Introduction

The 2030 Agenda for Sustainable Development Goals is to reduce premature mortality from Non-Communicable Diseases (NCDs) by one third [1]. World Health Organization’s (WHO) “Package of Essential Non-Communicable Diseases Intervention for Primary Healthcare in Low-Resource Settings” (PEN) proposes a minimum set of cost-effective interventions for early diagnosis and management of NCDs [2] and is introduced as a tool to reduce the NCD-attributable premature mortality. Although the feasibility and cost-effectiveness of PEN has been assessed in a number of low-resource countries, the capacity to implement the package, its cost of implementation and effectiveness are, however, still under question. [3–16]. In other words, there is not adequate information on how the cost of implementation differs from the predictions of WHO and in what extend. The detailed information on the costs of implementing PEN package is required for the countries that are willing to adopt this package because countries need accurate estimations of cost of implementation to assess whether they should adopt the package in terms of costs and efficiency and in consideration of their resources, what are the detailed costs of implementation to configurate the package according to their resources and needs, and how to insure the sustained implementation of the practice if they decide to adopt it. This study helps feel the existing gap on the aforementioned notions by studying the case of pilot implementation of PEN in Iran and estimating the detailed cost of PEN implementation in Iran.

Due to high burden of NCDs in Iran [17], with the proportion of deaths attributable to NCDs being 82% in 2017 in Iran, Ministry of Health and Medical Education (MoHME) has developed a “National Action Plan for Prevention and Control of Non-Communicable Diseases and the related risk factors in Iran, 2015–2025” [18]. IraPEN (the PEN package implemented in Iran) is the name of the plan adopted from both WHO PEN package and National Action Plans for NCDs [2, 18]. Considering the high burden of NCDs and the financial limitations in addressing the burden of these diseases and prioritization concerns, Iranian healthcare policy makers are motivated to apply suggestions of expert organizations on efficient and effective policies and interventions. Thus, IraPEN is an attempt by healthcare policymakers and deputies to address challenges regarding NCD prevention and control in Iran by implementing a screening and referral system for the most common NCDs or with highest burden by healthcare providers at primary health care centers [19]. In general, healthcare policymakers considered IraPEN to be a comprehensive and effective program and exceeding the previously established type of practice in being comprehensive and integrated. Nevertheless, and like any other comprehensive policy, there are cost and structural concerns for upscaling the program.

IraPEN includes 5 protocols for: 1) prevention of myocardial infarction and stroke through integrated care of diabetes, hypertension, and dyslipidemia (MI & Stroke prevention); 2,3) screening of breast, cervical (female cancer prevention), and colorectal cancers (CRC prevention); 4) screening of asthma and other respiratory disorders including chronic obstructive pulmonary disease (Respiratory diseases screening); 5) Survey of NCD risk factors related to nutrition, alcohol/tobacco use, and low physical activity, followed by health education and counseling on health behaviors (NCD risk factors survey) [19]. This program was funded by MoHME and universities of medical sciences responsible for delivering healthcare programs at the district level.

There was a variety of managerial, political, and organizational challenges for the full-scale implementation of IraPEN [20]. Additionally, the upscaling and continued implementation the program required the long-term provision of financial resource. Therefore, MoHME started with piloting IraPEN in 4 districts to assess the feasibility and incremental cost of the program. In this research, we seek address the knowledge gap regarding the cost and resource use of IraPEN in the two pilot districts of Naqadeh and Shahreza from February 2016 to March 2017. The provided evidence can help with its future planning and may also be useful to other developing countries planning to implement cost-effective interventions to control the rapid emergence of NCDs and their associated complications.

Materials and methods

IraPEN program pilot implementation was performed in four districts of Iran. The districts were chosen based on the assessment of the experts in MoHME on the following matters: 1) the set of locations being representative of all parts of the country in terms of the healthcare provision and population characteristics, 2) the respective Universities of Medical Sciences being representative of the types of practices that are performed in the medical universities of the country because medical universities are responsible for the provision of the type of the care that is prescribed by PEN package, and 3) the estimated cost of implementation based on experts’ previous experiences and opinions, and not mathematical estimations, do not exceed the budget of the pilot program. This resulted in choosing 4 districts in 4 provinces of the country.

In this study, we estimated the incremental per capita cost of IraPEN program pilot-implementation in Shahreza and Naqadeh districts of Iran using a bottom-up approach [21]. An overall view of analysis framework has been illustrated in Fig 1. Capital and recurrent expenditure data was initially gathered via information forms. Expenditures were then re-categorized into fixed and variable costs. Cost per capita calculated by dividing fixed and variable costs by total eligible populations and the population covered by the pilot programs respectively. Total per capita cost per service was then calculated for each protocol, by including specific and non-specific costs of the protocol, and the whole program by adding these figures. The protocols consisted of a combination of the interventions designed for: 1) prevention of myocardial infarction and stroke through integrated care of diabetes, hypertension, and dyslipidemia (MI & Stroke prevention); 2,3) screening of breast, cervical (female cancer prevention), and colorectal cancers (CRC prevention); 4) screening of asthma and other respiratory disorders including chronic obstructive pulmonary disease (Respiratory diseases screening); 5) Survey of NCD risk factors related to nutrition, alcohol/tobacco use, and low physical activity, followed by health education and counseling on health behaviors (NCD risk factors survey) [19].

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Fig 1. An overall view of analysis framework to calculate incremental cost of implementing the world health organization Package of essential non-communicable (PEN) diseases interventions in Iran.

https://doi.org/10.1371/journal.pgph.0000449.g001

Results

A total of 637 individuals, from 551 families, who met IraPEN eligibility criteria were interviewed, out of whom 265 individuals had received IraPEN services at least once, corresponding to an overall coverage of 40.74% in two districts. Naqadeh and Shahreza had a coverage of 46.1%, and 36.82%, respectively. Over 75% of participants living in rural areas were covered by IraPEN.

Total expenditures are presented in Table 1. Introduction cost only contributed to 2.07% of the total costs. The human resources and supplies had the highest contribution in the total program cost (74.97% and 15.76%, respectively). Expenditure on human resources also contributed the highest portion of cost of each protocol (S2 Table). The cost categories with lowest contribution were retraining followed by customization.

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Table 1. Summary of annual costs of IraPEN pilot program in Naqadeh and Shahreza (US$).

https://doi.org/10.1371/journal.pgph.0000449.t001

When focusing on the proportion of each program in equipment, personnel, and supplies MI & Stroke prevention had the highest share of supplies and equipment costs and NCD risk factors survey had the highest share of personnel costs. Interestingly, NCD risk factors survey was the protocol with the lowest share in supplies and equipment costs (Table 1).

The final incremental costs of the IraPEN implementation per user, with and without introduction cost, were US$24.90 and US$25.32, respectively. The total incremental cost per capita for each protocol ranged between US$1.05 to US$7.45. Among all protocols, MI & Stroke prevention protocol had the highest cost per user followed by NCD risk factors survey (Table 2). The protocol with the lowest cost was respiratory diseases screening.

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Table 2. Costs per protocol per capita categorized by fixed and variable costs (US$).

https://doi.org/10.1371/journal.pgph.0000449.t002

Discussion

This research aimed to estimate the incremental cost of PEN implementation in Iran from healthcare provider perspective. The results show human resources to have had the highest contribution, followed by supplies. The final incremental costs of the IraPEN implementation per capita, excluding the cost of program introduction, was US$24.90. Total incremental cost per capita for each protocol ranged between US$1.05 and US$7.45, with MI & Stroke prevention protocol being the highest and respiratory diseases screening protocol being the lowest. The highest cost of supplies and equipment were for MI & Stroke prevention protocol and the highest cost of personnel was for NCDs risk factors survey protocol.

Our study is one of the first to evaluate the incremental implementation cost of health interventions proposed by PEN program in primary health care settings in a middle-income country [16]. Original WHO cost estimates for implementing the PEN’s package of “best-buy” s, was less than US$3 per capita in a UMIC, much lower than our US$24.90 figure for IraPEN [2, 25–27]. Best-buys should constitute a small proportion of the overall health spending of a country, less than 1% in upper middle-income countries [27]. Our results show the cost of IraPEN package to be 6.80% of the annual per capita healthcare expenditure in Iran [28], and can thus can be considered high-cost. The observed differences could be generally due to two reasons of accuracy and context. First, WHO cost calculations are mainly based on the total expected cost of implementation and in many cases, there is lack of accurate data and the gap is filled by expert estimations [29]. Additionally, WHO calculations are based on predicted costs, whereas we assessed the realized costs of implementation. Therefore, we consider the approach of this study to be accurate and thus more valid. The differences could come from the particular context of the study. Nevertheless, we expect not this to be the case because WHO considers Iran an upper-middle income country and incorporates the characteristics of upper-middle income countries in recommendations. And finally, and as depicted later in the discussion, WHO do not recommend detailed implementation. Therefore, a part of the difference could come from lack of efficiency of the IraPEN implementation and this is why we believe with configurations in the proposed plan, we could get closer to WHO target.

Nevertheless, this costing report can be considered as best estimate currently available for implementing a PEN variant in an MIC. Our study was the first attempt at gathering and presenting empirical evidence regarding the cost of implementing a PEN-based program. We took ingredients approach of costing for supplies, human resources, and equipment which is considered to be more precise compared to other methods like reference costing [22, 30, 31]. The results may offer empirical inputs for macroeconomic costing tools, such as OneHealth, for more realistic cost projections of PEN program in the future and in different countries. The information presented here may also be used internationally by policymakers to estimate the budgets necessary for implementing PEN in settings with previously established primary health care system.

Our study faced some limitations which should be discussed in brief. On top of all, though cost matters, an important factor to consider in making the decision about implementation of an intervention or a policy is the perspective of the patients and healthcare deputies. Due to the financial limitations and being out of the scope of the main goal in the study design, we did not systematically record the perspectives of the stakeholders. Nevertheless, we could infer that a great part of the opinion about the program for healthcare deputies is formed by the cost of the program in our informal discussion policy makers and decision makers in MoHME, UMSs, and DHSs. Additionally, the process of IraPEN implementation did not change the type and configuration of the service provision to patients in the sense that they did notice any big change in the healthcare center and service provision very likely stayed the same in their eyes. This design helped us in two matters. First, we are confident that the measurements are not affected by the patients’ expected outcomes of the changes. Additionally, as patients probably did not notice any difference, their perspective is very likely to be the same before and after the implementation of IraPEN. Therefore, the decision about continuing or halting the program could put patients’ perspective aside in further decision-making steps.

Our estimations just covered incremental cost of implementation in the Iranian healthcare context. The total cost of the program is required to be calculated for further studies and considerations. Nevertheless, and considering all strengths and limitations, our findings could be utilized in low and upper-middle income countries with limited resources and funding to inform the requirements for development and implementation of low cost and effective interventions for prevention and control of NCDs. Based on our findings we suggest some strategies to reduce the cost of the PEN program implementation in the Iranian context as well as other settings: 1) Because the human resource training, preparation, wages, and their supervision contributed the most of the program implementation cost, we suggest alterations of the current program to reduce the necessity and role of humans. Inserting the low-cost innovative technology to the chain of care have shown to reduction and efficiency improvements [32–35]. A primary example of this would be to utilize eHealth strategies in CVD risk calculation and consequent education on associated behavioral risk factors. In addition, any future performance monitoring system and cost reduction strategy requires the relevant data to be collected. Therefore, further strengthening of electronic record keeping for the program will assist in gathering valuable intelligence regarding local needs besides cost reduction. Moreover, it allows for customizable resource planning and allocation of the program which would help furtherly with increasing the efficiency of the program and decreasing its cost. 2) Restriction of the program’s inclusion criteria to target individuals at higher risk of NCDs will lower cost of human resources and the required materials as well. Provision of services could be planned according to the disease’s prevalence and their relative burden in the population. For instance, the incidence rate of cervical and colorectal cancers in the Iranian population was, respectively, 3.2 and 7.65 in 100,000 in 2015 [36]. It therefore seems that the colorectal cancer poses a greater population risk than cervical cancer and should be thus prioritized. Additionally, the cost-effectiveness of these early screening interventions will need to be thoroughly considered and funds should be prioritized and allocated accordingly. 3) Besides direct interventions for patients from healthcare providers, there is a need for exploration of more innovative behavioral approaches, targeted at the reduction of NCDs risk factors at the public and individual levels [27, 37]. It should however be noted that such interventions, while relatively straightforward to initiate, are shown to have mixed records of success [38, 39] and require careful review of the available evidence prior to making and implementing policy decisions [40].

Conclusions

Taken together, the present study showed that the IraPEN program implementation is considered a high-cost package in Iran. It is, however, difficult to make decisions on the implementation of NCD prevention and control programs purely based on their cost. Informed decision making, in this regard, requires an assessment of a programs’ effectiveness at national and subnational levels. Moreover, justifications and alterations to the current package could reduce the costs, leading to increased efficiency of the program, in the similar contexts comparing to Iran.

Supporting information

Acknowledgments

The authors thank all staff and colleagues in Non-Communicable Diseases Research Center (NCDRC) at Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences, helping conducting such valuable studies.