Modeling Health Equity and Financial Risk Protection Impacts of Cardiovascular Disease Prevention in Low- and Middle-Income Countries

Abstract

Many low- and middle-income countries (LMICs) are embarking on journeys towards universal health coverage to achieve health system goals of improving health and financial risk protection. The large and growing burden of noncommunicable diseases, including cardiovascular diseases (CVDs), poses a real threat in delivering on those goals. Cost-effective interventions exist to prevent CVD through treatment and control of risk factors such as hypertension. However, there is poor and unequal health systems performance for managing hypertension in LMICs, leading to severe underuse of high-value healthcare. In addition to the health threat, the growing burden of CVDs and expensive healthcare costs may exacerbate already poor financial protection outcomes in many countries. These impacts can be especially pronounced among poor households who often bear a disproportionate burden of CVDs and face greater financial risk from seeking care. There is a huge opportunity to improve the level and distribution of health and financial protection in LMICs through enhanced management of hypertension. In this dissertation, I quantified the health equity and financial protection impacts of improved CVD prevention in both a global and local (Uganda) context to inform the design of efficient and equitable health systems that can provide high-value primary care to the large and growing population of people living with CVDs or at-risk of developing CVDs in LMICs. In Chapter 2, I developed a microsimulation model to evaluate the potential health equity impacts of improving hypertension management across socioeconomic groups in 44 LMICs. I find that eliminating socioeconomic-based disparities in hypertension diagnosis and treatment can reduce CVD risk disparities within countries. Importantly, implementing equity-sensitive hypertension management programs requires reducing disparities in linkage to treatment. In Chapter 3, I extended the simulation modeling framework to estimate the financial protection impacts of improved hypertension management. I show that targeted interventions to eliminate socioeconomic-based disparities in hypertension treatment coverage in LMICs can also provide financial protection through avoided hospitalizations, particularly for the poorest. However, directly covering inpatient costs would provide greater financial protection benefits at a lower cost, especially when considering socioeconomic-based disparities in healthcare use after a CVD event. This demonstrates the need to combine financing mechanisms and health interventions to address both out-of-pocket costs and disease prevention, especially for the poor, to jointly improve population health and financial protection. In Chapter 4, I further adapted the microsimulation model to the local context of Uganda where national health insurance is high on the policy agenda. Using a participatory modeling approach with stakeholders, I simulated the potential distributional health and financial protection impacts of a national health insurance scheme that generates demand for preventive healthcare among Ugandan adults living with hypertension. I find that the potential health and financial protection impacts of national health insurance are dampened by staggered enrollment into insurance (compared to universal enrollment) and constrained by supply-side capacity to diagnose and treat hypertension. Foregone health and financial protection benefits would be greatest among the informally employed sector and unemployed. Uganda should aim to pursue policies to reach universal insurance enrollment with focused efforts to enroll the informal sector and unemployed population and invest in improving quality-of-care and service delivery infrastructure to maximize the potential benefits of a national health insurance program. As countries across the world face the growing challenge of caring for aging cohorts, enhanced understanding of the role of the health system in improving health, reducing health disparities, and contributing to financial protection can inform targeted population-based risk reduction strategies and health system performance improvements that eliminate, rather than exacerbate, health and economic disparities. In this dissertation, I have shown that high performing primary healthcare systems in LMICs can improve the level and distribution of health and financial protection in the population.