Monetary value of disability-adjusted-life-years lost from all causes in Mauritius


 Background The Republic of Mauritius lost a total of 402,565 disability-adjusted-life-years (DALY) from all causes in 2017. The objectives of this study were (a) to estimate the monetary value of DALY lost in 2017, and projected to be lost from all causes in Mauritius in 2030; and (b) to estimate the monetary value of DALY savings in year 2030, if the country would attain the United Nations Sustainable Development Goal 3 (SDG3) targets 3.1, 3.2, 3.3, 3.4 and 3.6.Methods Human capital approach is used to monetarily value DALY lost from 293 causes in 2017. The monetary value of DALY lost in 2017 from each cause is equal to the Mauritius net gross domestic product (GDP) per capita multiplied by the number of DALY lost from a specific cause. The percentage reductions implied in the five SDG3 targets were used in the projections of the monetary values of DALY expected in 2030. The potential savings equals monetary value of DALY lost in 2017 minus monetary value of DALY expected in 2030. The DALY data was obtained from the Institute of Health Metrics and Evaluation Global Burden of Disease Study 2017 database; the current health expenditure per capita data was from the WHO Global Health Expenditure Database; and the per capita GDP data was obtained from the IMF outlook database.Results The DALY lost in 2017 had a total monetary value of Int$9,564,741,771. Of which, 82.9% resulted from non-communicable diseases; 10.2% from communicable, maternal, neonatal and nutritional diseases; and 6.9% from injuries. Full attainment of the five SDG 3 targets would avert DALY losses with a value of Int$2,986,241,156.Conclusions Diseases and injuries causes a significant DALY lost per year with a substantive monetary value. Full achievement of the SDG3 targets 3.1, 3.2, 3.3, 3.4 and 3.6 might potentially save the country about 9.351% of the total GDP of Mauritius in 2019. In order to achieve such savings, the country require to further strengthen the national health system, the other systems that tackle social determinants of health, and the national health research system.

Diseases and injuries causes a significant DALY lost per year with a substantive monetary value. Full achievement of the SDG3 targets 3.1, 3.2, 3.3, 3.4 and 3.6 might potentially save the country about 9.351% of the total GDP of Mauritius in 2019. In order to achieve such savings, the country require to further strengthen the national health system, the other systems that tackle social determinants of health, and the national health research system.

Background
The Republic of Mauritius is one of the 16 Southern African Development Community (SADC) member states [1]. It has an estimated population of 1.279 million persons. In 2019, the estimated total gross domestic product (GDP) is International Dollars (Int$) 31.935 billion; and the GDP per capita is Int$ 4 mortality to at least as low as 25 per 1,000 live births. Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.
Target 3. 4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and wellbeing. Target 3. 6: By 2020, halve the number of global deaths and injuries from road traffic accidents" (p.14).
The current health expenditure (CHE) per capita in Mauritius was US$553 in 2016 [7]. It consisted of the domestic general government health expenditure of US$244 per capita; domestic private health expenditure of US$308 per capita (of which US$266 was from out-of-pocket spending); and external health expenditure of US$1 per capita. The Mauritius current health expenditure per capita ranged between US$ 297 (minimum) and US$ 984 (maximum) per person per year of health systems investment recommended for attaining SDG3 among upper middle-income economies [8]. The fact that out-of-pocket payments (OOPS) constitutes 48% of CHE is a matter of concern. This is because according to WHO [9], when OOPS exceed 20% of total health expenditure, the incidence of financial catastrophe and impoverishment increases. In 2012, 1.79% of households reported experiencing catastrophic health expenditure as a result of OOPS compared to 1.22% in 2012 at a threshold where total OOP payments exceed 25% of total household expenditure. Increasing the threshold to 40%, the incidence of catastrophic health expenditure was 1.25% in 2012 compared to 0.93% in 2006. In the same vein impoverishment due to OOPS based on an International Poverty Line of US$ 3.1 daily rose from 0.2% in 2006 to 0.34% in 2012 [10].
The Mauritius domestic general government health expenditure as a percentage of the general government expenditure of 10% was below the African Heads of State and Government 2001 target of allocating at least 15% national budget to health development [11]. Furthermore, the Mauritius per capita CHE of US$553 (2.2% of GDP per capita) was about 7-fold lower than the average of US$4,003 (9.0% of average GDP per capita) for the OECD countries [12]. As a result, the country has a universal coverage index of 64%, denoting a gap in essential health services coverage of 36% [13].
Embracing the principles of a welfare state Mauritius ensures provision of free health care at point of use in any public facilities. Steady economic growth over the last decade has enabled the national economy to sustain social protection systems, including health [10,14]. In order to attain SDG3, Mauritius needs to sustainably increase its investments into the national health system and the other systems that address social determinants of health [15]. Even though health is wealth for Mauritius, the health sector will have to keep on competing for the scarce budgetary allocations with economic sectors. Thus, it is imperative that the health and health-related sectors ought to mount sustained evidence-based advocacy within the government and the private sector to sustain and grow funding for health development to bridge existing gap in access to essential health services.
People who control the national resources in public and private sectors are not public health experts [14]. And thus, they may not fully understand the intricacies around the negative impact of disability and premature mortality (from various causes) on economic indicators, such as, the GDP. Therefore, health sector stakeholders will have to couch their advocacy messages in a language that those who control national resources can understand [16,17,18].
Evidence from economic burden of disease studies in both economically developed and developing countries continue to be used to advocate for increased investments in health development [19][20][21][22][23][24][25][26][27][28][29][30][31][32]. The WHO Regional Office for Africa (WHO/AFRO) report entitled "A heavy burden: the productivity cost of illness in Africa" contains useful aggregated economic evidence for use in advocacy at global and regional forums [33]. However, it is of limited usefulness to individual countries for two reasons: Mauritius was to attain SDG3 disease and injury related targets 3.1, 3.2, 3.3, 3.4 and 3.6.

The DALY
The seminal application of the DALY to measure global burden of disease was in 1993 by the World Bank in its report entitled 'World Development Report 1993: Investing in Health', which "..examined 6 the interplay between human health, health policy, and economic development (p. iii)" [34]. However, it was only in 1994 that Professor CJL Murray developed and published in the Bulletin of the World Health Organization the conceptual basis for the DALY [35]. He defined DALY as the sum of potential years of life lost (PYLL) due to premature death and years lived with disability (YLD).
WHO [36] further explains that DALY for a specific cause are calculated using the following formula: for specific disease or injury c, age a, sex s and year t.
Even though debate has been ranging since 1996 around various real and perceived short-comings of the DALY [37][38][39][40], it has withstood the test of time, and continues to be a useful metric in the global health discourse [41].
In the study reported in this paper, we calculated the monetary value of DALY lost in Mauritius in 2017 from 293 causes. The DALY data were acquired from the Institute for Health Metrics and Evaluation (IHME) global burden of disease (GBD) study 2017 database [4]. Methodological details and sources of data used in the Global Burden of Disease study 2017 can be found in the article published by the GBD 2017 DALY and HALE Collaborators [42].

Estimating the money value of DALY lost in Mauritius in 2017
This study employed human capital approach initially suggested by Weisbrod [43], and subsequently, adapted to financially value DALY in Kenya among the elderly [44] and 15-59 year olds [45], the Arab Maghreb Union [46], the Central African Economic and Monetary Community [47], the East African Community [48], and the African region [33], to estimate the economic value of DALY lost in 2017 in Mauritius. The development of health-related human capital begins at birth and ends at death; and thus, diseases have inter-and intra-generational negative impact on the process of human capital creation [43].

Estimating expected monetary value of DALY lost in 2030
We adapt in this subsection, the formulae used in past studies in Africa [44][45][46][47][48][49] to estimate the monetary value of DALY losses in 2030, assuming the five disease-related SDG3 targets in Table 1 are fully accomplished in Mauritius. The reductions in the monetary value of DALY lost from maternal disorders (SDG 3 target 3.1); 8 neonatal disorders (SDG 3 target 3.2); HIV/AIDS (SDG 3 target 3.3a); tuberculosis (SDG 3 target 3.3b); neglected tropical disease (SDG 3 target 3.3c); viral hepatitis (SDG 3 target 3.3d); NCD (SDG 3 target 3.4); and transport injury (SDG 3 target 3.6) were estimated using the eight equations contained in Additional File 1. For example, the equation used in estimating the SDG 3 target 3.1 envisaged reduction in the monetary value of DALY from maternal disorders (MD) was as follows: (See Formulas 2 n the Supplementary Files)

Data sources
The DALY data for the 293 causes was obtained from the IHME GBD study 2017 database [4]; the current health expenditure per capita data was gotten from the WHO Global Health Expenditure Database [7]; and the per capita GDP data was obtained from the IMF outlook database [2].

Data analysis
The analysis was conducted using Excel Software developed by Microsoft (New York). It was undertaken in 7 steps.

Step 1: Construction of economic model on Excel software
The economic model containing the 13 equations was built on Excel spreadsheet.
Step 2: Collating DALY data The 2017 data on DALY lost from 293 causes was extracted from the IHME GBD [4] and saved in an Excel spreadsheet. The data was then sorted by the three broad categories of health conditions, i.e.
NCDs, CMNND and INJ. That was followed by organizing the 293 causes under relevant broad category.
Step 3: Collating health expenditure data The Mauritius current health expenditure per capita () of Int$1,207 was obtained from the WHO Global Health Expenditure Database [7].
Step 3: Collating the per capita GDP data The Mauritius GDP per capita () of Int$24,966.51 was acquired from the IMF World Economic Outlook Step 4: Calculating the non-health per capita GDP 9 The non-health GDP per capita was estimated as a difference between GDP per capita and current health expenditure per capita. The non-health per capita GDP (NHGDPPC) = GDPPC -CHEPC = Int$24,966.51 -Int$1,207 = Int$23,759.51.
Step     Mental disorders: Figure 7 shows the monetary value of DALY lost from mental disorders was Other non-communicable diseases: Figure 9 shows that other NCDs resulted to DALY lost with a   underpin the implementation of those policy and strategic documents.

Expected monetary value of DALY lost in 2030
The formulation and implementation of the national policy and strategies are buttressed by the SADC strategy for sexual and reproductive health rights [60]; the SADC regional gender based violence strategy and framework for action [61]; the African Union (AU) ministers of health commitments on universal health coverage [62] and ending preventable maternal and child deaths in Africa [63]; the AU Assembly decision on progress on maternal, new born and child health [64]; and the AU Assembly declaration on addressing social determinants of health using health in all policies approach [65].
Mauritius efforts to reduce child and maternal morbidity, disability and deaths are informed and supported by various pertinent WHO Governing Bodies resolutions, for example, the Regional Committee for Africa (RC) strategic plan for immunization [66] and its resolution [67]; the World Health Assembly (WHA) resolution on reduction of perinatal and neonatal mortality [68]; the global vaccine action plan [69] and related WHA resolution [70]; and the global strategy for women's, The Mauritius battle against HIV/AIDS, TB and hepatitis is also guided by the SADC strategy for HIV prevention, treatment and care and sexual and reproductive health [81]; the framework for the prevention and control of sexually transmitted infections [82]; and the strategic plan for the control of TB [83]; and the advocacy strategy on HIV/AIDs, TB and sexually transmitted infections the framework for action on prevention, care and treatment of viral hepatitis in the African region [90] and resolution AFR/RC64/R5 [91]; the global health sector strategy on sexually transmitted infections [92]; the neglected tropical diseases [93]; the regional strategy on NTDs in the WHO African Region [94] and its resolution AFR/RC63/R6 [95]; the global vector control response strategy [96] and its resolution WHA70.16 [97]; the regional strategy for integrated disease surveillance and response [98] and its draft resolution AFR/RC69/WP2/Rev1 [99]; and the health promotion strategy for the African region [100] and resolution AFR/RC62/R4 [101].

SDG Target 3.4: Non-communicable diseases
We and control of non-communicable diseases as well as the African Union commitment on NCDs [116,117].
The Mauritius NCD strategies and plans were partially informed by various WHA and RC resolutions on global strategy for the prevention and control [118] and its resolution WHA53.17 [119]; the global action plan for the prevention and control of NCD [120] and its endorsing resolution WHA66. 10 [131]; the global action plan on physical activity resolution WHA71. 6 [132]; the NCD regional strategy for the African region [133] and its resolution AFR/RC50/R4 [134]; the Brazzaville declaration on NCDs prevention and control in the African region [135] and its resolution [136]; the strategic plan to reduce the double burden of malnutrition [137] and its resolution AFR/RC69/WP1/Rev1 [138]; the regional oral health strategy [139] and the resolution AFR/RC66/R1 [140]; and the health promotion strategy for the African region [100] and its resolution AFR/RC62/R4 101].
The UNGA declaration on NCDs [141], ageing [142][143], food [144] and nutrition [145] commits the Mauritius Government to provide high-level political leadership and requisite resources to prevent and control NCDs.

SDG Target 3.6: Transport injuries
Mauritius could potentially avert DALY with a monetary value of Int$ 119.04 million if the country succeeds in reducing by half the transport-related injuries. With a view to realizing those potential savings, related to attainment of SDG target 3.6, the government will need to fully implement its national road safety strategy 2016 -2025, whose overarching objective is to achieve a 50% reduction  and contribution of the elderly in reconciling differences among family members (social cohesion) and transmitting community values and indigenous knowledge to children and youth [160]. The index also does not capture the negative effects of economic production processes on the environment, animal and human health [161]. In addition, GDP does not account for inequalities in distribution of income and wealth across households and individuals [162], and also does not indicate whether societal quality of life has improved as a result of GDP growth [163]. However, as the African Union ministers of health underscored in their commitment on accountability mechanism, the existence of policies, strategies, declarations, decisions and resolutions does not necessarily assure attainment of the national and internationally agreed health development goals [175]. They called upon governments and other relevant stakeholders at national, regional and continental levels to provide committed, sustained, and aligned resources for accelerated and monitored implementation of national health development policy framework.
In terms of all socioeconomic indicators, Mauritius has accomplished far much more than other WHO African region countries [13]. However, it's important not to be complacent, in order to sustain the health (and related) gains. Therefore, it is vital for the Mauritius Government and the domestic private sector to work together to further strengthen the national health system (including the social protection mechanisms to reduce reliance on OOPS), the other systems that tackle social determinants of health [15], and the national health research system [176,177]

Funding
The study was funded by the World Health Organization through Agreement for Performance of Work Purchase Order Number 202341143. LM is current employee of the WHO. He participated in design of the study, collating of data, analysis, interpretation of findings and writing the manuscript.

Availability of data and materials
All data generated or analysed during this study are included in the published article and its supplementary information files.

Ethics approval and consent to participate
Not applicable. No ethical approval was required since the study relied completely on analysis of secondary data publicly available the Institute of Health Metrics and Evaluation Global Burden of Disease Study 2017 database; the WHO Global Health Expenditure Database; and IMF outlook database.

Consent for publication
Not applicable.

Figure 10
Monetary value of DALYs lost from injuries (2019, Int$ or PPP)

Supplementary Files
This is a list of supplementary files associated with this preprint. Click to download. Abbreviations.pdf