NCDs and Effects of Vertical and Horizontal Health Aid

Economics and Human Biology 41 (2021) 100935
Contents lists available at ScienceDirect
Economics and Human Biology

journal homepage: www.elsevier.com/locate/ehb
Noncommunicable disease outcomes and the effects of vertical

and horizontal health aid
Deliana Kostovaa,* , Rachel Nugentb , Patricia Richtera
a
Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
b
RTI International, United States
A R T I C L E I N F O A B S T R A C T
Article history: Foreign health aid forms a substantial portion of health spending in many low- and middle-income
Received 15 April 2020 countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds
Received in revised form 10 September 2020 used for broad health sector strengthening). Historically, most health aid has been disbursed vertically
Accepted 15 October 2020
toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High
Available online 18 November 2020
NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence
on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and
Keywords:
disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000–2016, and
Foreign health aid
Health financing
evaluated the relationship between these indicators and vertical and horizontal health aid using country
Vertical assistance fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country
Horizontal assistance heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in
Noncommunicable diseases NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic
Low-income and middle-income countries respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to
reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319
deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical
assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in
LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for
assessing the role of horizontal assistance.
Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4.0/).
1. Introduction noncommunicable diseases (NCDs) (Institute for Health Metrics

and Evaluation (IHME), 2018). Assistance for health systems
Foreign health aid, also known as development assistance for strengthening has remained relatively low at around 10 % of all
health, is funding provided to low- and middle-income countries health aid over the past decade (Institute for Health Metrics and
(LMICs) by external governmental and nongovernmental donors Evaluation (IHME), 2018).
with the goal of improving population health. In many LMICs, such Despite relatively weak funding, health systems strengthening
aid constitutes a large portion of national health spending (Chang has been the focus of much policy attention in recent years (Chang
et al., 2019). There are two allocative strategies for health aid – et al., 2019; Buffardi, 2018; Stenberg et al., 2017; Hafner and
vertical, where funding is earmarked for specific diseases and Shiffman, 2013; Frenk, 2009; Mills, 2005). Health systems
program-specific investments, and horizontal, where funding is strengthening guides many of the global health targets in the
distributed for health systems strengthening across the health 2030 Sustainable Development Goals (SDG), such as improved
sector. Historically, the large majority of health aid has been preventive care, protection from NCDs, and expanded access to
vertical, allocated primarily to HIV/AIDS, malaria, tuberculosis, and care (World Health Organization, 2020). A growing policy
maternal and child health, with minimal allocations for emphasis on expanding health coverage and primary care has
recently reinvigorated the debate about vertical-versus-horizontal
approaches to health financing, but the topic’s relevance is
longstanding. A seminal synopsis of the issue, published in 1965
* Corresponding author at: Centers for Disease Control and Prevention, Center for
Global Health, Division of Global Health Protection, 4770 Buford Hwy, Atlanta, GA,
at the World Health Organization (WHO) by Gonzales (Gonza’lez
30341, United States. and World Health Organization, 1965), duscussed the comparative
E-mail address: kiv0@cdc.gov (D. Kostova). advantages of each approach, indicating that the benefits of
http://dx.doi.org/10.1016/j.ehb.2020.100935
1570-677X/Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Kostova, R. Nugent and P. Richter Economics and Human Biology 41 (2021) 100935
vertical programs in alleviating acute health care needs for specific ofeffects of either vertical or horizontal funding on NCD
diseases can only be sustained over the long term within the outcomes are not available - possibly a reflection of the relatively
horizontal framework of structurally sound health systems. recent emergence of NCDs as a global public health priority
As the focus of global health strategies shifts toward sustainable (World Health Organization, 2015). The paucity of evidence is
health systems, health financing needs have changed as well, further compounded by estimation difficulties that can compli-
revealing a discordance between goals and current financing cate the evaluation of health aid effects using cross-national
practices. Resources required for advancing toward SDG 2030 data. As summarized in Stuckler et al. (2013), estimates of the
objectives are estimated to be large (Stenberg et al., 2017), while association between foreign health funding and health outcomes
external health assistance to LMICs is unlikely to bridge the gap in LMICs are often inconsistent across studies and can be subject
between countries’ domestic health expenditure and their to estimation concerns including aid selection bias (whereas
anticipated health needs (Global Burden of Disease Health countries with higher health needs tend to attract more
Financing Collaborator Network, 2020; Global Burden of Disease assistance), generalizability issues (e.g., unrepresentative coun-
Health Financing Collaborator Network, 2017; Dieleman et al., try samples), or lags in health response. Although it is
2016). The shortfall in resources relative to needs in LMICs is empirically unfeasible to address the universe of potential
further aggravated by a persistent misalignment between health estimation issues in identifying the effects of health assistance,
funding allocations and disease needs – a disparity that is addressing or lessening such issues has become more attainable
particularly notable in the case of NCDs (Dieleman et al., 2014; because of recent expansions in available data on health funding
Reidpath and Allotey, 2012; Nugent and Feigl, 2010). In 2017, NCDs mechanisms and health outcomes across countries (Dieleman
accounted for over 73 % of deaths but received less than two and Haakenstad, 2017).
percent of foreign health aid (Institute for Health Metrics and The contributions of the present study are twofold. To the best
Evaluation (IHME), 2018). Correspondingly, countries that are most of our knowledge, it is the first to examine the role of foreign health
vulnerable to the effects of NCDs have remained least ready to aid in specific NCD outcomes in LMICs, focusing on high-burden
address them (Moucheraud, 2018; Bollyky et al., 2017), deepening disease categories including cardiovascular diseases, cancers,
the economic and societal harm from NCD morbidity in developing chronic respiratory diseases, and diabetes. It is also the first to
nations (Bloom et al., 2011; Stuckler, 2008). investigate the relative contributions of vertical and horizontal
The trifecta formed by limited resources, a large burden of assistance, thereby informing policy approaches to foreign health
NCDs, and increased policy emphasis on health systems strength- aid. Using annual country-level data from 116 LMICs from 2000 to
ening motivates a deeper look into the implications of different 2016, we evaluate the relationship between NCD burden indicators
health aid strategies for disease patterns in LMICs. Moreover, new and prior disbursements of development assistance for health
considerations regarding the value of NCD assistance have been (DAH). We distinguish between two types of DAH with potential
revealed by the remarkable influence of underlying chronic NCD relevance – vertical assistance for NCDs, where funds are
conditions on COVID-19 pandemic outcomes. Hospitalization is allocated to programs for the prevention and control of NCDs, and
six times more likely for COVID-19 patients with chronic horizontal assistance to the health sector, where funds are
comorbidities than those without, and death is 12 times more allocated to broad infrastructural support across health system
likely (Stokes et al., 2020). Key predictors of adverse COVID-19 elements such as healthcare access and delivery, health workforce
outcomes overlap with the most prevalent chronic conditions such development, and information and monitoring systems. In this
as hypertension, diabetes, and chronic pulmonary disease (Wang study, indicators of NCD burden include disease-attributable
et al., 2020), exposing the opportunistic role of common NCDs in deaths and disability-adjusted life years (DALYs) for high-burden
exacerbating infectious disease outbreaks. The rising prominence NCDs as well as the prevalence of elevated blood pressure, a
of NCDs in the domain of global health security further motivates leading preventable cause of death globally (Qamar and Braun-
the investigation of optimal approaches to NCD financing. Will wald, 2018). NCD burden trends were modeled in relation to health
assistance strategies for NCDs follow the model used for infectious assistance indicators using a longitudinal framework that incor-
diseases, where the vertical approach has been key to addressing porates multiple-year lags in health response while accounting for
HIV and vaccine-preventable illnesses in LMICs? Or will they confounding from fixed and time-variant differences across
benefit from investment in health systems, where elements like nations. The analysis sheds light on the potential ability of external
preventive services and broad healthcare access have special health financing to generate a nudge toward population-level
relevance for NCDs? health improvements in LMICs.
2. Literature review 3. Data
Although theoretical arguments can illustrate the importance Health indicators used to represent NCD burden included all-
of both vertical and horizontal assistance for addressing NCDs in age and under-70 NCD-attributed deaths and DALYs for five disease
LMICs, empirical evidence on the relative merits of these categories: cardiovascular diseases (CVD), neoplasms, chronic
approaches is virtually nonexistent. Prior empirical analyses have respiratory diseases (CRD), diabetes type 1, and diabetes type 2.
primarily focused on assessing the role of vertical funding for These were obtained for 116 LMICs over 2000–2016 from the
infectious diseases. De Jongh et al. (2014) conducted a systematic Global Burden of Disease database (Institute for Health Metrics and
review of 13 scientific articles on the effects of disease-specific Evaluation (IHME), 2018). DALY is an estimate of the number of
funding for HIV, tuberculosis and malaria, concluding that the years lost due to disability or early death from a particular disease –
findings were not sufficiently strong in demonstrating health a summary definition of morbidity that standardizes the measure-
impact, having been subject to data and analytic limitations. ment of disease burden across different disease types (World
Evidence of significant links between foreign health aid and Health Organization, 2018a). An additional NCD risk indicator, the
population-health proxies such as infant mortality can be found in age-adjusted population prevalence of elevated blood pressure
Mishra and Newhouse (2009), who evaluated effects of total health (systolic blood pressure of 140 mm Hg or more or a diastolic blood
aid in a cross-national setting of 118 countries, and in Wagstaff pressure of 90 mm Hg or more), was obtained for 2000–2015 from
(2011), who evaluated effects of horizontal aid programs in the NCDRisc Country Database (NCD Risk Factor Collaboration
Vietnam. To the best of our knowledge, similar evaluations Group, 2020), providing a country-level measure of uncontrolled
2
hypertension in the population. Health indicators for available

countries and years were matched to lagged indicators of DAH and
total health expenditure obtained from the IHME Financing Global
Health Database (IHME Financing Global Health, 2018), where DAH
indicators were categorized as DAH-NCD (DAH designated for
NCD-specific program areas), DAH-HS (DAH designated for health
system strengthening), and net DAH (total remaining DAH
excluding DAH-NCD and DAH-HS). Throughout this study, DAH-
NCD designates vertical health assistance and DAH-HS designates
horizontal health assistance. Additional country attributes were
obtained from the World Bank’s World Development Indicators
(World Development Indicators, 2020) and NCDRisc to account for
differences across countries in income levels, urbanization,
education, population size, and obesity. The sample of 116
countries included in the study represents approximately 95 %
percent of the population in 138 countries designated as LMICs by
the World Bank. The sample of participating countries was
determined by the availability of matched data for a minimum
of three years per country, necessary to ensure sufficient Fig. 2. DALYs by cause per sample year, 116 LMICs, 2000–2016. NCD: noncommu-
longitudinal variation within each country. The resulting average nicable diseases. CVD: cardiovascular disease. CRD: chronic respiratory disease.
length of observation was 12 years per country for the NCD analysis DM: diabetes mellitus (types 1 and 2). Other NCDs: Digestive disorders,
sample (N = 1,441) and 11 years per country for the elevated blood neurological disorders, mental and substance use disorders, musculoskeletal
disorders, kidney diseases, skin diseases, congenital defects.
pressure analysis sample (N = 1,379).
Descriptive means of indicators for 116 participating LMICs are
et al., 2019). In many LMICs, DAH has grown faster than any other
presented in Appendix Table A1 for mortality outcomes,
source of health spending, underscoring the relative importance of
Appendix Table A2 for morbidity outcomes, and
foreign aid to local health (Chang et al., 2019). While annual per
Appendix Table A3 for country attributes used as explanatory
capita DAH-NCD allocations were very low on average, with a
variables. On average, out of the approximately 40 million deaths
population-weighted sample mean of $0.02 per capita measured in
that occurred annually in our sample of countries, 62 % were due to
2017 USD, they were high in some countries with particularly small
NCDs, with nearly half of NCD deaths taking place before the age of
populations, for instance reaching $16 per capita in Tonga
70, mostly due to CVD (38 %), neoplasms (25 %), CRD (8 %), and
(Appendix Table A3). With a sample average of $0.36 per capita,
diabetes (3 %) (Fig. 1). NCD morbidity was heavily concentrated
DAH-HS was higher than DAH-NCD, but was still relatively low
among the non-elderly population, with over 80 % of NCD-
compared with the $2.02 of per-capita DAH allocated to all other
attributed DALYs occurring before age 70 (Fig. 2). The population-
health targets (Fig. 3).
weighted average rate of elevated blood pressure in the sample
was 24.6 %, ranging from 16.5 % in Peru to 33.6 % in Mauritania
4. Methods
(Appendix Table A2).
DAH is sourced from bilateral, multi-lateral and philanthropy
First, we examined the unadjusted correlation between NCD
sources, where the U.S. serves as the largest contributor with
mortality and DAH by plotting the weighted average annual NCD
approximately a third of all DAH in 2018, followed by the U.K. and
death rate against concurrent DAH-NCD and DAH-HS average
the Gates Foundation at approximately eight percent each (Chang
disbursements (Fig. 3). Note that the resulting chart depicts a
simple contemporaneous relationship, unadjusted for lags in
health outcomes or other factors. As such, it does not shed light on
the directional effects of health funding, but, rather, describes how
funding would have historically mapped to pre-existing disease
Fig. 1. Deaths by cause per sample year, 116 LMICs, 2000–2016. NCD: non-
communicable diseases. CVD: cardiovascular disease. CRD: chronic respiratory Fig. 3. Trends in NCD mortality, DAH-NCD and DAH-HS, 2000–2016, 116 LMICs.
disease. DM: diabetes mellitus (types 1 and 2). Other NCDs: Digestive disorders, NCD: noncommunicable diseases. DAH: development assistance for health. DAH-
neurological disorders, mental and substance use disorders, musculoskeletal NCD: DAH for NCD-specific program areas. DAH-HS: DAH for health system
disorders, kidney diseases, skin diseases, congenital defects. strengthening.
3
patterns. Next, we assessed the relationship between lagged DAH estimation was performed using ordinary least squares with
indicators and NCD health outcomes using a fixed-effects clustering of the error term, ejt , at the country level, lessening
longitudinal framework (Reeves et al., 2015). This modeling estimation bias by adjusting for correlation of health outcomes
approach reduces confounding from unobserved country-specific within countries (Bertrand et al., 2004). Each of the coefficients b1
characteristics that may jointly influence health outcomes and through b5 represents the average annual change in the measured
health funding levels, while also incorporating lagged DAH effects outcome (e.g., the number of averted DALYs or deaths) associated
to reduce bias from reverse causality between funding and disease with an additional dollar in per-capita DAH-NCD one to five years
patterns. The model is specified as follows: prior, respectively; b6 through b10 represent the corresponding
X
5 X
5 associations for DAH-HS; and b11 through b15 represent the
Y jt ¼ b0 þ bi DAHNCDj;ti þ biþ5 DAHHSj;ti corresponding associations for total DAH net of DAH-NCD and
i¼1 i¼1 DAH-HS. The analysis was performed using Stata version 14.0.
X
5
To explore the validity of the estimation approach, we
þ biþ10 DAHotherj;ti þ b16 X jt þ g 0j þ g 1j T t þ t t þ ejt ð1Þ
i¼1 conducted specification checks using two alternative models: a
random effects model with a Hausman specification test, and a
In alternate specifications, Yjt denotes one of 25 outcomes for fixed effect model that did not include country-specific time
country j and year t: number of DALYs and number of deaths, each trends. Our main estimation approach, described in Equation 1, is
attributed to one of two age groups: all-age and under age 70, and based on the variation of DAH across and within countries. It
to one of six disease subtypes: 1) all NCD, 2) CVD, 3) neoplasms, 4) presumes that the relationship between health aid and NCD
CRD, 5) diabetes type 1 and 6) diabetes type 2; and the age- burden is subject to bias from nonrandom distribution of health
standardized prevalence of elevated blood pressure (the estimated aid both across countries and within countries over time. The two
percent of the population with systolic blood pressure of 140 mm alternative models explore the sensitivity of the main results to
Hg or higher or diastolic blood pressure of 90 mm Hg or higher . specifications where country-specific selection bias is unad-
DAH NCDj ,DAH HSj and DAH otherj denote the per-capita dressed: i.e., the random-effects model ignores bias from
amounts of development assistance for health received by country selective distribution of aid across countries, while the fixed-
j for NCDs, for health sector strengthening, and for all remaining effects model without country-specific time trends ignores bias
health focus areas, respectively, in each of the five years preceding from selective distribution of aid within countries over time.
year t, in constant 2017 US dollars. Xjt is a vector of time-variant
country attributes for country j in year t, which includes total per- 5. Results
capita DAH, total per-capita health expenditure net of DAH, per-
capita GDP, average age-adjusted BMI, and proxies for country During 2000–2016, DAH-HS and DAH-NCD showed an upward
education level (secondary-school enrollment rate), speed of average trend, with some downward fluctuations toward the end
urbanization (the urban population growth rate), and population of the period(Fig. 3). DAH-NCD remained very low throughout,
size, which can independently increase both disease outcomes and starting with an average of less than 1 cent per capita in 2000,
health expenditure needs (Jung et al., 2017). reaching a high of $0.05 in 2013, and subsequently falling to $0.02
In addition to controlling for a number of measurable country per capita in 2016. In a similar fashion, the average DAH-HS
attributes, all models include country fixed effects, denoted by disbursement at the end of the study period ($0.21 in 2016) had
g 0j – a vector of country dummy variables; and country-specific dropped near the level observed at the beginning of the study
time trends, denoted by g 1j T t – the interaction terms between each period ($0.27 in 2000) after reaching a high of $0.53 in 2014. The
country dummy variable and a linear time trend. This approach is average patterns of the two DAH indicators point to a positive
used to reduce confounding from fixed or time-variant unobserved contemporaneous correlation between average DAH and overall
country characteristics (such as, for example, the capacity of NCD burden: both metrics trended up over time, while peak NCD
the local health infrastructure or the level of public or mortality coincided with peak DAH-NCD allocations in 2013
political interest in health promotion) that may jointly influence (Fig. 3).
both disease outcomes and health funding allocations. If left Estimators of the relationship between lagged DAH indicators
unaddressed, unobserved differences in country circumstances and health outcomes, obtained by the model in Equation 1, are
could result in both under- and over-estimation of the association reported in Table 1 for NCD morbidity outcomes, Table 2 for NCD
between health outcomes and funding, with unclear downstream mortality outcomes, and Table 3 for elevated blood pressure. In
implications for the overall direction of bias. On the one hand, contrast to the positive contemporaneous relationship suggested
underestimation could occur if funding is disproportionately by the unadjusted trends in Fig. 3, the adjusted association
allocated to countries with worse health outcomes – a type of a between NCD health outcomes and lagged DAH-NCD was negative.
selection bias where countries may sort into receiving more The estimated inverse association between DAH-NCD and all-NCD
assistance based on having a larger health burden. In such case, the DALYs and deaths was statistically significant and subject to a
effects of additional funding would be attenuated by factors that delayed health response of up to 3 years. The magnitude of this
simultaneously depress health outcomes (Stuckler et al., 2013; de association was larger for longer time lags: an additional dollar in
Jongh et al., 2014). On the other hand, overestimation could occur if per-capita DAH-NCD was associated with a decrease in the average
funding is disproportionately allocated to countries with histories annual country NCD burden of 7,459 DALYs/281 deaths after one
of more rapid health improvement (Wilson, 2011). In such year, 7,728 DALYs/319 deaths after two years, and 8,958 DALYs/346
instance, the resulting positive selection bias would inflate after three years. The large majority of this averted morbidity
estimates of the relationship between funding and health burden was under age 70: an additional dollar in per-capita DAH-
outcomes. In the present analysis, country fixed effects address NCD was associated with a decrease in the under-70 NCD
confounding from time-invariant country heterogeneity, while morbidity burden of 6,757 DALYs after one year, 7,136 DALYs after
country-specific time trends account for time-variant country two years, and 8,229 DALYs after three years. Across disease
heterogeneity. categories, the largest year-lagged DAH-NCD effect was observed
In all specifications, year fixed effects, denoted by t t , were used for chronic respiratory disease (2,323 DALYs/82 deaths) and CVD
to control for secular time trends in health outcomes. The (2,264 DALYs/101 deaths), followed by neoplasms (1,339 DALYs/49
4
Table 1
Summary results†, models of NCD DALYs, 116 LMICs, 2000–2016 (N = 1,441).
NCD DALYs NCD DALYs by cause
CVD Neoplasms CRD DM 1 DM 2
Premature All-age Premature All-age Premature All-age Premature All-age Premature All-age Premature All-age
DAH-NCD
Lagged 1 year 6757.2** 7459.3** 2207.5* 2264.4* 1311.6* 1339.0* 1887.7** 2323.7** 54.3 55.0 204.1 245.1
(2517.9) (2833.9) (932.3) (1083.8) (617.9) (603.1) (716.9) (871.5) (31.0) (32.8) (244.5) (307.3)
Lagged 2 years 7136.2* 7728.3** 2302.5 2256.1 1434.4 1434.1* 2018.8** 2459.7** 61.6* 61.1* 331.7 402.2
(2910.2) (2851.7) (1183.4) (1154.6) (724.7) (650.1) (750.1) (880.3) (31.0) (30.8) (320.0) (399.0)
Lagged 3 years 8229.3* 8957.7* 2475.7 2486.9 1960.4 1933.0 1953.9** 2433.3** 63.8* 66.7** 244.1 289.9
(3568.7) (3888.1) (1454.4) (1652.8) (1060.4) (1031.7) (712.8) (892.8) (25.4) (25.2) (345.0) (430.7)
Lagged 4 years 6137.2 7256.4 2008.6 2402.7 1510.4 1565.3 1276.4 1675.1 49.2 52.0 232.5 286.0
(6178.6) (6743.6) (2143.3) (2413.1) (1810.9) (1777.5) (1243.1) (1553.9) (55.8) (60.1) (364.3) (462.4)
Lagged 5 years 164.0 539.7 542.2 285.0 159.8 231.3 204.4 426.9 5.3 20.4 247.9 270.7
(7828.0) (8356.7) (2459.4) (2562.2) (1720.7) (1650.6) (2195.9) (2715.5) (73.6) (77.1) (429.5) (542.0)
DAH-HS
Lagged 1 year 301.4 480.0 45.3 96.8 66.6 79.9 191.5 274.3 2.4 4.0 16.5 18.6
(613.2) (707.6) (258.5) (301.5) (129.3) (128.0) (153.1) (202.4) (5.4) (6.0) (24.7) (30.7)
Lagged 2 years 356.5 684.5 124.4 276.2 33.3 71.6 156.5 244.0 5.0 6.7 16.7 22.2
(631.7) (734.9) (228.2) (275.3) (138.3) (137.4) (154.5) (204.5) (6.2) (6.7) (33.8) (41.2)
Lagged 3 years 1523.9 1863.7 499.0 622.8 334.7 354.9 397.6 533.0 11.3 13.3 6.5 8.2
(942.3) (1143.2) (371.2) (472.7) (225.9) (236.7) (214.1) (279.9) (8.6) (9.5) (55.6) (70.0)
Lagged 4 years 1361.6 1647.8 471.4 592.3 280.6 299.3 338.2 441.4 12.3 13.3 21.9 25.2
(791.5) (968.0) (339.8) (433.1) (189.6) (196.8) (193.2) (252.8) (7.5) (8.6) (50.8) (63.8)
Lagged 5 years 1415.9 1674.5 579.9 706.8 230.4 243.8 351.7 435.9 20.3 20.1 115.0 135.5
(1336.9) (1586.1) (511.2) (623.2) (263.5) (276.0) (363.6) (467.5) (13.9) (14.7) (92.5) (114.4)
DAH-other
Lagged 1 year 21.5 25.7 9.2 32.7 49.5 49.3 21.5 36.6 2.3 2.9 13.0 16.5
(433.2) (481.9) (163.9) (182.2) (106.3) (104.7) (96.4) (123.2) (4.1) (4.5) (24.4) (30.4)
Lagged 2 years 745.4 772.1 234.6 212.4 173.2 156.8 201.0 250.1 5.3 5.9 0.8 0.5
(539.7) (603.1) (221.3) (259.8) (134.0) (127.8) (118.9) (152.1) (5.1) (5.6) (28.0) (36.0)
Lagged 3 years 600.1 638.9 207.5 202.0 112.9 101.3 185.3 227.3 7.0 7.3 24.9 29.0
(493.8) (581.3) (187.8) (226.5) (97.2) (97.8) (145.3) (185.6) (5.6) (6.2) (32.9) (40.2)
Lagged 4 years 235.6 324.4 93.5 130.2 9.3 16.3 107.9 138.1 5.2 5.2 42.5 50.9
(492.3) (578.1) (177.3) (214.2) (112.1) (112.2) (129.7) (169.0) (4.9) (5.3) (31.7) (39.2)
Lagged 5 years 864.4 896.2 351.7 332.3 201.1 173.1 175.8 223.0 8.1 8.0 91.7 110.2
(1217.7) (1355.7) (484.6) (547.7) (277.3) (278.8) (253.7) (324.8) (11.1) (11.9) (61.4) (74.4)
†Notes: Coefficients represent the average (country-year) change in DALYs associated with a $1 increase in per-capita DAH.
Definitions/acronyms: Premature: under age 70. DALY: disability-adjusted life year. DAH: development assistance for health. DAH-NCD: DAH for NCD-specific program areas.
DAH-HS: DAH for health system strengthening. DAH-other: total DAH net of DAH-NCD and DAH-HS. CVD: cardiovascular disease. CRD: chronic respiratory disease. DM 1:
diabetes mellitus type 1. DM 2: diabetes mellitus type 2.
* Statistically significant at the 5% level.
** Statistically significant at the 1% level.
Standard errors in parentheses.Estimates obtained from fixed effects linear models with clustering of the standard errors by country. All models include controls for
contemporaneous (unlagged) total DAH, total health expenditure net of DAH, population size, urbanization (urban population growth rate), schooling (% age-eligible
population enrolled in secondary school), income (per-capita GDP), average BMI. All models include country fixed effects, year fixed effects, and country-specific time trends.
deaths). The effect was smaller and more delayed for diabetes prevalence of elevated blood pressure of 0.0008 percentage
Type 1 and was not statistically significant for diabetes Type 2. NCD points (Table 3).
morbidity and mortality outcomes were not significantly associ- To check for spurious correlation between DAH-NCD and NCD
ated with DAH-HS (Tables 1 and 2). Cumulatively, the estimated burden indicators, we estimated falsification models by replacing
three-year reduction in NCD burden associated with a dollar the dependent variables in Equation 1 with non-NCD burden
increase in per-capita DAH-NCD was 24,145 averted NCD DALYs indicators, i.e. deaths and DALYs from causes not related to NCDs.
and 946 averted NCD deaths, translating to cost-effectiveness (Appendix Table A4). These models did not indicate significant
estimates of $1,892 per averted DALY and $48,300 per averted NCD assistance effects, consistent with the assumption that the
death. These figures fit within the context of current cost- main DAH-NCD effects were not merely reflective of coincidental
effectiveness thresholds, which generally categorize an investment changes in general health patterns. Further, we explored the
as cost-effective if the cost per averted DALY is less than three sensitivity of the results to potential influence from observations
times the national per-capita GDP (Bertram et al. 2016); by with exceptionally high vertical health aid compared to other
comparison, the average per-capita GDP for the present sample of countries. To do so, we re-estimated the main models summa-
countries is $4,029. rized in Tables 1–3 while excluding three nations with average
Elevated blood pressure, on average, was estimated to have a DAH-NCD exceeding $10 per capita (Cabo Verde, Sao Tome and
small but statistically significant inverse correlation with DAH-HS Principe, and Tonga). These sensitivity models supported the
with a lag of four years, though it was not significantly correlated narrative of the main results: NCD burden indicators were
with DAH-NCD (Table 3). An additional dollar in per-capita DAH- inversely associated with lagged vertical assistance but not with
HS was associated with a decrease in the average country lagged horizontal assistance (Appendix Tables A5 and A6), and
5
Table 2
Summary results†, models of NCD deaths, 116 LMICs, 2000–2016 (N = 1,441).
NCD deaths NCD deaths by cause
DAH-NCD
Lagged 1 year 192.5* 280.5* 75.8* 100.8* 43.6* 48.6* 48.1* 81.5* 2.1 2.3 5.8 10.0
(74.8) (109.3) (33.8) (49.5) (18.8) (18.8) (19.6) (33.9) (1.1) (1.2) (3.2) (5.9)
Lagged 2 years 226.7* 319.4** 88.7* 110.3* 53.5* 57.4** 55.4* 92.2* 2.3* 2.5* 7.4 13.2
(94.5) (117.3) (44.7) (53.7) (23.3) (19.4) (22.1) (35.6) (1.1) (1.2) (4.0) (7.3)
Lagged 3 years 247.9* 346.2* 90.9 117.0 65.1* 67.3* 51.9* 87.9* 2.4* 2.8** 8.2 14.1
(110.9) (151.8) (49.7) (69.9) (32.4) (32.1) (21.0) (36.5) (1.0) (1.0) (4.1) (7.3)
Lagged 4 years 194.6 319.9 76.2 130.1 52.7 60.7 34.5 64.5 1.9 2.3 7.7 13.8
(185.3) (257.2) (76.2) (109.2) (56.2) (56.5) (34.1) (58.8) (2.0) (2.4) (5.7) (9.9)
Lagged 5 years 10.5 37.9 14.0 4.4 2.0 7.4 3.1 16.1 0.1 1.3 2.8 2.3
(244.5) (338.0) (96.3) (126.7) (60.8) (59.6) (59.4) (100.4) (2.6) (3.1) (8.6) (16.4)
DAH-HS
Lagged 1 year 8.2 25.1 1.6 8.3 1.8 3.3 4.3 9.9 0.1 0.2 0.0 0.1
(18.0) (28.2) (8.4) (13.3) (4.2) (4.4) (3.9) (7.3) (0.2) (0.2) (0.6) (1.0)
Lagged 2 years 10.0 40.0 4.0 19.6 1.1 4.5 3.5 9.9 0.2 0.3 0.4 0.9
(18.5) (31.0) (7.8) (14.9) (4.6) (4.9) (4.1) (7.9) (0.2) (0.3) (0.7) (1.1)
Lagged 3 years 43.5 77.9 16.8 31.7 10.4 12.8 9.8 19.5 0.4 0.6 1.0 1.9
(26.8) (44.5) (12.3) (21.3) (6.8) (7.9) (5.6) (10.4) (0.3) (0.4) (0.8) (1.4)
Lagged 4 years 38.1 65.2 15.4 28.1 8.8 10.8 8.5 16.3 0.4 0.5 1.2 1.8
(22.9) (38.7) (11.2) (19.6) (5.9) (6.6) (4.8) (9.3) (0.3) (0.3) (0.8) (1.4)
Lagged 5 years 47.0 76.6 21.2 36.3 9.4 11.0 10.1 18.0 0.7 0.7 2.3 3.5
(40.3) (66.6) (17.9) (30.6) (8.9) (10.5) (9.6) (17.9) (0.5) (0.6) (1.7) (2.8)
DAH-other
Lagged 1 year 1.8 4.8 0.2 3.6 1.9 1.5 0.1 1.3 0.0 0.1 0.1 0.3
(12.7) (17.9) (5.5) (7.9) (3.5) (3.4) (2.5) (4.5) (0.1) (0.2) (0.4) (0.7)
Lagged 2 years 21.2 27.6 7.9 8.8 5.2 4.5 4.8 8.2 0.2 0.3 0.5 0.9
(14.8) (20.9) (7.0) (10.5) (3.8) (3.5) (3.0) (5.4) (0.2) (0.2) (0.4) (0.6)
Lagged 3 years 17.5 24.5 7.0 9.1 3.6 3.2 4.5 7.6 0.2 0.3 0.7 1.2
(14.2) (23.2) (6.3) (10.5) (3.0) (3.4) (3.7) (6.8) (0.2) (0.2) (0.6) (1.0)
Lagged 4 years 8.2 17.5 3.5 8.1 0.8 1.5 2.8 5.3 0.2 0.2 0.6 1.0
(14.8) (24.3) (6.1) (10.5) (3.6) (4.0) (3.5) (6.5) (0.2) (0.2) (0.6) (1.0)
Lagged 5 years 35.5 54.9 15.9 23.0 8.8 8.3 5.7 10.5 0.3 0.4 1.9 3.7
(36.7) (53.6) (16.9) (24.9) (9.1) (9.7) (6.6) (12.0) (0.4) (0.4) (1.2) (2.0)
†Notes: Coefficients represent the average (country-year) change in deaths associated with a $1 increase in per-capita DAH.
Standard errors in parentheses. Estimates obtained from fixed effects linear models with clustering of the standard errors by country. All models include controls for
contemporaneous (unlagged) total DAH, total health expenditure net of DAH, population size, urbanization (urban population growth rate), schooling (% age-eligible
population enrolled in secondary school), income (per-capita GDP), average BMI. All models include country fixed effects, year fixed effects, and country-specific time trends.
elevated blood pressure showed a limited inverse association importance of controlling for unobserved temporal country-level
with lagged horizontal assistance only (Appendix Table A7). confounders.
We estimated a number of alternative specifications including
random-effects models and abridged fixed-effects models without 6. Discussion
country-time trends (Appendix Table A8). These results help to
validate the main estimation approach by indicating that country We investigated whether foreign health aid influences the
heterogeneity, both fixed and time-variant, is an important source of trajectory of NCDs in LMICs, distinguishing between vertical and
confounding if left unaddressed. First, a Hausman test comparing horizontal assistance. We found that vertical assistance for NCDs
estimates from fixed- and random-effects specifications revealed that (denoted as DAH-NCD) was significantly associated with reduc-
the random-effects approach is strongly rejected as a way to obtain tions in NCD morbidity and mortality with a lag of up to three
efficient or consistent estimators; country fixed effects are thus years, pointing to the possibility of cumulative returns over time.
essential to reducing bias from country-level unobservable factors. The association between horizontal assistance (denoted as DAH-
Furthermore, because such unobservable factors are unlikely to HS) and NCD burden was not found to be statistically significant.
remain fixed within countries over time, additional effort would be This finding might reflect the short-term nature of the analysis,
required to address temporal heterogeneity within countries. where lags in response to funding were not tracked beyond five
Abridged versions of country fixed-effects models that omit years - a time window that may not be sufficiently long to observed
country-specific time trends estimated either insignificant and/or returns to investment in the health sector. The health sector is
positive associations between DAH and health burden indicators – a defined as the public infrastructure that integrates the following
relationship consistent with the selective propensity of higher-burden components of health provision: health service delivery, health
periods to attract larger amounts of assistance and highlighting the workforce, health information systems, essential medicines, and
6
Table 3 system’s overall capacity for seeing more patients, primary care
Summary results†, models of elevated blood pressure, 116 LMICs, 2000–2015
providers might not be adequately trained in providing preventive
(N = 1,379).
care and NCD risk factor screening, or local treatment practices
Elevated blood pressure (percent of population) might not incorporate extended patient follow-up needed for
DAH-NCD chronic disease management. Such concerns are consistent with
Lagged 1 year 0.00292 recent evidence suggesting that expanded health coverage, alone
(0.00205)
may not be sufficient to maximize population health outcomes in
Lagged 2 years 0.00268
(0.00216)
LMICs, unless accompanied by improvements in the quality of
Lagged 3 years 0.00044 existing health systems (Kruk et al., 2018).
(0.00242) Vertical NCD programs are recognized pathways for channel-
Lagged 4 years 0.00317 ing horizontal aid toward NCD objectivess (Kruk et al., 2015;
(0.00304)
Samb et al., 2010; Gaziano et al., 2007). Horizontal approaches
(0.00348) whose implementation can be facilitated through vertical
DAH-HS initiatives include key health systems elements such as health
Lagged 1 year 0.00014 services integration and workforce task sharing (Kruk et al.,
(0.00024)
2015; World Health Organization, 2017). The integration of
(0.00029)
services across prevention, diagnosis and treatment is illustrat-
Lagged 3 years 0.00002 ed by primary care tools such as smoking cessation and CVD
(0.00045) management protocols (Bertram et al., 2018). A successful
Lagged 4 years 0.00076* example of a program that blends a vertical approach within a
(0.00037)
country’s horizontal primary infrastructure is WHO’s Global
(0.00053) Hearts Initiative, a program that guides prevention and
DAH-other treatment of CVD risk factors in primary care settings (World
Lagged 1 year 0.00008 Health Organization, 2018c). From a workforce perspective, the
(0.00022) shortage of healthcare providers in lower-income countries has
(0.00022)
been well documented and represents a substantial impediment
Lagged 3 years 0.00048 to the functioning of health systems regardless of available
(0.00031) financing (Chen et al., 2004). Vertical programs to promote
Lagged 4 years 0.00011 workforce task sharing, where some services are shifted from
(0.00019)
physicians to nurses or community health workers, can help to
(0.00091) deliver basic NCD healthcare, such as hypertension control, to
†
underserved segments of the population in LMICs (Seidman and
Notes: Coefficients represent the average percentage point change in the
population prevalence of elevated blood pressure associated with a $1 increase
Atun, 2017; Jafar et al., 2011).
in lagged per-capita DAH. Although vertical NCD assistance was not found to play a
Definitions/acronyms: DAH: development assistance for health. DAH-NCD: DAH for significant role in the prevalence of elevated blood pressure, we
NCD-specific program areas. DAH-HS: DAH for health system strengthening. DAH- estimated that horizontal assistance was associated with a
other: total DAH net of DAH-NCD and DAH-HS.
statistically significant, albeit small and delayed, reduction in
* Statistically significant at the 5 % level.
** Statistically significant at the 1 % level. this health indicator. In interpreting this finding, it is important to
Standard errors in parentheses. note that the prevalence of elevated blood pressure in this study
Estimates obtained from fixed effects linear models with clustering of the standard is defined as the proportion of the population whose blood
errors by country. All models include controls for contemporaneous (unlagged) pressure exceeds the clinical thresholds for hypertension, not
total DAH, total health expenditure net of DAH, population size, urbanization (urban
population growth rate), schooling (% age-eligible population enrolled in secondary
counting persons with successfully controlled hypertension.
school), income (per-capita GDP), average BMI. Thus, a reduction in this proportion would partially reflect
All models include country fixed effects, year fixed effects, and country-specific improved hypertension control. Since horizontal investments in
time trends. the health sector through DAH-HS could improve access to care in
the general population, the mechanism for observing slight but
significant population-level reductions in elevated blood pressure
after a rise in DAH-HS might point to improved the health sector
health financing (World Health Organization, 2018b). Insofar as capacity in reaching more patients, with previously uncontrolled
health systems in many LMICs have been historically tailored to hypertension. Treatment of hypertension across LMICs is cur-
acute care rather than long-term and preventive care (Kruk et al., rently suboptimal, with control rates below 15 % (Chow et al.,
2015; Bollyky et al., 2017), the average infrastructural capacity for 2013). Improving hypertension control in LMICs represents a
addressing NCDs may be limited. This can in turn inhibit the potential area for large public health gains (Frieden and
potential of horizontal assistance to play an immediate role in NCD Bloomberg, 2018; Frieden and Jaffe, 2018; Kontis et al., 2019),
outcomes, obscuring the estimated effect of DAH-HS on NCD particularly in the context of the Covid-19 pandemic, where
burden. treatment for hypertension has been shown to reduce mortality
Because NCD care depends on the presence of robustly (Baral et al., 2020).
functioning health systems, it could be tempting to presume that This study is subject to analytic limitations shared by
horizontal investment in health systems in LMICs would accord- observational cross-national analyses. First, the effects of financing
ingly translate into improved NCD outcomes (Allen, 2017). Our on health outcomes are difficult to identify, in part because health
findings suggest that there may be caveats to this presumption. outcomes, particularly those related to NCDs, are the product of
Some lower-income countries do not have the infrastructural complex behavioral, socioeconomic and policy factors. For exam-
elements to deliver adequate NCD prevention and control services ple, democratic, more than autocratic, governments are likely to
across their populations (Bollyky et al., 2017; Samb et al., 2010). invest in national-level health care (Bollyky et al., 2019).
which could impede the effectiveness of horizontal assistance. For Consequently, external health aid is not randomly distributed
example, while additional horizontal spending might expand a across countries. Special estimation concerns arise from selection
7
bias, where countries with more adverse health outcomes are implications by indicating that a vertical approach to funding may
disproportionately more likely to receive more aid, thereby be an appropriate strategy for addressing short-term NCD needs in
attenuating the expected inverse relationship between funding LMICs. The majority of averted NCD burden was estimated to occur
and health burden (Stuckler et al., 2013). We mitigated this in persons under age 70, and for cardiovascular and chronic
concern by employing country fixed effects and country-specific respiratory diseases. This finding has relevance in the context of
time trends, which, coupled with clustering of the standard errors the Covid-19 pandemic, whose severity has been shown to depend
by country, helps to reduce confounding from unobserved country on the underlying prevalence of CVD and pulmonary comorbid-
heterogeneity. Incorporating lagged effects further helps to reduce ities. Our study may not have a sufficiently long observational
simultaneity or feedback bias between health aid and health horizon for informing the relation between horizontal aid and NCD
burden. Nonetheless, the estimated relationships may not be trajectories, pointing to an area for future research. Nonetheless,
interpreted as causal due to potential residual interference from we find that horizontal assistance is associated with reductions in
country heterogeneity and selective health assistance. Another the prevalence of elevated blood pressure, underscoring the link
empirical limitation is the diffusion of spending objectives between the strength of health systems and hypertension control.
represented in each type of assistance. For example, while DAH- Noncommunicable diseases in LMICs remain severely under-
NCD reflects assistance for NCD-specific uses, DAH-HS can span a funded despite being a leading threat to health and development.
wide variety of health sector elements that might have varied Although health aid for NCDs has lagged far behind other types of
levels of relevance to short-term NCD outcomes. Such lack of health assistance, it may be an effective way to improve chronic
specificity is likely to blur the estimated effects of horizontal aid. disease outcomes in LMICs over the short term.
Other empirical limitations include missing data for some
variables that prevented us from including the full set of CRediT authorship contribution statement
country-years, as well as measurement error from using survey-
derived variables. Finally, the reported associations between Deliana Kostova: Conceptualization, Investigation, Formal
health burden and health aid indicators represent average effects analysis, Writing - original draft, Writing - review & editing.
at the sample mean and cannot be attributed to specific countries. Rachel Nugent: Conceptualization, Writing - review & editing.
Patricia Richter: Conceptualization, Writing - review & editing.
7. Conclusions
Appendix A
Evidence that vertical NCD assistance is significantly associated
with subsequent reductions in NCD burden has important policy
Table A1
Characteristics of NCD mortality burden by country, 116 LMICs, 2000–2016.
Country Number of All-cause NCD deaths Premature NCD Premature NCD deaths by cause (% of premature
sample deaths, annual (% of all-cause deaths (% of all NCD NCD deaths)
years average deaths) deaths)
CVD Neoplasms CRD Diabetes Diabetes
Type 1 Type 2
Afghanistan 13 241,777 44.8 67.0 43.5 14.9 5.3 2.5 2.1
Albania 17 18,526 89.7 33.2 45.1 35.9 2.6 0.3 0.5
Algeria 12 144,866 75.2 44.5 45.7 20.2 3.4 1.4 1.8
Angola 7 201,610 26.3 73.7 28.1 17.3 5.9 2.0 2.2
Argentina 16 303,478 80.7 34.8 33.8 37.5 5.4 1.0 2.8
Armenia 9 26,501 91.3 37.2 43.2 32.9 3.5 2.1 4.6
Bangladesh 16 871,560 57.8 56.0 42.2 18.2 11.4 1.8 2.0
Belarus 9 128,486 89.6 35.9 53.4 26.5 1.8 0.2 0.3
Belize 16 1,478 63.9 52.7 29.2 24.2 4.8 2.8 7.8
Benin 9 77,213 29.1 61.3 26.6 18.9 6.2 1.8 1.8
Bhutan 14 3,937 63.0 51.7 34.7 19.2 11.7 1.4 1.5
Bolivia 17 61,205 62.8 49.9 27.3 28.8 4.4 1.8 4.0
Botswana 9 22,873 21.5 47.6 32.7 27.0 7.5 2.6 5.5
Brazil 12 1,143,541 72.6 47.5 35.8 28.7 5.3 1.6 3.3
Bulgaria 17 110,154 94.0 31.5 53.8 30.0 2.9 1.1 0.9
Burkina Faso 16 178,065 26.8 64.8 25.4 18.6 3.9 2.0 2.0
Burundi 15 90,066 26.2 71.9 27.2 17.9 5.8 2.0 2.3
Cabo Verde 17 2,764 60.3 37.2 31.0 29.6 4.1 1.4 1.9
Cambodia 8 103,356 46.9 61.8 34.1 20.1 5.0 2.3 1.6
Cameroon 16 198,476 29.0 64.6 29.1 20.7 6.8 2.0 2.5
Central African Republic 6 67,599 24.0 76.1 33.8 16.0 6.6 2.4 2.5
Chad 17 142,917 20.9 61.6 29.8 17.9 6.3 1.8 1.6
China 12 8,679,495 85.2 39.0 36.8 39.5 7.5 0.8 0.9
Colombia 15 206,767 70.7 39.4 32.3 34.5 5.0 1.1 2.8
Comoros 5 4,479 47.2 59.9 32.0 24.8 4.9 2.4 2.7
Congo 4 39,260 33.6 63.7 34.8 19.8 6.2 2.4 3.2
Congo, Dem. Rep. 9 691,335 29.2 66.8 29.1 15.2 6.0 1.8 2.3
Costa Rica 16 17,653 81.5 39.3 28.3 35.9 3.5 0.5 1.8
Cote d'Ivoire 3 192,562 32.3 68.6 35.0 15.4 5.3 2.0 2.0
Dominica 14 592 83.8 32.2 30.3 31.6 3.4 2.3 6.7
Dominican Republic 14 55,116 66.6 44.4 42.7 24.2 3.0 1.8 3.7
Ecuador 15 73,149 68.1 43.2 27.0 29.2 2.6 1.5 5.4
Egypt 12 438,336 74.5 63.2 52.7 14.4 4.9 1.4 2.2
8
Table A1 (Continued)
Type 1 Type 2
El Salvador 17 37,417 67.4 42.5 24.1 22.8 2.4 1.4 5.9
Equatorial Guinea 4 6,926 26.1 68.1 26.8 17.7 5.5 1.9 3.2
Ethiopia 14 731,730 24.3 66.2 27.2 22.3 5.4 2.6 2.4
Fiji 11 6,210 80.2 66.6 42.2 11.9 6.8 3.4 21.7
Gambia 3 12,990 42.3 59.6 32.1 18.0 5.0 1.7 1.9
Georgia 14 47,169 91.7 33.4 56.2 25.5 3.9 1.6 1.1
Ghana 16 197,463 36.1 63.0 36.9 19.9 4.6 2.2 3.2
Grenada 12 844 82.5 38.4 34.7 29.3 3.1 2.1 7.7
Guatemala 16 72,769 53.2 55.1 20.0 22.7 2.5 2.7 7.2
Guinea 10 118,142 31.2 55.4 31.5 22.3 6.2 1.8 1.6
Guinea-Bissau 3 17,125 30.0 73.1 31.9 15.0 5.4 1.8 1.5
Guyana 9 5,367 66.6 58.3 44.5 16.5 2.6 4.4 7.4
Honduras 10 40,694 65.3 49.4 34.0 20.5 5.7 1.2 2.2
India 17 9,072,519 53.1 55.6 40.4 16.9 15.6 1.3 2.1
Indonesia 17 1,525,596 67.4 57.2 42.8 18.8 6.7 4.2 4.3
Iran 16 332,751 72.6 44.9 42.0 22.7 3.9 1.5 2.7
Iraq 5 150,662 62.9 63.9 48.0 15.1 2.7 1.5 3.8
Jamaica 15 17,296 81.4 35.0 29.0 33.4 4.1 3.7 10.1
Jordan 13 20,347 71.5 58.2 34.2 22.2 2.8 0.9 6.1
Kazakhstan 9 142,550 81.9 49.6 50.7 21.4 4.4 0.4 0.8
Kenya 10 324,257 25.5 63.7 27.4 19.6 5.4 2.2 2.8
Kiribati 9 892 63.5 71.4 38.7 12.9 7.8 2.9 14.0
Kyrgyzstan 16 37,464 77.3 49.2 47.6 16.7 5.4 0.6 0.7
Laos 17 50,542 52.6 61.7 42.6 17.2 7.9 2.3 2.0
Lebanon 17 25,537 85.1 44.0 41.1 34.3 3.3 1.5 3.9
Lesotho 17 34,167 30.1 55.7 36.1 22.0 9.8 3.3 6.7
Liberia 4 36,644 29.0 61.0 31.2 17.6 4.2 1.7 2.0
Libya 4 21,911 78.3 52.6 43.9 25.3 3.7 1.5 3.1
Macedonia 14 17,040 93.6 38.4 48.0 36.2 2.4 0.8 3.2
Madagascar 10 170,239 37.3 68.8 42.2 17.3 8.2 1.7 1.8
Malawi 16 173,553 23.8 60.1 25.0 23.7 4.4 2.1 2.4
Malaysia 3 154,951 71.0 50.3 46.3 27.6 3.6 0.5 1.2
Maldives 5 1,098 73.6 54.1 45.5 16.5 10.0 1.2 2.6
Mali 14 169,060 25.1 67.2 26.4 19.9 8.3 1.6 1.5
Marshall Islands 10 387 71.0 76.0 47.5 15.7 7.7 2.2 6.0
Mauritania 16 20,580 42.8 53.3 32.6 22.8 5.2 1.9 2.7
Mauritius 17 8,815 87.6 50.0 36.5 17.1 4.1 4.1 12.7
Mexico 17 548,454 76.7 46.7 20.7 21.8 3.5 1.9 9.7
Moldova 16 45,845 87.5 43.6 45.9 23.6 2.9 0.4 0.7
Mongolia 11 19,608 72.8 62.8 44.1 27.6 2.2 0.5 0.2
Montenegro 12 5,931 93.1 34.5 48.9 36.9 0.9 2.9 0.1
Morocco 13 197,656 74.8 47.6 56.0 17.3 3.6 1.8 2.5
Mozambique 15 276,699 24.3 68.1 32.5 19.1 4.7 2.4 2.7
Myanmar 12 472,070 59.2 57.3 23.4 22.4 13.7 4.9 3.4
Namibia 8 24,973 31.8 48.3 38.5 22.8 7.8 2.9 4.8
Nepal 16 169,140 53.9 53.3 38.9 18.3 15.9 1.5 1.8
Nicaragua 9 20,162 68.1 49.5 23.5 21.8 2.9 1.0 5.7
Niger 17 172,505 18.5 70.2 28.0 20.3 6.5 1.7 1.6
Nigeria 13 1,720,741 20.4 58.8 21.2 20.6 3.8 1.0 1.1
Pakistan 14 1,370,957 52.0 61.5 40.0 23.9 6.8 1.5 2.1
Panama 14 15,204 72.7 38.6 29.2 31.8 3.6 2.0 4.6
Paraguay 13 26,873 71.2 45.2 34.3 28.6 3.1 1.7 6.3
Peru 17 128,231 64.9 42.2 22.6 35.4 4.7 1.2 2.7
Philippines 11 540,130 63.0 60.1 41.9 20.5 6.6 1.6 3.5
Romania 17 257,377 91.6 33.7 45.7 33.2 2.9 0.4 0.7
Russia 13 2,073,782 85.2 43.2 54.8 23.5 2.1 0.3 0.5
Rwanda 17 83,372 31.2 67.7 20.2 21.2 6.1 2.2 2.0
Samoa 15 977 78.0 49.5 43.9 17.3 6.8 2.2 7.1
Sao Tome and Principe 13 1,047 59.0 55.9 26.8 18.9 10.2 0.8 0.9
Senegal 14 89,500 38.9 58.2 29.0 21.1 5.8 2.2 2.4
Serbia 17 117,800 93.9 31.3 42.2 39.7 3.2 1.3 1.9
Sierra Leone 6 73,793 30.0 62.1 33.4 16.1 5.0 1.6 1.6
Solomon Islands 9 3,547 58.5 67.6 45.8 15.2 7.2 3.0 6.0
South Africa 15 656,489 33.3 52.7 33.2 26.0 8.2 2.5 6.6
Sri Lanka 5 120,379 78.7 43.8 38.1 21.9 8.1 4.0 6.8
St. Lucia 17 1,070 80.9 39.7 32.1 29.3 4.5 2.1 8.7
St. Vincent and the 16 837 79.0 41.0 33.2 27.6 2.4 3.4 9.2
Grenadines
Sudan 14 228,518 51.0 57.4 46.0 11.6 3.9 1.1 1.1
Suriname 13 3,611 71.9 51.0 38.9 22.5 3.4 2.0 4.9
Swaziland 15 16,568 25.5 65.8 31.8 23.2 7.5 3.4 8.9
Tajikistan 14 39,013 62.8 51.7 44.7 18.0 4.9 1.7 1.9
Tanzania 3 373,634 33.3 62.7 22.2 20.2 3.6 1.8 1.9
9
Type 1 Type 2
Thailand 14 393,838 69.2 49.2 26.6 37.8 4.9 1.4 3.0
Timor-Leste 14 6,468 57.1 58.2 40.3 18.9 7.2 1.9 2.0
Togo 9 54,722 25.8 70.1 32.7 17.5 5.9 1.7 1.6
Tonga 14 669 77.6 46.3 28.0 27.0 5.8 2.4 12.9
Tunisia 16 55,544 82.1 34.6 50.4 25.4 3.6 1.4 2.2
Turkey 16 347,691 84.3 45.3 33.6 36.6 5.5 1.0 3.3
Ukraine 15 719,144 89.3 38.1 54.2 25.0 3.0 0.4 0.4
Uzbekistan 15 188,629 79.8 49.2 54.5 15.3 3.1 1.7 3.1
Vanuatu 7 1,622 69.7 66.9 46.6 17.3 8.7 2.0 2.6
West Bank and Gaza 17 16,205 62.2 50.9 41.2 22.0 3.2 0.4 4.6
Zimbabwe 6 180,387 24.3 60.2 34.7 28.4 6.9 2.2 3.4
Table A2
Characteristics of NCD morbidity burden by country, 116 LMICs, 2000–2016.
Country All-cause DALYs, NCD DALYs (% of all- Premature NCD Premature NCD DALYs by cause (% of premature Elevated blood
annual average cause DALYs) DALYs (% of all NCD NCD DALYs) pressure (% of
DALYs) population)
Type 1 Type 2
Afghanistan 17,059,304 35.1 89.9 21.9 8.7 5.0 1.4 2.3 30.1
Albania 766,335 76.6 70.4 22.5 16.7 3.3 0.3 2.1 30.3
Algeria 8,688,204 66.7 83.3 17.8 8.2 4.2 0.6 2.7 28.3
Angola 14,929,648 22.8 92.6 13.5 8.9 5.7 1.0 2.9 30.4
Argentina 11,095,235 74.3 71.1 17.0 18.2 4.5 0.7 3.4 25.5
Armenia 959,895 81.2 67.8 24.4 18.7 3.7 1.2 6.0 26.6
Bangladesh 53,483,008 45.8 84.7 20.4 9.8 7.4 1.0 2.6 25.4
Belarus 4,081,503 80.3 66.4 33.0 16.5 2.7 0.2 1.9 28.8
Belize 82,989 57.8 85.4 13.8 11.4 5.4 1.4 6.6 23.7
Benin 5,482,246 24.4 88.9 12.5 8.9 5.1 0.9 2.2 29.2
Bhutan 233,755 53.0 83.9 15.8 9.1 7.3 0.7 2.5 27.9
Bolivia 3,347,507 52.9 82.2 13.5 14.2 4.7 0.9 3.9 19.5
Botswana 1,267,031 19.5 82.1 13.8 11.4 7.5 1.1 5.0 31.8
Brazil 57,175,844 66.5 81.3 16.6 13.1 4.5 0.8 3.0 25.8
Bulgaria 3,147,317 85.8 60.1 35.0 19.3 3.7 0.8 2.6 30.6
Burkina Faso 12,709,242 22.2 89.7 12.1 9.3 4.1 1.0 2.0 32.3
Burundi 6,093,500 23.2 91.9 13.6 9.9 5.1 1.0 2.3 27.5
Cabo Verde 144,548 51.5 78.1 14.0 12.6 3.6 0.7 2.7 31.5
Cambodia 6,113,408 39.7 86.5 17.9 10.8 4.9 1.2 2.6 24.7
Cameroon 13,193,259 24.6 89.1 14.7 10.5 5.7 1.1 2.4 26.8
Central African 4,487,864 20.4 92.4 18.0 9.2 5.8 1.4 3.2 31.3
Republic
Chad 10,545,658 16.5 88.6 14.7 8.7 5.3 0.9 1.9 32.2
China 348,965,376 76.2 73.4 19.7 20.2 6.1 0.4 3.1 20.4
Colombia 10,686,840 61.7 78.1 13.4 14.4 4.5 0.6 3.1 21.0
Comoros 272,971 39.0 86.1 16.1 13.5 4.7 1.2 3.0 27.0
Congo 2,454,215 28.0 87.8 17.4 10.8 5.8 1.3 3.9 28.2
Congo, Dem. Rep. 48,615,896 24.8 90.4 13.4 7.4 5.1 0.9 3.1 28.6
Costa Rica 848,903 74.2 78.3 12.4 15.1 4.5 0.3 3.3 20.5
Cote d'Ivoire 13,128,915 29.3 91.1 16.8 7.5 4.8 1.1 2.4 27.4
Dominica 20,995 74.7 69.2 16.0 16.7 4.0 1.4 6.9 24.9
Dominican Republic 2,830,077 56.0 80.7 19.8 11.6 3.9 1.0 4.0 23.5
Ecuador 3,751,442 60.7 80.7 12.9 13.3 3.3 0.7 4.5 19.1
Egypt 25,712,836 64.5 88.0 26.3 8.1 5.4 0.8 3.4 26.1
El Salvador 1,717,185 58.8 78.6 12.7 11.6 3.6 0.8 5.4 20.3
Equatorial Guinea 504,640 22.8 91.1 11.9 8.3 5.1 0.9 3.5 29.0
Ethiopia 51,609,576 20.8 89.9 13.2 11.8 4.7 1.2 2.3 28.6
Fiji 308,930 69.8 87.3 27.7 8.1 7.1 2.3 17.7 22.5
Gambia 825,609 35.1 86.6 15.4 9.2 4.5 0.9 2.1 30.5
Georgia 1,485,679 81.0 63.9 34.4 16.0 4.1 1.0 4.0 26.1
Ghana 12,200,472 31.5 88.1 18.4 10.4 4.9 1.2 3.2 25.8
Grenada 31,064 76.7 72.9 18.8 16.1 4.0 1.3 7.6 24.4
Guatemala 4,292,904 48.3 85.6 10.6 11.0 3.5 1.4 5.9 21.9
Guinea 7,621,634 23.4 84.7 16.3 11.7 5.5 1.0 1.7 30.1
Guinea-Bissau 1,185,058 24.5 91.9 17.2 8.5 4.7 1.0 1.7 31.1
Guyana 273,446 57.2 84.9 24.6 9.9 3.6 2.6 7.2 22.7
Honduras 2,215,974 56.4 83.2 16.3 10.5 6.1 0.7 3.4 21.9
India 501,562,112 44.6 83.1 20.8 9.1 10.0 0.8 2.7 25.3
Indonesia 76,034,208 60.0 83.6 23.7 10.9 6.3 2.4 4.7 24.7
10
Country All-cause DALYs, NCD DALYs (% of all- Premature NCD Premature NCD DALYs by cause (% of premature Elevated blood
annual average cause DALYs) DALYs (% of all NCD NCD DALYs) pressure (% of
DALYs) population)
Type 1 Type 2
Iran 20,768,156 66.0 83.9 15.2 8.6 3.3 0.6 2.8 22.7
Iraq 10,211,396 53.3 89.7 23.4 8.2 3.6 0.8 3.8 28.3
Jamaica 700,532 70.7 73.4 14.2 15.8 4.6 1.8 7.8 23.1
Jordan 1,531,514 65.1 89.1 12.2 8.8 4.1 0.4 4.3 23.9
Kazakhstan 5,989,038 70.4 78.1 31.2 13.1 4.1 0.3 2.6 27.4
Kenya 20,396,976 23.4 89.2 13.2 9.8 4.7 1.1 2.8 25.9
Kiribati 49,316 54.9 89.6 26.3 8.6 7.8 2.0 11.9 21.5
Kyrgyzstan 1,813,799 62.3 80.0 26.1 9.8 4.7 0.4 2.3 26.6
Laos 3,057,879 41.5 86.8 24.3 10.3 7.4 1.3 3.0 25.0
Lebanon 1,412,283 77.2 81.5 15.7 14.2 5.2 0.7 4.6 22.6
Lesotho 1,782,841 23.6 82.1 20.6 13.0 9.2 1.9 6.0 28.4
Liberia 2,553,755 24.5 88.9 14.3 8.2 4.0 0.9 2.4 29.0
Libya 1,339,416 72.4 86.3 20.5 10.9 4.0 0.7 3.6 27.7
Macedonia 627,201 83.0 68.7 27.1 20.3 3.7 0.6 4.8 30.0
Madagascar 11,790,445 30.5 90.8 22.0 9.6 7.4 0.9 2.1 28.1
Malawi 11,102,156 20.2 87.3 12.3 13.4 4.4 1.1 2.6 27.6
Malaysia 6,871,874 71.8 81.2 23.3 13.6 4.3 0.3 4.5 23.2
Maldives 64,002 64.3 84.1 19.6 7.7 7.6 0.5 3.2 23.8
Mali 12,825,234 20.1 90.2 13.7 10.1 6.0 0.9 1.8 32.3
Marshall Islands 21,156 62.7 92.0 31.8 10.7 7.8 1.5 7.3 22.5
Mauritania 1,332,442 35.1 84.9 14.5 10.4 5.0 1.0 2.9 33.6
Mauritius 369,822 80.5 79.3 21.4 10.0 4.5 2.4 11.4 25.6
Mexico 26,904,898 68.5 81.1 10.6 11.1 3.7 1.0 8.7 21.7
Moldova 1,632,236 77.6 71.8 27.7 15.4 3.0 0.4 2.5 30.3
Mongolia 1,029,973 58.6 86.1 27.4 16.5 2.8 0.4 1.5 31.5
Montenegro 198,816 83.4 65.5 27.8 20.9 2.5 1.6 3.4 31.1
Morocco 10,438,258 65.1 82.0 25.7 8.4 4.0 0.8 3.1 28.3
Mozambique 18,182,948 20.6 90.2 16.1 10.6 4.6 1.3 2.5 28.7
Myanmar 24,300,032 49.4 83.3 14.0 13.8 10.1 2.9 4.1 24.2
Namibia 1,328,904 24.8 79.5 19.5 12.9 7.8 1.5 4.6 30.2
Nepal 9,681,654 45.0 83.0 18.1 9.0 10.4 0.8 2.4 28.6
Nicaragua 1,231,248 57.9 84.9 10.5 10.2 3.9 0.6 4.9 22.4
Niger 13,392,777 16.1 92.1 13.4 9.4 5.5 0.8 1.9 33.3
Nigeria 128,100,192 17.3 89.1 9.2 9.5 4.0 0.5 1.4 26.6
Pakistan 85,988,784 39.2 87.0 21.6 15.0 5.7 1.0 2.8 30.0
Panama 767,191 63.7 78.3 12.6 13.4 4.4 0.8 4.5 21.1
Paraguay 1,447,989 62.9 82.0 14.6 12.4 4.1 0.8 5.1 26.7
Peru 6,861,032 59.2 80.7 10.8 14.4 4.5 0.5 2.7 16.5
Philippines 29,387,902 57.6 86.4 22.4 11.4 7.9 0.9 4.0 22.8
Romania 8,145,344 81.1 63.4 28.0 20.5 3.9 0.3 2.4 30.9
Russia 71,356,496 75.4 71.2 36.4 15.5 2.7 0.3 1.8 29.7
Rwanda 5,713,897 27.3 90.7 9.8 11.2 5.8 1.1 2.0 26.1
Samoa 47,894 68.3 81.2 23.4 9.4 7.9 1.2 7.5 22.9
Sao Tome and 61,421 50.0 85.7 14.6 11.1 7.6 0.5 1.7 27.7
Principe
Senegal 5,868,247 32.4 86.8 13.6 10.0 4.9 1.1 2.9 31.1
Serbia 3,471,206 85.3 60.9 26.0 24.2 4.0 0.8 4.0 31.8
Sierra Leone 5,063,505 24.4 88.5 16.7 8.2 4.6 0.9 1.9 31.0
Solomon Islands 201,062 49.9 88.3 26.9 9.5 7.4 1.9 6.3 21.2
South Africa 34,326,960 28.0 82.8 17.6 13.8 8.4 1.4 5.7 28.9
Sri Lanka 5,168,947 73.3 77.1 19.0 10.6 6.5 1.9 7.0 22.0
St. Lucia 44,147 73.0 76.1 16.4 14.8 4.8 1.2 8.0 26.4
St. Vincent and the 34,223 70.5 75.4 17.9 15.2 3.4 2.0 8.7 24.5
Grenadines
Sudan 15,939,425 41.3 88.2 21.0 5.7 4.0 0.6 1.6 29.8
Suriname 173,148 63.5 81.2 20.4 12.3 4.3 1.2 5.6 23.9
Swaziland 938,691 21.3 87.7 18.1 13.7 7.6 2.0 7.6 29.7
Tajikistan 2,413,596 47.5 83.6 20.8 10.2 4.4 1.0 3.2 25.4
Tanzania 24,799,886 30.3 89.3 10.1 10.5 4.2 0.8 1.8 27.0
Thailand 18,500,154 67.0 80.5 14.8 18.1 5.0 0.7 3.7 22.4
Timor-Leste 399,115 45.7 84.8 19.9 9.8 6.4 0.9 3.1 27.2
Togo 3,805,193 23.0 91.5 15.7 8.7 5.2 0.9 1.9 29.9
Tonga 29,592 68.5 78.2 16.2 15.0 7.6 1.4 10.6 22.3
Tunisia 2,575,401 74.6 76.0 19.1 9.8 4.1 0.6 3.3 25.6
Turkey 18,294,936 76.2 79.8 14.5 15.4 6.0 0.5 3.6 23.5
Ukraine 22,653,814 80.3 66.7 34.3 16.5 3.4 0.3 2.0 29.8
Uzbekistan 8,972,958 64.0 80.0 29.9 9.8 3.5 1.1 4.3 25.4
Vanuatu 87,398 58.8 87.9 30.2 11.4 9.1 1.3 4.2 23.3
West Bank and Gaza 1,087,874 53.7 86.1 15.7 9.3 3.9 0.3 3.8 24.7
Zimbabwe 10,167,904 20.5 86.0 19.7 16.2 6.8 1.3 3.8 28.9
11
Table A3
Average annual country attributes, 116 LMICs, 2000–2016.
Country Per-capita DAH by Per-capita total health Per-capita GDP Population Urban Secondary school Obesity (%
category (constant 2017 expenditure net of DAH (constant 2017 population enrollment (% of age- of
USD) (constant 2017 USD) USD) growth rate (%) eligible) population)
DAH- DAH- DAH-

NCD HS other
Afghanistan 0.122 1.553 7.50 37.89 479 28,269,089 4.8 39.8 4.0
Albania 0.329 2.793 4.17 209.53 3,388 2,963,251 1.6 84.4 17.9
Algeria 0.001 0.022 0.08 144.82 3,534 33,719,631 2.7 79.2 21.4
Angola 0.011 0.188 3.45 99.21 3,343 20,413,357 5.5 19.9 5.2
Argentina 0.384 1.829 3.60 801.52 12,824 40,201,845 1.3 99.2 25.0
Armenia 0.447 1.354 6.20 149.51 2,568 2,967,492 0.8 92.7 16.6
Bangladesh 0.005 0.160 1.76 23.46 979 147,582,887 3.8 51.3 2.4
Belarus 0.029 0.124 1.45 311.25 5,577 9,488,295 0.5 106.7 23.6
Belize 0.247 0.938 11.27 239.29 4,891 309,354 2.0 76.8 21.0
Benin 0.005 1.305 7.25 22.81 730 8,537,395 3.8 38.6 7.0
Bhutan 0.002 0.801 6.10 67.08 2,145 710,138 4.5 60.3 4.9
Bolivia 0.134 1.170 7.15 132.95 2,601 9,605,105 2.4 83.2 17.0
Botswana 0.112 0.280 35.76 297.48 5,588 1,833,084 2.2 79.5 14.8
Brazil 0.011 0.473 0.58 780.60 9,505 193,751,850 1.4 99.9 19.1
Bulgaria 0.020 1.786 1.65 431.78 5,982 7,535,040 0.4 93.6 22.4
Burkina Faso 0.011 1.028 6.89 18.07 543 15,015,360 6.4 20.7 3.7
Burundi 0.041 1.078 7.81 24.53 344 8,420,380 5.6 23.8 3.9
Cabo Verde 10.212 3.995 10.44 114.51 2,694 490,156 2.7 79.5 9.0
Cambodia 0.083 0.929 7.07 38.27 698 13,017,219 2.4 30.7 1.9
Cameroon 0.009 0.521 3.93 55.34 1,260 19,020,713 3.8 40.7 8.7
Central African 0.007 0.442 4.99 16.30 530 4,284,206 1.7 14.6 5.7
Republic
Chad 0.005 0.695 3.32 27.62 636 11,236,320 3.7 19.0 4.5
China 0.004 0.051 0.16 194.42 4,325 1,314,835,417 3.5 76.4 3.9
Colombia 0.008 1.862 3.07 302.90 5,120 45,182,499 1.5 91.9 19.6
Comoros 0.001 2.488 9.01 75.87 821 650,161 2.4 48.3 5.8
Congo 0.013 0.661 2.59 27.72 1,608 3,787,125 3.5 43.5 6.7
Congo, Dem. 0.037 0.664 7.30 11.39 396 66,961,295 4.6 42.2 5.5
Rep.
Costa Rica 0.019 2.324 1.00 712.26 9,364 4,434,084 3.0 96.6 21.1
Cote d'Ivoire 0.014 0.155 10.55 44.63 1,496 23,111,914 3.8 43.0 10.5
Dominica 0.424 0.423 5.77 349.25 7,334 70,959 0.7 103.9 23.5
Dominican 0.187 3.102 8.66 269.24 5,219 9,756,318 2.9 74.0 23.2
Republic
Ecuador 0.018 0.584 2.00 363.74 5,368 14,459,109 2.0 79.0 17.0
Egypt 0.013 0.204 0.71 98.07 2,038 81,723,251 2.1 78.7 27.7
El Salvador 0.043 1.888 4.80 227.15 3,354 6,110,017 1.3 69.0 20.2
Equatorial 0.000 1.306 7.93 135.67 8,553 669,452 4.2 23.5 5.0
Guinea
Ethiopia 0.010 0.204 6.18 15.40 395 80,567,307 4.5 27.5 2.9
Fiji 0.623 2.113 9.97 152.59 4,637 834,030 1.4 86.5 25.1
Gambia 0.003 0.688 13.81 16.79 493 1,640,094 4.6 57.7 8.0
Georgia 0.051 1.257 6.19 195.98 2,493 4,075,936 0.9 87.0 17.5
Ghana 0.077 2.286 8.06 59.34 1,164 23,326,846 3.9 47.3 8.2
Grenada 0.421 0.306 5.29 491.28 8,818 104,415 0.3 104.3 18.2
Guatemala 0.013 0.428 6.10 240.17 4,015 14,143,901 3.1 54.4 17.4
Guinea 0.001 0.775 4.56 20.99 616 10,091,502 3.2 29.9 5.3
Guinea-Bissau 1.185 1.420 6.15 37.77 629 1,345,579 4.3 27.3 5.4
Guyana 0.120 3.758 34.80 149.80 3,440 749,299 0.0 89.5 15.8
Honduras 0.121 0.483 8.39 166.73 2,251 8,371,476 3.1 63.8 19.2
India 0.007 0.083 0.61 43.55 1,203 1,193,683,740 2.6 59.9 2.8
Indonesia 0.005 0.260 1.02 81.19 2,735 236,253,559 3.0 70.3 4.6
Iran 0.001 0.038 0.18 287.30 4,544 72,598,434 2.2 81.0 21.6
Iraq 0.003 1.566 1.37 105.95 3,542 25,630,346 2.8 43.7 24.2
Jamaica 0.036 0.391 8.11 263.71 5,112 2,779,923 0.9 87.4 20.6
Jordan 0.427 1.612 6.96 352.08 4,326 6,586,694 4.1 81.4 31.8
Kazakhstan 0.021 0.606 1.57 289.64 7,526 16,613,730 1.0 102.1 19.0
Kenya 0.018 0.487 9.27 54.02 1,122 35,676,362 4.4 47.6 4.2
Kiribati 1.757 5.788 31.37 189.59 1,650 90,931 2.4 83.7 39.4
Kyrgyzstan 0.071 2.249 5.18 66.07 960 5,386,006 1.5 88.5 13.1
Laos 0.062 1.366 7.11 46.16 1,516 6,043,000 5.2 46.8 3.3
Lebanon 0.141 1.225 1.99 710.65 8,708 4,393,359 3.9 76.8 29.2
Lesotho 0.087 6.133 21.96 47.43 928 2,015,393 3.3 44.4 12.7
Liberia 0.054 1.751 38.13 105.43 479 3,961,262 4.1 39.0 8.4
Libya 0.000 0.013 0.06 377.33 10,848 5,704,398 1.7 100.5 26.8
Macedonia 0.095 2.579 2.34 305.87 4,290 2,062,613 0.0 81.4 20.1
Madagascar 0.010 0.368 4.98 18.22 448 21,402,507 4.8 32.3 4.1
Malawi 0.133 2.083 18.04 4.97 295 14,578,797 3.7 31.9 4.2
Malaysia 0.003 0.003 0.13 367.17 9,257 30,712,812 2.6 84.9 15.4
Maldives 0.003 0.221 0.55 513.46 6,954 294,877 6.1 62.2 3.6
Mali 0.025 1.248 9.28 31.98 736 14,523,604 5.4 33.4 6.3
12
Country Per-capita DAH by Per-capita total health Per-capita GDP Population Urban Secondary school Obesity (%
category (constant 2017 expenditure net of DAH (constant 2017 population enrollment (% of age- of
USD) (constant 2017 USD) USD) growth rate (%) eligible) population)
DAH- DAH- DAH-

NCD HS other
Marshall 0.607 25.511 158.66 476.00 3,275 52,322 0.5 82.8 49.6
Islands
Mauritania 0.047 0.800 4.02 39.56 1,014 3,455,585 4.2 23.4 9.8
Mauritius 0.011 0.035 0.83 326.07 7,705 1,236,467 0.0 88.7 8.9
Mexico 0.013 0.948 0.83 472.42 8,229 114,045,446 1.8 83.2 25.4
Moldova 0.192 1.410 7.20 148.77 1,587 3,584,661 0.3 86.7 16.6
Mongolia 0.345 2.578 4.50 87.43 2,169 2,608,787 2.8 85.9 15.3
Montenegro 0.662 3.584 3.48 407.31 6,314 617,551 0.6 94.6 21.0
Morocco 0.012 0.537 2.28 115.92 2,275 30,951,719 2.0 53.2 20.4
Mozambique 0.036 2.931 16.99 0.21 311 22,908,867 3.6 19.6 5.2
Myanmar 0.002 0.087 1.13 13.88 597 48,618,623 2.4 45.2 3.3
Namibia 0.013 0.646 22.45 378.56 3,773 1,994,826 3.8 63.4 10.9
Nepal 0.035 0.957 3.54 28.62 649 26,523,761 3.6 53.9 2.8
Nicaragua 0.062 3.329 11.93 87.46 1,572 5,365,873 1.8 66.1 18.4
Niger 0.013 0.505 4.00 18.14 332 15,526,030 4.7 12.5 4.1
Nigeria 0.002 0.406 4.24 52.53 1,609 146,552,143 4.7 37.3 6.0
Pakistan 0.009 0.311 2.09 34.73 1,318 169,500,953 3.1 35.3 6.8
Panama 0.044 1.020 3.40 669.74 9,907 3,490,955 2.3 69.9 19.1
Paraguay 0.030 1.324 2.08 184.22 3,210 5,863,993 2.2 67.6 15.9
Peru 0.029 0.489 3.37 233.94 4,903 28,733,376 1.8 90.9 17.1
Philippines 0.005 0.614 1.12 74.77 2,015 88,661,373 1.3 82.3 4.6
Romania 0.051 2.145 0.55 385.24 7,630 20,793,895 0.6 88.9 19.8
Russia 0.001 0.020 0.30 529.65 9,789 143,503,425 0.0 91.6 21.6
Rwanda 0.140 1.931 21.56 21.58 507 9,837,104 7.1 25.3 3.9
Samoa 1.912 19.190 12.24 180.46 3,832 183,705 0.1 84.0 43.5
Sao Tome and 10.126 4.515 25.85 81.45 1,620 174,387 3.5 55.8 10.0
Principe
Senegal 0.012 1.214 10.13 34.52 890 12,525,645 3.3 32.9 6.7
Serbia 0.187 1.493 1.79 446.72 4,870 7,325,766 0.1 91.5 19.1
Sierra Leone 0.066 0.657 15.09 35.55 467 6,612,039 3.4 37.4 7.5
Solomon 0.344 18.547 20.79 117.36 1,753 481,656 4.7 35.8 17.3
Islands
South Africa 0.012 0.328 9.63 393.35 5,610 50,077,873 2.1 91.4 23.5
Sri Lanka 0.201 0.717 1.42 96.54 3,441 20,545,274 0.7 98.6 4.4
St. Lucia 1.358 4.829 16.59 507.06 8,710 168,447 1.6 84.6 16.5
St. Vincent and 2.395 1.482 8.05 255.01 6,385 108,932 0.8 98.7 19.9
the
Grenadines
Sudan 0.017 0.131 2.39 106.55 2,085 32,763,976 2.6 39.2 6.2
Suriname 1.378 5.188 14.82 327.42 5,766 519,073 1.0 72.4 23.7
Swaziland 0.042 0.791 33.99 159.23 2,896 1,167,006 1.0 52.9 13.1
Tajikistan 0.023 0.612 4.02 23.77 503 7,121,489 2.0 81.6 10.5
Tanzania 0.037 2.320 20.43 30.01 772 48,606,061 5.5 32.0 7.0
Thailand 0.004 0.043 0.99 184.01 5,160 66,520,853 3.7 82.7 6.6
Timor-Leste 0.650 1.036 14.70 36.47 2,426 1,091,087 4.4 56.5 2.6
Togo 0.001 0.365 2.83 21.46 522 5,606,371 4.0 42.2 5.1
Tonga 16.057 31.293 14.53 124.26 3,550 102,250 0.7 102.6 43.2
Tunisia 0.082 0.505 0.91 178.44 3,041 10,441,822 1.4 86.0 23.0
Turkey 0.021 0.585 0.37 355.75 7,361 70,319,205 2.3 88.6 27.4
Ukraine 0.002 0.063 1.33 147.69 2,446 46,798,144 0.4 98.2 21.6
Uzbekistan 0.048 0.250 1.50 53.97 985 28,166,657 1.5 91.0 13.6
Vanuatu 1.256 10.308 23.98 54.45 2,865 210,331 3.6 43.9 19.3
West Bank and 1.405 5.202 11.04 298.47 2,944 3,654,705 3.1 85.1 29.0
Gaza
Zimbabwe 0.013 1.237 11.42 100.79 1,253 13,248,028 1.9 43.9 12.3
13
Table A4
Summary results†, models of non-NCD DALYs and deaths, 116 LMICs, 2000–2016 (N = 1,441).
Non-NCD DALYs Non-NCD deaths
Premature All-age Premature All-age

DAH-NCD
Lagged 1 year 9227.9 9450.6 181.6 192.2
(7642.1) (7754.2) (140.8) (147.7)
Lagged 2 years 9251.8 9483.3 167.9 178.2
(8966.6) (9130.1) (155.2) (165.4)
Lagged 3 years 4782.8 4916.8 92.3 95.8
(6138.7) (6282.3) (98.0) (106.9)
Lagged 4 years 4370.2 4386.8 80.0 86.4
(12904.3) (13142.5) (223.9) (238.8)
Lagged 5 years 13254.2 13305.2 243.7 244.7
(17995.5) (18296.3) (315.2) (330.3)
DAH-HS
Lagged 1 year 1159.2 1151.8 23.0 21.8
(1391.9) (1406.4) (26.6) (27.7)
Lagged 2 years 176.2 194.5 2.7 4.6
(851.4) (865.4) (14.5) (15.4)
Lagged 3 years 561.8 556.1 11.4 9.7
(1453.9) (1477.1) (22.6) (24.2)
Lagged 4 years 131.1 126.0 1.1 0.5
(921.6) (936.0) (14.9) (15.9)
Lagged 5 years 3536.6 3534.5 65.0 65.4
(2815.3) (2840.7) (51.5) (53.2)
DAH-other
Lagged 1 year 1313.0 1327.3 24.5 25.6
(1063.8) (1074.8) (19.3) (20.0)
Lagged 2 years 114.4 112.9 2.6 3.0
(813.9) (822.9) (12.9) (13.5)
Lagged 3 years 868.5 865.0 16.6 16.8
(952.3) (958.6) (17.3) (17.8)
Lagged 4 years 1315.3 1317.6 25.5 25.9
(1231.6) (1241.8) (22.3) (23.0)
Lagged 5 years 4453.3 4491.3 92.1 95.8
(4334.6) (4377.3) (82.5) (85.3)
†Notes: Coefficients represent the average change in outcomes associated with a $1 increase in per-capita DAH.
** Statistically significant at the 1 % level.
Standard errors in parentheses.
Estimates obtained from fixed effects linear models with clustering of the standard errors by country. All models include controls for contemporaneous (unlagged) total DAH,
total health expenditure net of DAH, population size, urbanization (urban population growth rate), schooling (% age-eligible population enrolled in secondary school), income
(per-capita GDP), average BMI. All models include country fixed effects, year fixed effects, and country-specific time trends.
14
Table A5
Summary results†, models of NCD DALYs, 113 LMICs, 2000–2016 (N = 1,397). Models are identical to those in Table 1, after excluding three countries with average annual per-
capita DAH-NCD>$10 (Cabo Verde, Sao Tome and Principe, Tonga).
NCD DALYs NCD DALYs by cause
DAH-NCD
Lagged 1 6013.9 6715.5 1950.7 1950.1 1195.4 1210.3 1869.3# 2353.5# 49.8 48.4 331.3 387.2
year (3788.7) (4223.3) (1310.3) (1409.2) (869.7) (877.8) (952.7) (1190.7) (34.8) (34.9) (339.9) (415.1)
Lagged 2 7935.7* 9415.1* 2869.7* 3419.1* 1650.6# 1733.4# 2054.8# 2659.4# 56.6 54.5 315.1 350.2
years
(3825.1) (4587.6) (1338.3) (1654.7) (940.3) (975.7) (1046.5) (1365.1) (36.1) (38.7) (311.3) (383.4)
Lagged 3 9438.6# 11380.1* 2964.0# 3643.7# 2355.1 2499.0# 2295.9* 3022.4* 61.8# 62.9 288.9 325.9
years
(4831.3) (5607.3) (1757.6) (2140.8) (1473.8) (1488.1) (1063.9) (1412.1) (36.3) (39.6) (399.5) (492.7)
Lagged 4 33361.2 34650.4 11475.5 11251.7 9213.8 8727.5 5777.6 7136.1 271.4# 289.7 396.0 462.7
years
(22437.5) (23513.6) (8540.9) (9261.1) (7390.4) (7139.0) (3682.4) (4675.6) (161.5) (178.1) (1366.6) (1722.7)
Lagged 5 26635.2 21680.5 8327.4 4329.3 6821.2 5642.7 4736.7 4821.0 267.1 254.1 1665.0 1995.5
years
(26144.1) (26558.0) (10783.9) (10566.7) (6522.7) (5935.1) (5740.1) (7459.2) (181.7) (204.3) (1207.2) (1477.8)
DAH-HS
Lagged 1 536.6 376.4 280.5 235.8 122.5 94.2 72.6 133.2 2.9 0.9 20.1 19.9
year
(676.0) (726.6) (287.7) (305.9) (180.4) (171.2) (167.9) (222.1) (6.7) (7.5) (44.7) (56.2)
Lagged 2 133.7 49.4 34.2 38.5 27.6 11.4 41.9 103.4 0.5 1.5 33.0 37.9
years
(853.4) (969.2) (317.9) (367.3) (195.5) (198.1) (205.8) (267.0) (8.2) (8.9) (48.8) (60.4)
Lagged 3 1815.2 2119.7 650.4 790.4 422.2 420.8 366.5 501.5 9.5 11.7 58.7 77.3
years
(1602.7) (1875.4) (630.5) (759.1) (374.5) (384.1) (338.7) (439.9) (13.6) (15.0) (106.0) (131.7)
Lagged 4 2261.9 2690.0 831.7 1021.8 443.7 462.0 561.5 728.1 18.5 18.6 55.2 59.0
years
(1360.9) (1657.7) (591.1) (743.0) (300.2) (310.9) (331.5) (439.3) (12.8) (14.8) (94.1) (116.1)
Lagged 5 3383.9 3936.8 1410.1 1664.4 574.4 578.6 852.8 1075.6 39.0 37.9 233.8 271.4
years
(2196.0) (2629.5) (855.2) (1059.9) (454.5) (478.3) (571.7) (745.1) (24.3) (27.3) (147.5) (183.1)
DAH-
other
Lagged 1 213.5 228.6 109.9 106.6 18.7 3.8 62.5 87.2 3.5 4.2 8.4 9.9
year
(570.8) (650.9) (223.2) (258.6) (122.1) (125.9) (128.0) (164.2) (5.5) (6.0) (30.3) (37.1)
Lagged 2 1182.8 1239.8 412.6 417.4 270.0 245.9 257.7 323.2 7.2 7.8 10.8 17.4
years
(830.6) (936.2) (338.7) (395.2) (209.7) (202.1) (172.0) (222.5) (7.2) (8.2) (56.9) (71.2)
Lagged 3 1205.7 1339.2 451.1 488.5 217.0 206.1 335.4 416.1 12.6 12.3 65.3 75.0
years
(747.6) (890.8) (291.0) (361.6) (162.4) (164.4) (203.5) (264.1) (8.8) (10.0) (47.8) (59.2)
Lagged 4 853.4 1034.9 346.5 417.6 114.3 120.0 274.6 347.8 12.0 11.6 92.2 109.6
years
(724.1) (857.5) (258.5) (320.3) (159.6) (161.7) (194.1) (253.3) (8.2) (9.1) (48.4) (61.1)
Lagged 5 1136.5 1174.8 476.6 454.5 259.0 225.7 233.8 290.6 10.5 10.2 114.5 137.2
years
(1401.7) (1565.4) (538.9) (608.7) (332.3) (336.3) (300.3) (384.3) (13.2) (14.1) (74.2) (90.6)
†Notes: Coefficients represent the average (country-year) change in DALYs associated with a $1 increase in per-capita DAH.
# Statistically significant at the 10% level.
15
Table A6
Summary results†, models of NCD deaths, 113 LMICs, 2000–2016 (N = 1397). Models are identical to those in Table 2, after excluding three countries with average annual per-
capita DAH-NCD>$10 (Cabo Verde, Sao Tome and Principe, Tonga).
NCD deaths NCD deaths by cause
DAH-NCD
Lagged 1 year 188.6 299.4# 72.1 105.4 43.6 50.1 48.5# 86.6# 2.0 2.1 7.6 12.8
(120.7) (178.9) (50.0) (70.8) (30.0) (33.0) (27.2) (47.4) (1.3) (1.4) (5.4) (9.5)
Lagged 2 years 243.7* 414.2* 98.2* 174.2* 56.9# 68.8* 53.3# 100.1# 2.2 2.3 8.5 13.3
(112.4) (188.0) (46.5) (80.1) (29.2) (33.7) (28.1) (52.7) (1.2) (1.5) (4.5) (7.8)
Lagged 3 years 290.5# 482.3* 105.0# 185.3# 78.6# 93.7# 61.7* 115.9* 2.5* 2.9 10.3 16.1
(149.3) (230.7) (61.2) (98.3) (46.2) (49.2) (29.6) (56.8) (1.3) (1.6) (5.3) (8.9)
Lagged 4 years 1063.1 1375.3 430.1 519.3 312.4 296.6 159.5 261.3 10.0 12.2 34.4 58.3
(712.6) (894.9) (301.0) (383.7) (233.4) (217.7) (99.3) (170.5) (5.6) (7.1) (17.7) (33.0)
Lagged 5 years 914.9 827.0 361.2 188.0 263.0 198.9 147.3 177.5 9.9 10.0 41.6 72.5
(830.0) (1061.7) (376.4) (453.7) (215.7) (188.9) (150.9) (273.7) (6.6) (8.9) (21.9) (40.6)
DAH-HS
Lagged 1 year 14.1 3.0 8.5 4.7 3.5 1.5 1.7 5.8 0.1 0.1 0.7 0.9
(20.8) (30.0) (9.2) (12.9) (5.8) (5.6) (4.6) (8.7) (0.2) (0.3) (0.8) (1.6)
Lagged 2 years 4.2 14.5 1.7 7.7 1.5 0.4 0.1 3.4 0.1 0.1 0.4 0.3
(25.0) (36.6) (10.8) (16.7) (6.4) (6.6) (5.4) (9.5) (0.3) (0.3) (0.8) (1.3)
Lagged 3 years 45.2 78.5 18.4 35.8 11.1 12.3 7.3 15.7 0.3 0.5 0.5 0.7
(43.6) (68.5) (19.9) (32.2) (10.7) (12.0) (8.6) (15.7) (0.4) (0.6) (1.4) (2.4)
Lagged 4 years 62.1 106.4 25.7 47.8 13.6 16.2 13.5 25.8 0.7 0.7 2.2 3.1
(38.9) (64.9) (19.2) (32.9) (9.0) (10.2) (8.2) (15.9) (0.4) (0.6) (1.5) (2.7)
Lagged 5 years 108.9 177.7 49.3 84.0 21.5 24.2 23.0 42.0 1.4 1.3 5.1 7.7
(62.2) (101.8) (28.4) (48.1) (14.1) (16.6) (14.7) (27.7) (0.8) (1.0) (2.8) (4.6)
DAH-other
Lagged 1 year 5.6 12.8 3.2 6.6 0.2 0.2 0.9 2.5 0.1 0.1 0.3 0.6
(16.4) (23.8) (7.5) (11.0) (3.9) (4.2) (3.3) (5.8) (0.2) (0.2) (0.5) (0.9)
Lagged 2 years 30.8 41.8 12.3 16.7 7.4 6.5 5.6 9.7 0.2 0.3 0.7 1.0
(21.9) (31.8) (10.3) (15.7) (5.7) (5.5) (4.2) (7.7) (0.2) (0.3) (0.7) (1.2)
Lagged 3 years 35.8 54.4 15.0 23.0 7.2 7.3 8.4 14.7 0.4 0.5 1.6 2.5
(20.7) (33.1) (9.4) (15.8) (4.8) (5.3) (5.1) (9.5) (0.3) (0.4) (0.9) (1.5)
Lagged 4 years 28.8 50.3 12.7 22.9 4.8 6.0 7.4 13.6 0.4 0.4 1.6 2.6
(20.0) (32.9) (8.4) (14.7) (4.6) (5.3) (5.1) (9.6) (0.3) (0.3) (0.9) (1.5)
Lagged 5 years 46.2 69.3 20.9 29.3 11.4 10.7 7.5 13.5 0.4 0.5 2.5 4.6
(42.2) (61.8) (18.9) (27.8) (10.9) (11.7) (7.8) (14.2) (0.4) (0.5) (1.4) (2.4)
†Notes: Coefficients represent the average (country-year) change in deaths associated with a $1 increase in per-capita DAH.
diabetes mellitus type 1. DM 2: diabetes mellitus type 2. # Statistically significant at the 10% level.
Table A7
Summary results†, models of elevated blood pressure, 113 LMICs, 2000–2015 (N = 1,337). Model is identical to that in Table 3, after excluding three countries with average
annual per-capita DAH-NCD>$10 (Cabo Verde, Sao Tome and Principe, Tonga).
Elevated blood pressure (percent of population)

DAH-NCD
Lagged 1 year 0.00258
(0.00186)
(0.00267)
(0.00510)
(0.00767)
(0.01626)
DAH-HS
(0.00047)
(0.00037)
(0.00063)
Lagged 4 years 0.00121*
(0.00058)
16

(0.00116)
DAH-other
(0.00030)
(0.00033)
(0.00047)
(0.00042)
(0.00111)
†Notes: Coefficients represent the average percentage point change in the population prevalence of elevated blood pressure associated with a $1 increase in per-capita DAH.
# Statistically significant at the 10% level.
Table A8
Specification checks: summary of coefficients from alternative models.
Models of NCD DALYs Models of NCD Deaths Models of elevated blood pressure
Random Fixed effects model without Random Fixed effects model without Random Fixed effects model without
effects model country-time trends effects model country-time trends effects model country-time trends
Hausman test statistic 1194.55 (p = – 1232.06 (p = – 1223.03 (p = –
(chi2/p-value) 0.000) 0.000) 0.000)
DAH-NCD
Lagged 1 year 27734.5 765.3 1267.2 90.1 0.05011 0.01361
(44089.1) (5729.9) (2201.1) (195.8) (0.04139) (0.01928)
Lagged 2 years 21004.1 739.0 929.4 40.8 0.04372 0.01599
(50894.5) (5428.5) (2540.8) (192.0) (0.04547) (0.01418)
Lagged 3 years 17941.1 3301.0 860.3 136.9 0.03043 0.05861**
(52113.1) (6756.2) (2601.6) (252.8) (0.07429) (0.02015)
Lagged 4 years 20462.1 18707.6 1099.2 607.1 0.04027 0.01499
(86415.3) (11283.8) (4314.1) (385.3) (0.07698) (0.02835)
Lagged 5 years 5058.4 27600.2 261.0 1302.9 0.01609 0.00510
(89664.0) (14375.6) (4476.3) (669.6) (0.08089) (0.03546)
DAH-HS
Lagged 1 year 666.7 368.7 29.8 59.2 0.00602 0.00816**
(9135.0) (1158.4) (456.0) (57.5) (0.00791) (0.00238)
Lagged 2 years 652.0 217.7 100.2 45.5 0.00491 0.00891**
(9579.7) (1770.6) (478.3) (78.0) (0.00828) (0.00263)
Lagged 3 years 324.4 1930.2 76.1 131.2 0.00648 0.01445**
(10099.6) (1946.9) (504.2) (115.5) (0.00954) (0.00374)
Lagged 4 years 2172.7 694.4 165.4 51.2 0.00462 0.00048
(11311.1) (1379.5) (564.7) (69.7) (0.01065) (0.00414)
Lagged 5 years 5052.5 1363.5 346.1 79.9 0.01893 0.00084
(13527.7) (3392.6) (675.3) (153.1) (0.01209) (0.00799)
DAH-other
Lagged 1 year 1535.3 1910.9 97.8 66.3 0.00460 0.00004
(7207.8) (1169.8) (359.8) (39.4) (0.00637) (0.00232)
Lagged 2 years 637.3 118.5 43.3 23.0 0.00160 0.00258
(6764.8) (880.8) (337.7) (49.2) (0.00609) (0.00192)
Lagged 3 years 1392.0 1175.5 81.6 66.8 0.00449 0.00888**
(5959.1) (1146.5) (297.5) (50.0) (0.00693) (0.00177)
Lagged 4 years 1338.8 2504.3 79.6 128.4 0.00244 0.00090
(7112.0) (1485.2) (355.1) (76.0) (0.00670) (0.00211)
Lagged 5 years 7961.2 646.2 362.7 1.4 0.01847 0.01944**
(11556.7) (3059.9) (576.9) (113.0) (0.01137) (0.00515)
N 1,441 1,441 1,441 1,441 1,379 1,379
** Statistically significant at the 1 % level.
17
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NCDs and Effects of Vertical and Horizontal Health Aid

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NCDs and Effects of Vertical and Horizontal Health Aid

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Economics and Human Biology 41 (2021) 100935

Contents lists available at ScienceDirect

Economics and Human Biology

Noncommunicable disease outcomes and the effects of vertical

1. Introduction noncommunicable diseases (NCDs) (Institute for Health Metrics

2. Literature review 3. Data

hypertension in the population. Health indicators for available

NCD DALYs NCD DALYs by cause

CVD Neoplasms CRD DM 1 DM 2

NCD deaths NCD deaths by cause

CVD Neoplasms CRD DM 1 DM 2

DAH- DAH- DAH-

DAH- DAH- DAH-

Non-NCD DALYs Non-NCD deaths

Premature All-age Premature All-age

NCD DALYs NCD DALYs by cause

CVD Neoplasms CRD DM 1 DM 2

NCD deaths NCD deaths by cause

CVD Neoplasms CRD DM 1 DM 2

Elevated blood pressure (percent of population)

Lagged 5 years 0.00045

References IHME Financing Global Health. . http://www.healthdata.org/policy-report/

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