Pecuniary Value of Disability-Adjusted-Life-Years in the Arab Maghreb Union in 2015

This study bridges extant information gap on the pecuniary value of disabil-ity-adjusted-life-years (DALYs) lost in the Arab Maghreb Union (AMU). The DALYs lost in 2015 are converted into money using human capital (lost output) approach. The AMU total value of DALYs lost from all causes is the sum of each of the five country’s pecuniary value of DALYs (PVD) lost from all causes. The PVD associated with DALYs lost due to j th disease among persons of a specific age group is the product of the per capita non-health GDP in international dollars (Int$) and the total DALYs lost. The 27,175,610 DALYs lost in AMU in 2015 had a pecuniary value of Int$ 289,033,271,814, which is equivalent to 25.6% the sub-region’s 2015 GDP. The average pecuniary value per DALY lost was Int$ 10,636, which ranged from a minimum of Int$ 4226 in Mauritania to a maximum of Int$ 13,852 in Algeria. The pecuniary value of DALYs lost from all causes in the AMU sub-region annually is substantive.


Introduction
The Arab Maghreb Union (AMU) consists of five member countries, i.e. Algeria, Libya, Mauritania, Morocco and Tunisia. The five countries had a total population of 95.423 million in 2015 [1]. The population was distributed as follow: 42% in Algeria, 7% in Libya, 4% in Mauritania, 36% in Morocco, and 12% in Tunisia. Algeria and Libya are upper-middle income countries; and the remaining three countries are lower-middle income countries.
The life expectancy at birth was 75.6 years in Algeria, 72.7 years in Libya, 63.1 years in Mauritania, 74.3 years in Morocco and 75.3 year in Tunisia [1]. The life expectancies, except for Mauritania, were higher than the average global life expectancy of 71.4 years. The physician and pharmaceutical personnel densities per 10,000 population of AMU countries are lower than the global averages (see Table 1) [3] [4]. Likewise, the density of health infrastructure and technologies (e.g. psychiatric beds, radiotherapy units) for AMU are lower than the global averages [3]. The global per capita total expenditure on health is 4-fold than that of AMU countries. The per capita total expenditure on health for AMU countries is between US$49 and US$372 [4], which falls short of the US$ 146 (lower-middle income) to US$ 536 (upper-middle income) per person per year health systems investment recommended for achieving health sustainable development goal (SDG) 3 [5]. Consequently, there is need for AMU sub-region economic burden of disease estimates for use in sensitization of Ministries of Finance, private sector and development partners to increase health development investments to the levels recommended for achievement of SDG3. Such studies are routinely conducted in economically developed countries to raise public and whole-government awareness of potential economic returns from health development investments [6]- [17]. Economic burden of disease studies has been conducted in Southeast Asia [18]- [23] and West Pacific [24] [25] [26] [27] [28]. Latin America has also recorded conduct of some economic burden of disease studies [29]- [36].
A number of studies in Africa have attempted to estimate the economic burden of premature mortality from neglected tropical diseases [37], childhood diseases [38], cholera [39], diabetes mellitus [40], disasters [41] "the sum of the present value of future years of life time lost through premature mortality, and the present value of years of future life time adjusted for the average severity (frequency and intensity) of any mental or physical disability caused by a disease or injury (p. 326)." This study contributes to bridging the existing knowledge gap on the pecuniary value of DALYs lost in the AMU in 2015. This paper answers the question: What is the total pecuniary value of DALYs lost from all causes in the AMU?
The specific objective was to estimate the total pecuniary value of DALYs lost from all causes in the AMU in 2015.

Study Area and Population
The study focuses on DALYs lost from all causes amongst seven age groups in AMU in 2015. The causes comprise all communicable diseases, maternal condi-tions, neonatal conditions and nutritional deficiencies; all non-communicable diseases (NCDs), covering malignant neoplasms, mental and substance-use disorders, neurological conditions, sense-organ diseases, cardiovascular diseases, respiratory diseases, digestive diseases, genitourinary diseases, musculoskeletal diseases, congenital anomalies, oral conditions and sudden infant death; and intentional and unintentional injuries [60].  [49] and availability of data on GDP per capita, total health expenditure per capita and DALYs for AMU. GDP of any country consists of four components: personal consumption expenditures, investment, government expenditure and net exports. The AMU GDP per capita equals total expenditure divided by total population. The methods of calculating DALY are contained in Murray [63] and WHO [60]. We hypothesis that DALY losses erode incomes and consumption of households and firms, savings and investment, taxes and service fees, and net exports.

Study
The AMU total pecuniary value of total DALYs (TPVD) lost from all causes is the sum of each of the five country's pecuniary value of DALYs (CPVD) lost from all causes:  [60][61][62][63][64][65][66][67][68][69], and 70 years and above (CPVD =>70 ). The CPVD associated with the j th disease DALYs lost among people of a specific age group are the product of the per capita non-health GDP in purchasing power parity (PPP) and the total j th disease DALYs lost within a specific age group [64].
Each i th country's discounted total CPVD attributable to the j th disease DALYs were estimated using equations (2) through (9) below [64].
The DALY estimates published by the WHO in the Global Health Observatory are discounted at a 3% rate [64]. Therefore, we did not introduce a discount factor in equations (3) to (9) to avoid double discounting. Table 2 reproduces the United Nations Sustainable Development Goal 3 targets. By 2030, end the preventable deaths of newborns and children under 5 years of age and reduce neonatal mortality to 12 per 1000 live births or lower and under-5 mortality to 25 per 1000 live births or lower in all countries [65].

Estimation of the Reductions in Pecuniary Value of DALY Losses in AMU Assuming SDG 3 Related Targets Are Achieved
By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and reduce hepatitis, water-borne diseases and other communicable diseases [65].
(a). HIV-related deaths will be reduced to fewer than reduce global HIV-related deaths to below 500,000 [66] in 2020 from a 2015 baseline of 1,062,352 [67], i.e. a target reduction of 52.93%.
(b). Malaria mortality rates will be reduced globally by at least 90% from 2015 to 2030 [68].
The number of TB deaths will be reduced by 90% from 2015 to 2030 [69].
Mortality due to vector-borne diseases will be reduced globally by at least 75% from 2016 to 2030 [70].
By 2030, reduce premature mortality due to NCDs by one third through prevention and treatment and promote mental health and well-being [65]. SDG 3.6 By 2020, halve the number of global deaths and injuries due to traffic accidents [65]. Table 2 were obtained from UN [65], WHO [66], WHO [67], WHO [68], WHO [69] and WHO [70].

Sources: Targets in
The reductions in AMU pecuniary values of DALYs lost assuming the SDG3 targets for maternal mortality ratio (Target 3.1), neonatal mortality (Target 3.2), children under 5 years of age mortality (Target 3.2), and HIV/AIDS deaths (Target 3.3) are achieved were estimated using the following formula: where: PVD HCj2030 is the total pecuniary value of DALYs expected to be lost in AMU from j th health condition in 2030 assuming related target is fully achieved; PVD HCj2015 is the total pecuniary value of DALYs actually in AMU from j th health condition in baseline year 2015; and SDG jHCT is the SDG j th health condition target mortality rate. The reductions in AMU pecuniary values of DALYs lost assuming the SDG3 targets for death associated with tuberculosis (Target 3.
The detailed elucidation of those algorithms can be found in Kirigia and Mwabu [64] study on monetary value of DALYs lost in the East African Community.

Data Source and Software
The nine equations in subsection 2.2 were estimated using per capita total health expenditure data from the WHO Global Health Expenditure Database [4], per capita GDP data from the International Monetary Fund World Economic Outlook database [2], and DALYs data from the WHO Global Health Observatory [67]. The nine equations were estimated using Excel Software developed by Microsoft (New York).

Estimates of Pecuniary Value of DALYs Lost in the AMU in 2015 without SDGs
In 2015, the AMU lost a total of 27,175,610 disability-adjusted-life years (DA-LYs) from all causes. Out of the total DALY loss, 40% was borne by Algeria, 6% by Libya, 8% by Mauritania, 35% by Morocco, and 11% by Tunisia ( Table 3). The DALY losses in the AMU translated into a total pecuniary value loss of Int$ 289,033,271,814; which is equivalent to 25.6% of the region's 2015 GDP. Out of which, 52% was borne by Algeria, 8% by Libya, 3% by Mauritania, 26% by Morocco, and 11% by Tunisia.
The average pecuniary value per DALY lost was Int$ 10,636; which ranged from a minimum of Int 4226 in Mauritania to a maximum of Int$ 13,852 in Algeria. Whilst, the average pecuniary value per person in population was Int$ 3022; and varied between Int$ 2199 in Morocco and Int$3,755 in Algeria. Nearly 24.3% of the pecuniary value of NCD DALY loss resulted from cardiovascular diseases; 12.3% from mental and substance use disorders; 11.8% from malignant neoplasms; 9% from diabetes mellitus; 8.0% from musculoskeletal diseases; 6.9% from neurological conditions; 5.6% from congenital anomalies; 4.8% from genitourinary diseases; 4.7% from sense organ diseases; 3.9% from digestive diseases; 3.8% from respiratory diseases; 1.6% from skin diseases; 1.6% from endocrine, blood, immune disorders; 1.3% from oral conditions; 0.5% from other neoplasms; and 0.1% from sudden infant death syndrome ( Figure 1). Cardiovascular diseases, mental and substance use disorders, malignant neoplasms, diabetes mellitus, and musculoskeletal diseases alone accounted for 65.3% of the total pecuniary value of DALYs lost in the AMU.
Approximately 43.8% of the pecuniary value of CMN DALY loss was from neonatal conditions (preterm birth complications, birth asphyxia and birth trauma, neonatal sepsis and infections, and other neonatal conditions); 23.4% from infectious and parasitic diseases; 20.1% from respiratory infectious diseases (lower respiratory infections, upper respiratory infections, and otitis media); 10.3% from nutritional deficiencies (e.g. protein-energy malnutrition, iodine deficiency, vitamin A deficiency, iron-deficiency anaemia, and other nutritional deficiencies); and 2.3% from maternal conditions ( Figure 2).
Neonatal conditions, respiratory infectious diseases and nutritional deficiencies are responsible for 74.3% of CMN pecuniary losses.
Almost 82% of the pecuniary value of injury-related DALY loss stemmed from unintentional injuries and 18% from intentional injuries. The three leading causes of pecuniary value of DALYs lost from intentional injuries were road injuries (46.8%), falls (9.7%) and exposure to mechanical forces (6.3%) (Figure 3). Journal of Human Resource and Sustainability Studies   Majority of the unintentional injuries pecuniary value of Int$ 5,621,933,544 was from self-harm (35.7%) and interpersonal violence (35.1%).

Pecuniary Value of DALY Losses from Five SDG 3 Related Targets
Approximately Int$ 240,663,156,194 (83.3%) of the total pecuniary value of DALYs lost in AMU in 2015 resulted from the SDG3 health conditions listed in Table 2. Table 4

Estimates of Reductions in Pecuniary Value of DALY Losses in AMU if the Five SDG 3 Related Targets Are Achieved
As shown in Table 5, if all the five SDG3 targets in Table 2

SDG Target 3.1: Maternal Health Conditions
The AMU lost DALYs worth Int$ 1,472,716,293 in 2015 from maternal conditions. However, if SDG target 3.1 is fully achieved, the pecuniary value of DALY losses in 2030 would be Int$ 551,874,414. This implies a saving of Int$ 920,841,879 per year. The reduction in maternal conditions related pecuniary losses may be realized if AMU states implement the UN Commission on the Status of Women resolution that calls upon Government authorities and international leaders at all levels to generate requisite political will, increased resources, commitment, international cooperation and technical assistance to strengthen health systems with a view to guaranteeing all women and girls universal access to comprehensive health services to decrease maternal mortality and morbidity, and improve maternal and new born health [71]. All such efforts should be guided by the UN Human Rights Council resolution A/HRC/RES/33/18 that urges States and encourages other relevant stakeholders to take action at all levels, utilizing a human rights-based approach to address the interlinked causes of maternal mortality and morbidity, such as inaccessibility to affordable and appropriate health-care services, lack of information and education, poverty, food insecurity, harmful cultural practices (including child marriage, wife inheritance, female genital mutilation), early childbearing, gender inequalities, discrimination and domestic violence against women [72].

SDG 3.2: Neonatal Health Conditions
The preterm birth complications, birth asphyxia and birth trauma, neonatal sepsis and infections, and other neonatal conditions led to a loss of DALYs valued at Int$ 27,787,753,001 in 2015. If SDG target 3.2 is fully attained, the pecuniary value of DALYs lost in 2030 would be Int$ 20,457,241,473, which denotes a saving of Int$ 7,330,511,528 per year. The saving can be made by adapting and implementing the African Union Maputo plan of action 2016-2030, which contains nine strategic areas of focus and priority interventions (plus indicators for monitoring progress) for assuring realization of sexual and reproductive health and rights, and ultimately, improve maternal, newborn, child and adolescent health [73]. First, the commitments agreed in the political declaration on HIV and AIDS, which calls for increasing and front-loading investments from domestic and external sources, and promote laws, policies and practices for ensuring universal access to high-quality, affordable and comprehensive sexual and reproductive health-care and HIV services, information and commodities with a view to ending the AIDS epidemic by 2030 [74] [75].

SDG Target 3.3: HIV/AIDs, Tuberculosis, Malaria and Neglected Tropical Diseases
Second, the commitments encapsulated in the political declaration on antimicrobial resistance, which urges member states to develop and adequately fund multi-sectoral One Health national policies, programmes and action plans to combat resistance of bacterial, viral, parasitic and fungal microorganisms to antimicrobial medicines [76].
Third, on 26 September 2018 UNGA adopted a political declaration on the fight against tuberculosis entitled "United to End Tuberculosis: An Urgent Global Response to a Global Epidemic". In that political declaration member states committed to provide diagnosis and treatment; address tuberculosis prevention, diagnosis, treatment and care in the context of child health and survival; prevent tuberculosis for those most at risk of falling ill through the rapid scale-up of access to testing for tuberculosis infection; develop national antim-icrobial resistance strategies, capacities and plans; find the missing people with tuberculosis; systematically screen relevant risk groups; adapt and implement rapidly the global End TB Strategy; develop community-based health services; explore how digital technologies could be optimally used for effective tuberculosis prevention, treatment and care; pursue multi-sectoral collaboration at all levels; foster cooperation between public and private sector entities; create an environment conducive to research and development of new tools for tuberculosis; mobilize sufficient and sustainable financing, from all sources, for universal access to quality prevention, diagnosis, treatment, and care of tuberculosis [77].
Fourth, the UNGA resolution A/RES/72/309 calls upon countries, multilateral and bilateral development partners to substantially increase funding to countries to provide universal access to existing life-saving tools for the prevention, diagnosis and treatment of malaria [78].
Lastly, the UN Commission on Population and Development resolution 2010/1 encourages Member States and international organizations to scale up actions aimed at ensuring universal access to prevention and treatment of neglected tropical diseases, and access to affordable safe water and sanitation [79].
In the London declaration on NTDs, pharmaceutical companies and international development partners committed to sustain, expand and extend drug access programmes to ensure the necessary supply of drugs and other interventions to help end NTD epidemic [80].

Conclusions
The study has successfully estimated pecuniary value of DALYs lost in the AMU in 2015, and reductions in pecuniary value of DALY losses if five SDG3 targets are achieved. The findings from this study could potentially be used by health development stakeholders to advocate for increased domestic and external investments towards achievement of SDG3.
The non-communicable and communicable diseases, and injuries resulted in a significant number of DALY losses valued at Int$ 289 billion in the AMU. Approximately 83% of the total pecuniary value of DALYs lost in AMU is from SDG-related health conditions. Full attainment of the five CDS, NCD and injuries-related SDG3 targets would reduce the total pecuniary value of DALYs lost 35% in AMU.
In order to significantly reduce the SDG3-related DALY losses, the AMU countries should intensify their whole-of-government and whole-of-society efforts to fully implement their past health-related commitments contained in Universal access to health services will not be sufficient for AMU States to attain the health SDG3 of ensuring healthy lives and promoting well-being for people at all ages. There is need for simultaneous policy actions to revamp systems that address other-related SDGs, such as SDG1 on ending poverty in all its forms, SDG2 on ending hunger through food security, SDG4 on equitable education and lifelong learning, SDG 5 on gender equality, SDG 6 on availability and sustainable management of water and sanitation, SDG 11 on inclusive, safe, resilient and sustainable human shelter (housing), SDG 13 on combating negative health impacts of climate change, and SDG 16 on promoting peaceful and inclusive societies [65]. This will require strong and efficiently coordinated collaboration across multiple sectors in individual member states. Cultivation and nurturing of solidarity and closer cooperation and partnership between the AMU States is bound to accelerate the progress towards attainment of SDG3 and other related SDGs. Significant reductions in burden of disease will have substantive social and economic impact on AMU. All along the AMU States (public and private sector leaders) and development partners should always remember that health is wealth of AMU.