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Background: In 2016, the South African government became the first in the African region to announce the introduction of an SSB tax based on sugar content as a public health measure to reduce obesity. This tax was introduced against the backdrop of South Africa having a large sugar production and SSB manufacturing industry, as well as very high unemployment rates. The introduction of fiscal measures, such as a SSB tax, has been met with well-coordinated and funded opposition in other countries., Methods: The aim of this study is to describe and analyse the arguments and strategies utilised by industry during policymaking processes to oppose regulatory actions in LMIC. This study analyses arguments and strategies used by the beverage and related industries during the public consultation phase of the process to adopt the South African SSB tax., Results: Industry opposition to the SSB tax was comprehensive and employed several tactics. First, industry underscored its economic importance and the potential job losses and other economic harms that may arise from the tax. This argument was well-received by policymakers, and similar to industry tactics employed in other middle income countries like Mexico. Second, industry discussed self-regulation and voluntary measures as a form of policy substitution, which mirrors industry responses in the US, the Caribbean and Latin America. Third, industry misused or disputed evidence to undermine the perceived efficacy of the tax. Finally, considerations for small business and their ability to compete with multi-national corporations were a unique feature of industry response., Conclusions: Industry opposition followed both general trends, and also introduced nuanced and context-specific arguments. The industry response experienced in South Africa can be instructive for other countries contemplating the introduction of similar measures.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare: JA is funded by the Centre for Diet and Activity Research (CEDAR). CEDAR is a UK Clinical Research Collaboration Public Health Research Centre of Excellence, with funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council (MRC), National Institute of Health Research (NIHR) and Wellcome Trust. JA has been a member of panels advising governmental and charitable organisations. KH has been a member of several ministerial task teams and national health committees and is a fellow of the Academy of Science of South Africa (ASSAf). J-CM helped develop the Nova system and has worked as a consultant for the Food and Agriculture Organization of the United Nations and PAHO. He is a member of the WHO Nutrition Policy sub-Group of the Nutrition Guidance Advisory Group, which is tasked with developing formal policy guidance on nutrition for all member states.

Background: The importance of tackling economic, social and health-related inequities is increasingly accepted as a core concern for the post-Millennium Development Goal framework. However, there is a global dearth of high-quality, policy-relevant and actionable data on inequities within populations, which means that development solutions seldom focus on the people who need them most. INTREC (INDEPTH Training and Research Centres of Excellence) was established with this concern in mind. It aims to provide training for researchers from the INDEPTH network on associations between health inequities, the social determinants of health (SDH), and health outcomes, and on presenting their findings in a usable form to policy makers., Objective: As part of a baseline situation analysis for INTREC, this paper assesses the current status of SDH training in three of the African INTREC countries - Ghana, Tanzania, and South Africa - as well as the gaps, barriers, and opportunities for training., Methods: SDH-related courses from the three countries were identified through personal knowledge of the researchers, supplemented by snowballing and online searches. Interviews were also conducted with, among others, academics engaged in SDH and public health training in order to provide context and complementary material. Information regarding access to the Internet, as a possible INTREC teaching medium, was gathered in each country through online searches., Results: SDH-relevant training is available, but 1) the number of places available for students is limited; 2) the training tends to be public-health-oriented rather than inclusive of the broader, multi-sectoral issues associated with SDH; and 3) insufficient funding places limitations on both students and on the training institutions themselves, thereby affecting participation and quality. We also identified rapidly expanding Internet connectivity in all three countries, which opens up opportunities for e-learning on SDH, though the current quality of the Internet services remains mixed., Conclusions: SDH training is currently in short supply, and there is a clear role for INTREC to contribute to the training of a critical mass of African researchers on the topic. This work will be accomplished most effectively by building on pre-existing networks, institutions, and methods.

Background: Malnutrition remains a pressing public health concern for mothers and children in South Africa. Despite the government's multisectoral response, unaddressed social needs prevent some mothers getting full benefit from interventions, spanning financial planning, income stability, housing, access to government services, social support, and provision of affordable, nutritious foods. Engaging with mothers and prioritising their concerns is important if we wish to overcome obstacles to women benefiting from government nutrition interventions. This study aimed to identify the programmes that women perceived as a priority in addressing the social needs of mothers of young infants and pregnant women to enhance nutrition in a resource-constrained urban township in South Africa. Methods: A cross-sectional study employed a quantitative preference elicitation survey, administered to 210 mothers and pregnant women from five primary healthcare facilities in Soweto. The survey tool was developed with the community to identify unmet social needs and potential solutions, which were synthesised with findings from the literature. The survey described 15 programmes, grouped into three delivery levels: clinics, community, and government. Participants were required to rank programme options in two stages. First, they selected their top two programmes within each delivery level. Subsequently, they allocated stickers to indicate the strength of their preference among the top programmes across the levels. Rankings were analysed using descriptive statistics. Results: The highest priority was given to five programmes. Two delivered at the community level: Women's economic empowerment groups and Job search assistance, two at the clinic level: Social needs assessment and referral, and Prescription-based food, and one at the government level: Free quality childcare. The lowest-ranked programmes were two clinic-based programmes, specifically Maternal nutrition groups and Couple antenatal education. Conclusion: Women expressed strong views about which programmes should be prioritised to support mothers and pregnant women in addressing their social needs and improving nutrition. Key areas included providing support with job searching and entrepreneurship, accessing childcare and the healthy foods recommended at clinics, as well as finding information on available community and government services. Leveraging multisectoral collaboration, aligned policy objectives, efficient public financing, and strengthened implementation capacity will be pivotal in delivering these programmes. [ABSTRACT FROM AUTHOR]

Background: Non-communicable diseases are on the rise across sub-Saharan Africa. The region has become a targeted growth market for sugar-sweetened beverages, which are associated with weight gain, cardiovascular diseases and diabetes. Objective: To identify politico-economic factors relevant to nutrition-related fiscal policies, and to draw lessons regarding strategies to strengthen sugar-sweetened beverages taxation in the region and globally. Methods: We collected documentary data on policy content, stakeholders and corporate political activity from seven countries in east and southern Africa augmented by qualitative interviews in Botswana, Namibia, Kenya and Zambia, and stakeholder consultations in Rwanda, Tanzania and Uganda. Data were analysed using a political economy framework, focusing on ideas, institutions, interests and power, and a 'bricolage' approach was employed to identify strategies for future action. Results: Non-communicable diseases were recognised as a priority in all countries. Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages, which varied in rate and tax base, but appeared to be motivated by revenue rather than health concerns. Botswana and Namibia indicated intention to adopt sugar-sweetened beverage taxes. Health-oriented sugar-sweetened beverage taxation faced challenges from entrenched economic policy paradigms for industry-led economic growth and was actively opposed by sugar-sweetened beverage-related industries. Strategies identified to support stronger sugar-sweetened beverage taxation included shifting the economic discourse to strengthen health considerations, developing positive public opinion, forging links with the agriculture sector for shared benefit, and leadership by a central government agency. Conclusions: There are opportunities for more strategic public health engagement with the economic sector to foster strong nutrition-related fiscal policy for non-communicable disease prevention in the region. [ABSTRACT FROM AUTHOR]

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems. Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws. Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures. Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention. [ABSTRACT FROM AUTHOR]

This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collabora-tively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy 'problems', the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region. [ABSTRACT FROM AUTHOR]

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems. Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia. Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws. Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures. Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention. [ABSTRACT FROM AUTHOR]

Background: Food and beverages high in sugar are recognized to be among the major risk factors for nutrition-related non-communicable diseases. The growing presence of ultra- processed food producers has resulted in shifts to diets that are associated with non- communicable diseases and which include sugar-sweetened beverages. Sugar-sweetened beverage taxation presents an opportunity to prevent non-communicable diseases but it comes with challenges. Objectives: To describe the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages in Rwanda. Methods: We conducted a desk-based policy analysis to assess the facilitators of and barriers to strengthening sugary beverage taxation policy. We consulted eight stakeholders to validate the findings of the desk review. Results: Non-communicable diseases are recognized as a public health challenge in Government health and non-health policy documents. However, sugar intake is not explicitly identified as a risk factor for non-communicable diseases and existing policies do not clearly aim to reduce sugar consumption. The Rwandan Government's commitment to growing the local sugar industry and the substantial economic contribution of Rwandan beverage producers are potential barriers to fiscal policies aimed at reducing sugar consumption. However, the current 39% excise tax levied on all soft drinks could support the adoption of future sugar-sweetened beverage policies. Conclusions: The landscape for strengthening a sugar-sweetened beverage tax in Rwanda is complex. The policy environment provides both facilitators of and impediments to strengthening the existing tax. A differential tax could be introduced by leveraging on the existing excise tax and linking it to the sugar content of beverages. [ABSTRACT FROM AUTHOR]

Background: The burden of undernutrition is significant in Kenya. Obesity and related non- communicable diseases are also on the increase. Government action to prevent non- communicable diseases is critical. Taxation of sugar-sweetened beverages has been identified as an effective mechanism to address nutrition-related non-communicable diseases, although Kenya is not yet committed to this. Objective: To assess the policy and stakeholder landscape relevant to nutrition related non - communicable diseases and sugar-sweetened beverage taxation in Kenya. Methods: A desk review of evidence and policies related to nutrition related non-communicable diseases and sugar-sweetened beverages was conducted. Data extraction matrices were used for analysis. Key informant interviews were conducted with 10 policy actors. Interviews were thematically analysed to identify enablers of, and barriers to, policy change towards nutrition-sweetened beverage taxation. Results: Although nutrition related non-communicable diseases are recognised as a growing problem in Kenya most food-related policies focus on undernutrition and food security, while underplaying the role of nutrition related non-communicable diseases. Policy development on communicable diseases is multi-sectoral, but implementation is biased towards curative rather than preventive services. An excise tax is charged on soft drinks, but is not specific to sugar-sweetened beverages. Government has competing roles: advocating for industrial growth, such as sugar and food processing industries to foster economic development, yet wanting to control nutrition related non-communicable diseases. There is no national consensus about the dangers posed by sugar-sweetened beverages. Conclusion: Nutrition related non-communicable diseases policies should reflect a continuum of issues, from undernutrition to food security, nutrition transition, and the escalation of nutrition related non-communicable diseases. A local advocacy case for sugar-sweetened beverage taxation has not been made. Public and policy maker education is critical to challenge the prevailing attitudes towards sugar-sweetened beverages and the western diet. [ABSTRACT FROM AUTHOR]

Background: Nutrition-related non-communicable diseases contribute to approximately half of the premature deaths in Namibia. Westernisation and urbanisation of communities have resulted in changing dietary patterns that see people eating more refined and high sugar content foods that are a risk for nutrition-related non-communicable diseases. Sugar- sweetened beverage taxation has been found to influence consumer purchasing behaviour and to raise revenue for health-promoting activity in other low- and middle-income countries. Objectives: To analyse Namibia's non-communicable diseases prevention policy landscape and assess the readiness of the Government to adopt sugar-sweetened beverage taxation policies for public health. Methods: Government policy documents relating to nutrition-related non-communicable diseases were analysed, utilising predetermined variables based on policy theory. Thirteen key informant interviews were conducted with stakeholders from Government, non- governmental organisations and academic institutions. Data sets were analysed utilising Kingdon's analytical theory for agenda setting. Results: Nutrition-related non-communicable diseases are an increasing problem that requires immediate action. Diet and lifestyle are recognised as major contributors to non- communicable diseases. The Government has adopted a multisectoral approach to the control and prevention of non-communicable diseases in Namibia. A sugar-sweetened beverage tax is envisaged in policy, but there is no progress towards its enactment. At the highest level of Government, the Ministry of Finance has ruled out immediate action towards sugar-sweetened beverage taxation. There is little publicly available information about the Namibian beverages industry, but it is closely tied to the South African drinking industry and is influenced by policy action in that country. Conclusion: The Government of Namibia has taken positive steps and the policy environment is friendly towards an SSB tax. The proximity of trade and the competitive nature of the Namibian drinks industry with South Africa suggest that a regional perspective to advocacy would be of value. [ABSTRACT FROM AUTHOR]

Uganda is experiencing an increase in nutrition-related non-communicable diseases. Risk factors include overconsumption of sugar-sweetened beverages. Fiscal and taxation policies aim to make the consumption of healthier foods easier. However, the adoption and implementation of fiscal policies by countries are constrained by political and economic challenges. We investigated the policy and political landscape related to the prevention of nutrition-related non-communicable diseases in Uganda to identify barriers to and facilitators of the adoption of sugar-sweetened beverage taxation in Uganda. A desk-based policy analysis of policies related to nutrition-related non-communicable diseases and sugar-sweetened beverage taxation was conducted. Four key informant consultations (n = 4) were conducted to verify the policy review and to gain further insight into the policy and stakeholder contexts. Analysis was framed by Kingdon's theory of agenda setting and policy change. Nutrition-related non-communicable diseases were recognised as an emerging problem in Uganda. The Government has adopted a comprehensive approach to improve diets, but implementation is slow. There is limited recognition of the consumption of sugar and sugar-sweetened beverages as a contributor to the nutrition-related non-communicable disease burden in policy documents. Existing taxes on soft drinks are lower than the World Health Organization's recommended rate of 20% and do not target sugar content. The soft drink industry has been influential in framing the taxation debate, and the Ministry of Finance previously reduced taxation of sugar-sweetened beverages. Maintaining competitiveness in a regional market is an important business strategy. However, the Ministry of Health and other public health actors in civil society have been successful (albeit marginally) in countering reductions in taxation, which are supported by industry. An established platform for sugar-sweetened beverage taxation advocacy exists in Uganda. Compelling local research that explicitly links soft drink taxes to health goals is essential to advance sugar-sweetened beverage taxation. [ABSTRACT FROM AUTHOR]

A growing body of evidence indicates that excessive sugar consumption is driving epidemics of obesity and related non-communicable diseases (NCDs) around the world. South Africa (SA), a major consumer of sugar, is also the third most obese country in Africa, and 40% of all deaths in the country result from NCDs. A number of fiscal, regulatory, and legislative levers could reduce sugar consumption in SA. This paper focuses on a sugar-sweetened beverage (SSB) tax. The purpose of the paper is to highlight the challenges that government might anticipate. Policies cannot be enacted in a vacuum and discussion is focused on the industrial, economic, and societal context. The affected industry actors have been part of the SA economy for over a century and remain influential. To deflect attention, the sugar industry can be expected either to advocate for self-regulation or to promote public–private partnerships. This paper cautions against both approaches as evidence suggests that they will be ineffective in curbing the negative health impacts caused by excessive sugar consumption. In summary, policy needs to be introduced with a political strategy sensitive to the various interests at stake. In particular, the sugar industry can be expected to be resistant to the introduction of any type of tax on SSBs. [ABSTRACT FROM PUBLISHER]

Background: Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care.Methods: Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients' out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined.Results: Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic.Conclusions: Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care. [ABSTRACT FROM AUTHOR]

Introduction: Given the burden of road traffic injuries (RTIs) in South Africa, economic evaluations of prevention interventions are necessary for informing and prioritising public health planning and policy with regard to road safety. Methods: In view of the dearth of RTI cost analysis, and in order to understand the extent to which RTI-related costs in South Africa compare with those in other low- and middle-income countries (LMICs), we reviewed published economic evaluations of RTI-related prevention in LMICs. Results: Thirteen articles were identified, including cost-of-illness and cost-effectiveness studies. Although RTI-related risk factors in South Africa are well described, costing studies are limited. There is minimal information, most of which is not recent, with nothing at all on societal costs. Cost-effective interventions for RTIs in LMICs include bicycle and motorcycle helmet enforcement, traffic enforcement, and the construction of speed bumps. Discussion: Policy recommendations from studies conducted in LMICs suggest a number of cost-effective interventions for consideration in South Africa. They include speed bumps for pedestrian safety, strategically positioned speed cameras, traffic enforcement such as the monitoring of seatbelt use, and breathalyzer interventions. However, interventions introduced in South Africa will need to be based either on South African cost-effectiveness data or on findings adapted from similar middle-income country settings. [ABSTRACT FROM AUTHOR]

Introduction: Type 2 diabetes poses an increasing public health burden in South Africa (SA) with obesity as the main driver of the epidemic. Consumption of sugar sweetened beverages (SSBs) is linked to weight gain and reducing SSB consumption may significantly impact the prevalence of obesity and related diseases. We estimated the effect of a 20% SSB tax on the burden of diabetes in SA. Methods and Findings: We constructed a life table-based model in Microsoft Excel (2010). Consumption data from the 2012 SA National Health and Nutrition Examination Survey, previously published own- and cross-price elasticities of SSBs and energy balance equations were used to estimate changes in daily energy intake and its projected impact on BMI arising from increased SSB prices. Diabetes relative risk and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study were used to estimate the effect of the BMI changes on diabetes burden. Diabetes cost estimates were obtained from the South African Council for Medical Schemes. Over 20 years, a 20% SSB tax could reduce diabetes incident cases by 106 000 in women (95% uncertainty interval (UI) 70 000–142 000) and by 54 000 in men (95% UI: 33 000–80 000); and prevalence in all adults by 4.0% (95% UI: 2.7%-5.3%). Cumulatively over twenty years, approximately 21 000 (95% UI: 14 000–29 000) adult T2DM-related deaths, 374 000 DALYs attributed to T2DM (95% UI: 299 000–463 000) and over ZAR10 billion T2DM healthcare costs (95% UI: ZAR6.8–14.0 billion) equivalent to USD860 million (95% UI: USD570 million–USD1.2 billion) may be averted. Conclusion: Fiscal policy on SSBs has the potential to mitigate the diabetes epidemic in South Africa and contribute to the National Department of Health goals stated in the National NCD strategic plan. [ABSTRACT FROM AUTHOR]

Background: To determine whether training community health workers (CHWs) about hypertension in order to improve adherence to medications is a cost-effective intervention among community members in South Africa. Methods: We used an established Markov model with age-varying probabilities of cardiovascular disease (CVD) events to assess the benefits and costs of using CHW home visits to increase hypertension adherence for individuals with hypertension and aged 25-74 in South Africa. Subjects considered for CHW intervention were those with a previous diagnosis of hypertension and on medications but who had not achieved control of their blood pressure. We report our results in incremental cost-effectiveness ratios (ICERs) in US dollars per disability-adjusted life-year (DALY) averted. Results: The annual cost of the CHW intervention is about $8 per patient. This would lead to over a 2% reduction in CVD events over a life-time and decrease DALY burden. Due to reductions in non-fatal CVD events, lifetime costs are only $6.56 per patient. The CHW intervention leads to an incremental cost-effectiveness ratio of $320/DALY averted. At an annual cost of $6.50 or if the blood pressure reduction is 5 mmHg or greater per patient the intervention is cost-saving. Conclusions: Additional training for CHWs on hypertension management could be a cost-effective strategy for CVD in South Africa and a very good purchase according to World Health Organization (WHO) standards. The intervention could also lead to reduced visits at the health centres freeing up more time for new patients or reducing the burden of an overworked staff at many facilities. [ABSTRACT FROM AUTHOR]

Chronic diseases are the largest cause of death in the world. In 2002, the leading chronic diseases—cardiovascular disease, cancer, chronic respiratory disease, and diabetes—caused 29 million deaths worldwide. Despite growing evidence of epidemiological and economic impact, the global response to the problem remains inadequate. Stakeholders include governments, the World Health Organization and other United Nations bodies, academic and research groups, nongovernmental organizations, and the private sector. Lack of financial support retards capacity development for prevention, treatment, and research in most developing countries. Reasons for this include that up-to-date evidence related to the nature of the burden of chronic diseases is not in the hands of decision makers and strong beliefs persist that chronic diseases afflict only the affluent and the elderly, that they arise solely from freely acquired risks, and that their control is ineffective and too expensive and should wait until infectious diseases are addressed. The influence of global economic factors on chronic disease risks impedes progress, as does the orientation of health systems toward acute care. We identify 3 policy levers to address these impediments elevating chronic diseases on the health agenda of key policymakers, providing them with better evidence about risk factor control, and persuading them of the need for health systems change. A more concerted, strategic, and multisectoral policy approach, underpinned by solid research, is essential to help reverse the negative trends in the global incidence of chronic disease. [ABSTRACT FROM AUTHOR]