danforth for assistance with literature reviews and document preparation, and the World Bank Publisher’s office for excellent production support.

Annex

The annex to this chapter is as follows. It is available at http://www.dcp-3.org/CVRD.

• Annex 1A. Costing the Essential Package for Cardiovascular, Respiratory, and Related Disorders Notes

Note

World Bank Income Classifications as of July 2014 are as follows, based on estimates of gross national income (GNI) per capita for 2013:

• Low-income countries (LICs) = US$1,045 or less
• Middle-income countries (MICs) are subdivided:

  1. lower-middle-income = US$1,046 to US$4,125
  2. upper-middle-income (UMICs) = US$4,126 to US$12,745
• High-income countries (HICs) = US$12,746 or more.

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