title: Cardiovascular disease and impoverishment averted due to a salt reduction policy in South Africa: an extended cost-effectiveness analysis.
abstract: The South African Government recently set targets to reduce cardiovascular disease (CVD) by lowering salt consumption. We conducted an extended cost-effectiveness analysis (ECEA) to model the potential health and economic impacts of this salt policy. We used surveys and epidemiologic studies to estimate reductions in CVD resulting from lower salt intake. We calculated the average out-of-pocket (OOP) cost of CVD care, using facility fee schedules and drug prices. We estimated the reduction in OOP expenditures and government subsidies due to the policy. We estimated public and private sector costs of policy implementation. We estimated financial risk protection (FRP) from the policy as (1) cases of catastrophic health expenditure (CHE) averted or (2) cases of poverty averted. We also performed a sensitivity analysis. We found that the salt policy could reduce CVD deaths by 11%, with similar health gains across income quintiles. The policy could save households US$ 4.06 million (2012) in OOP expenditures (US$ 0.29 per capita) and save the government US$ 51.25 million in healthcare subsidies (US$ 2.52 per capita) each year. The cost to the government would be only US$ 0.01 per capita; hence, the policy would be cost saving. If the private sector food reformulation costs were passed on to consumers, food expenditures would increase by <0.2% across all income quintiles. Preventing CVD could avert 2400 cases of CHE or 2000 cases of poverty yearly. Our results were sensitive to baseline CVD mortality rates and the cost of treatment. We conclude that, in addition to health gains, population salt reduction can have positive economic impacts-substantially reducing OOP expenditures and providing FRP, particularly for the middle class. The policy could also provide large government savings on health care.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA, Department of Medicine, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa, davidaw@uw.edu.
authors.forename: David A
authors.initials: DA
authors.lastname: Watkins
authors.affiliation: School of Public Health, The University of California, Berkeley, CA, USA.
authors.forename: Zachary D
authors.initials: ZD
authors.lastname: Olson
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Verguet
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA and.
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Nugent
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA and Global Health Sciences, The University of California, San Francisco, CA, USA.
authors.forename: Dean T
authors.initials: DT
authors.lastname: Jamison
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D005260:Female; D005382:Financing, Personal; D006306:Health Surveys; D006801:Humans; D008297:Male; D011203:Poverty; D011640:Public Policy / Q000191:economics* / Q000331:legislation & jurisprudence*; D012982:Sodium, Dietary / Q000008:administration & dosage*; D013019:South Africa
chemical_list: D012982:Sodium, Dietary
keywords: South Africa; cardiovascular disease; economic evaluation; equity; extended cost-effectiveness analysis; financial risk protection; health care financing; salt reduction
references.citation: Cochrane Database Syst Rev. 2004;(3):CD004937
references.pmid: 15266549
references.citation: Lancet Glob Health. 2015 Apr;3(4):e206-16
references.pmid: 25772692
references.citation: Lancet Neurol. 2009 Apr;8(4):355-69
references.pmid: 19233729
references.citation: BMJ Open. 2014 Apr 14;4(4):e004549
references.pmid: 24732242
references.citation: S Afr Med J. 2011 Dec 14;102(1 Pt 2):57-83
references.pmid: 22273141
references.citation: Health Aff (Millwood). 2009 Jul-Aug;28(4):1056-66
references.pmid: 19597204
references.citation: Lancet. 2007 Dec 15;370(9604):2044-53
references.pmid: 18063027
references.citation: Lancet. 2002 Dec 14;360(9349):1903-13
references.pmid: 12493255
references.citation: PLoS One. 2011;6(6):e20821
references.pmid: 21695127
references.citation: J Public Health Policy. 2011;32 Suppl 1:S102-23
references.pmid: 21730985
references.citation: Health Res Policy Syst. 2013 Aug 16;11:31
references.pmid: 23947294
references.citation: S Afr Med J. 2012 Jun 20;102(9):743-5
references.pmid: 22958695
references.citation: Health Econ. 2015 Mar;24(3):318-32
references.pmid: 24497185
references.citation: S Afr Med J. 2010 Nov 10;100(11 Pt 2):747-78
references.pmid: 21081029
references.citation: Trop Med Int Health. 2009 Apr;14(4):458-67
references.pmid: 19254274
references.citation: Lancet. 2008 Mar 15;371(9616):915-22
references.pmid: 18342686
references.citation: Cardiovasc J Afr. 2012 Aug;23(7):365-70
references.pmid: 22447241
references.citation: PLoS One. 2014 Jan 07;9(1):e84445
references.pmid: 24409297
references.citation: Lancet Glob Health. 2013 Aug;1(2):e66-e67
references.pmid: 25104152
references.citation: Adv Nutr. 2014 Jan 01;5(1):19-20
references.pmid: 24425717
references.citation: Arch Intern Med. 2012 Oct 8;172(18):1386-94
references.pmid: 22945249
references.citation: Lancet. 2013 Dec 7;382(9908):1898-955
references.pmid: 24309475
references.citation: Nutrition. 2005 Jan;21(1):39-50
references.pmid: 15661477
references.citation: Lancet. 2012 Dec 8;380(9858):2029-43
references.pmid: 23201214
references.citation: Lancet Glob Health. 2015 May;3(5):e288-96
references.pmid: 25889470
references.citation: Cardiology. 2011;120(3):125-9
references.pmid: 22179118
references.citation: Vaccine. 2013 Oct 1;31(42):4902-10
references.pmid: 23871824
references.citation: S Afr Med J. 2007 Aug;97(8 Pt 2):692-8
references.pmid: 17952226