Monetary valuation of DALYs: The methods of calculating DALY are well documented in Murray [11] and WHO [12] . The study reported in this paper focuses on monetary valuation of DALYs lost from all diseases and conditions in the EAC in 2015. The literature generally has two main methods that can be used to value a DALY lost into money. One is the willingness to pay (WTP) for a statistical life year or a DALY; which relies on asking for the maximum amount of money an individual would be willing to give up in order to avert loss of a DALY [13] .

Two is the lost output or human capital approach (HCA), which was first applied by Petty in 17^th century [14] , and whose theoretical basis was expounded in 20^th century by Landefeld and Seskin [15] , Weisbrod [16] , Mushkin and Collings [17] , and Fein [18] . The World Health Organization guidelines on economic impact of disease and injury proposed a further refinement in the following excerpt:

“A macroeconomic approach to assessing the impact of ill-health should be concerned with establishing the aggregate impact of disease and injury across different economic agents on three areas related to economic welfare (both now and in the future): non-health consumption possibilities, leisure time and health status. … it is important to note that GDP includes expenditure on health goods and services, so this component should be omitted and the focus of analysis be redirected towards establishing the present value of discounted aggregate flows of current and future consumption of non-health related goods and services linked to disease” [19] p.4.

In line with WHO [19] [20] , this study estimates the present value of discounted aggregate flows of current and future consumption of non-health related goods and services (non-health GDP) linked to a DALY lost from any cause. We applied HCA to convert the DALYs lost in ECA in 2015 into their monetary equivalents. Our choice of HCA was influenced by availability of data on GDP per capita, total health expenditure per capita and DALYs for EAC.

The EAC total monetary value of total DALYs (TMVD) lost from all causes is the sum of each of the five country’s monetary value of DALYs (CMVD) lost from all causes [21] :

T M V D E A C = ∑ c o u n t r y = i c o u n t r y = 5 { C M V D i j } (1)

where i = Burundi, Kenya, Rwanda, Tanzania and Uganda.

Each country’s CMVD_ij lost due to the j^th disease is the sum of MVD among people aged 0 - 4 years (MVD_0-4), 5 - 14 years (MVD_5-14), 15 - 29 years 15 - 29 years (MVD_15-29), 30 - 49 years (MVD_30-49), 50 - 59 years (MVD_50-59), 60 - 69 years (MVD_60-69), and 70 years and above (MVD_=>70). The MVD 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 [21] .

The i^th country’s discounted total CMVD attributable to the j^th disease DALYs were estimated using Equations (2) through (9) below [21] :

C M V D i j = M V D 0 − 4 + M V D 5 − 14 + M V D 15 − 29 + M V D 30 − 49     + M V D 50 − 59 + M V D 60 − 69 + M V D ≥ 70 (2)

M V D 0 − 4 = [ N H G D P P C I n t $ ] × [ D A L Y 0 − 4 ] (3)

M V D 5 − 14 = [ N H G D P P C I n t $ ] × [ D A L Y 5 − 14 ] (4)

M V D 15 − 29 = [ N H G D P P C I n t $ ] × [ D A L Y 15 − 29 ] (5)

M V D 30 − 49 = [ N H G D P P C I n t $ ] × [ D A L Y 30 − 49 ] (6)

M V D 50 − 59 = [ N H G D P P C I n t $ ] × [ D A L Y 50 − 59 ] (7)

M V D 60 − 69 = [ N H G D P P C I n t $ ] × [ D A L Y 60 − 69 ] (8)

M V D ≥ 70 = [ N H G D P P C I n t $ ] × [ D A L Y ≥ 70 ] (9)

where: NHGDPPC_Int$ is the per capita non-health GDP in purchasing power parity (PPP), which was obtained by subtracting the per capita total health expenditure (PCTHE) from the per capita GDP (GDPPC_Int$); DALY_0-4 is the total DALYs lost to the j^th disease among people aged 0 - 4 years in country i in 2015; DALY_5-14 is the total DALYs lost to the j^th disease among people aged 5 - 14 years in country i in 2015; DALY_15-29 is the total DALYs lost to the j^th disease among people aged 15 - 29 years in country i in 2015; DALY_30-49 is the total DALYs lost to the j^th disease among people aged 30 - 49 years in country iin 2015; DALY_50-59is the total DALYs lost to the j^th disease among people aged 50 - 59 years in country i in 2015; DALY_60-69 is the total DALYs lost to the j^th disease among people aged 60 - 69 years in country i in 2015; and DALY₇₀₊ is the total DALYs lost to the j^th disease among people aged 70 years and above in country_i in 2015.

Discount factor was not introduced in Equations (3) to (9) because the DALY estimates published by the WHO in the Global Health Observatory were already discounted at a 3% rate [12] .

The SDG 3 is about ensuring healthy lives and promoting well-being for people of all ages. It has 13 targets. The analysis in this section focuses on five of the 13 SDG 3 targets [22] :

・ SDG 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births;

・ SDG 3.2: By 2030, end the preventable deaths of new-borns 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;

・ SDG 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and reduce hepatitis, water-borne diseases and other communicable diseases;

・ SDG 3.4: By 2030, reduce premature mortality due to NCDs by one third through prevention and treatment and promote mental health and well-being;

・ SDG 3.5: By 2020, halve the number of global deaths and injuries due to traffic accidents.

Since SDG 3.3 is not specific, the following WHO global and regional strategies targets for AIDS, tuberculosis, malaria and NTDs were used:

1) HIV-related deaths will be reduced to fewer than 287,000 from a 2014 baseline of 790,000 (i.e., by 63.67%) by 2020 [23] ;

2) Malaria mortality rates will be reduced globally by at least 90% from 2015 to 2030 [24] ;

3) The number of TB deaths will be reduced by 90% from 2015to 2030 [25] ;

4) Mortality due to vector-borne diseases will be reduced globally by at least 75% from 2016 to 2030 [26] .

The formulas were used to estimate the reductions in EAC monetary value of DALYs lost assuming the SDG health targets are achieved.

Target 3.1: Reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030 [22] . EAC’s 2030 monetary value of DALYs lost due to MMR under SDG scenario were estimated as follows:

M V D M M R 2030 = ∑ c o u n t r y = 1 c o u n t r y = 5 { M V D M M R 2015 − [ M V D M M R 2015 × M M R 2015 − S D G 3.1 M M R 2015 ] }

where: M V D M M R 2030 represents themonetary value of DALYs lost due to maternal conditions in 2030; M V D M M R 2015 denotes themonetary value of DALYs lost due to maternal conditions in 2015; and M M R 2015 is the maternal mortality ratio in 2015; and S D G 3.1 is the value of Target 3.1, which is 70 per 100,000 live births.

Target 3.2: End the preventable deaths of new-borns 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 by 2030. EAC’s 2030 monetary value of DALYs lost due to neonatal mortality (NM) [22] under scenario 2 were estimated as follows:

M V D N M 2030 = ∑ c o u n t r y = 1 c o u n t r y = 5 { M V D N M 2015 − [ M V D N M 2015 × N M 2015 − S D G 3.2 N M 2015 ] }

where: M V D N M 2030 represents the monetary value of DALYs lost due to neonatal mortality in 2030; M V D N M 2015 denotes the monetary value of DALYs lost due to neonatal mortality in 2015; and N M 2015 is the neonatal mortality rate in 2015; and S D G 3.2 is the value of Target 3.2, which is 12 per 1000 live births.

EAC’s 2030 monetary value of DALYs lost due to under-five morbidity and mortality (U5M) was estimated as follows:

M V D U 5 M 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D U 5 M 2015 − [ M V D U 5 M 2015 × U 5 M 2015 − S D G 3.2 U 5 M 2015 ] }

where: M V D U 5 M 2030 represents the monetary value of DALYs lost due to neonatal mortality in 2030; M V D U 5 M 2015 denotes the monetary value of DALYs lost due to neonatal mortality in 2015; and U 5 M 2015 is the neonatal mortality rate in 2015; and S D G 3.2 is the value of Target 3.2, which is 25 per 1000 live births.

Target 3.3: End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and reduce hepatitis, water-borne diseases and other communicable diseases by 2030. HIV-related deaths will be reduced to fewer than 287,000 from a 2014 baseline of 790,000 (i.e., by 63.67%) by 2020 [23] . EAC’s 2030 monetary value of DALYs lost due to AIDS morbidity and mortality (AID) were estimated as follows:

M V D A I D 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D A I D 2015 − [ M V D A I D 2015 × A I D 2014 − A I D 2020 A I D 2014 ] }

where: M V D A I D 2030 represents the monetary value of DALYs lost due to HIV/AIDS-related mortality in 2030; M V D A I D 2015 denotes the monetary value of DALYs lost due to HIV/AIDS-related mortality in 2015; A I D 2014 is the HIV/AIDS-related mortality in 2014; and A I D 2020 is the HIV/AIDS-related mortality in 2020.

The WHO’s End TB Strategy target is “By 2030, reduce number of TB deaths by 90% compared with 2015” [25] . EAC’s 2030 monetary value of DALYs lost due to DALYs lost to tuberculosis morbidity and mortality were estimated as follows:

M V D T B 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D T B 2015 − [ M V D T B 2015 × S D G 3.3 T B ] }

where: M V D T B 2030 represents the monetary value of DALYs lost due to TB mortality in 2030; M V D T B 2015 denotes the monetary value of DALYs lost due to TB mortality in 2015; and S D G 3.3 T B is the is the value of Target 3.3, which is 90% reduction.

The WHO’s Global Technical Strategy for Malaria 2016-2030 target is “By 2030, reduce malaria mortality rates globally by at least 90% compared with 2015” [24] . EAC’s 2030 monetary value of DALYs lost due to DALYs lost to malaria morbidity and mortality were estimated as follows:

M V D M A L 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D M A L 2015 − [ M V D M A L 2015 × S D G 3.3 M A L ] }

where: M V D M A L 2030 represents the monetary value of DALYs lost due to malaria mortality in 2030; M V D M A L 2015 denotes the monetary value of DALYs lost due to malaria mortality in 2015; and S D G 3.3 M A L is the is the value of Target 3.3, which is 90% reduction.

The WHO’s Draft Global Vector Control Response at a Glance target is “By 2030, reduce mortality due to vector-borne diseases globally by at least 75% relative to 2015” [26] . EAC’s 2030 monetary value of DALYs lost due to DALYs lost to NTD morbidity and mortality were estimated as follows:

M V D N T D 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D N T D 2015 − [ M V D N T D 2015 × S D G 3.3 N T D ] }

where: M V D N T D 2030 represents the monetary value of DALYs lost due to NTD mortality in 2030; M V D N T D 2015 denotes the monetary value of DALYs lost due to NTD mortality in 2015; and S D G 3.3 N T D is the is the value of Target 3.3, which is 75% reduction.

The health SDG Target 3.4 states, “By 2030, reduce by one third premature mortality from non-communicable diseases (NCDs) through prevention and treatment and promote mental health and well-being” [22] . EAC’s 2030 monetary value of DALYs lost due to DALYs lost to NCD morbidity and mortality were estimated as follows:

M V D N C D 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D N C D 2015 − [ M V D N C D 2015 × S D G 3.4 N C D ] }

where: M V D N C D 2030 represents the monetary value of DALYs lost due to NCD mortality in 2030; M V D N C D 2015 denotes the monetary value of DALYs lost due to NCD mortality in 2015; and S D G 3.4 N C D is the is the value of Target 3.4, which is one third reduction.

Health SDG Target 3.6 states, “By 2020, halve the number of global deaths and injuries from road traffic accidents” [22] . EAC’s 2030 monetary value of DALYs lost due to DALYs lost to injury (INJ) morbidity and mortality were estimated as follows:

M V D I N J 2030 = ∑ c o u n t r y = i c o u n t r y = 5 { M V D I N J 2015 − [ M V D I N J 2015 × S D G 3.6 I N J ] }

where: M V D I N J 2030 represents the monetary value of DALYs lost due to injuries mortality in 2030; M V D I N J 2015 denotes the monetary value of DALYs lost due to injuries mortality in 2015; and S D G 3.6 I N J is the is the value of Target 3.6, which is 50% reduction.

The abovementioned nine equations were estimated using secondary per capita GDP data from the International Monetary Fund (IMF) World Economic Outlook database [2] , per capita total health expenditure from the WHO Global Health Expenditure Database [27] , and DALYs data from the WHO Global Health Observatory [1] . The Excel Software developed by Microsoft (New York) was used to estimate equations in subsections 2.1 and 2.2.

Table 1 shows the monetary value of DALYs lost by each of the five EAC countries. The 82,017,651 DALYs lost in EAC sub-region in 2015 was valued at Int$ 203,843,476,166; which is equivalent to 48.75% of the sub-region’s 2015 GDP. Out of the total monetary value of DALYs lost in EAC, Burundi incurred 2.8%, Kenya 33.9%, Rwanda 4.2%, Tanzania 39.5% and Uganda 19.6%. Kenya and Tanzania bore 73.4% of the EAC countries monetary value of DALYs lost. The average monetary value per DALY lost in the EAC is Int$ 2485. However, monetary value per DALY ranges from Int$764 in Burundi to Int$ 3167 in Kenya.

Approximately Int$ 118,575,096,576 (58.2%) of total EAC monetary value of DALYs lost was attributed to communicable, maternal, perinatal and nutritional conditions (CMN); Int$ 61,806,147,501 (30.3%)to non-communicable diseases (NCD); and Int$ 23,462,232,089 (11.5%) to injuries (INJ).

About 52.8% of the monetary value of CMN DALY loss was from infectious and parasitic diseases (Figure 1); 14.5% from respiratory infections; 3.7% from

Source: *Statistics obtained from WHO [1] . **Results from authors calculations.

maternal conditions; 20.9% from neonatal conditions; and 8.1% by nutritional deficiencies (Figure 2). HIV/AIDS, diarrhoeal diseases, malaria, and Tuberculosis were responsible for 73.6% of the monetary value of DALYs lost from infectious and parasitic diseases.

Approximately 14.6% of the monetary value of NCD DALY loss resulted from malignant neoplasms (cancers); 0.4% from other neoplasms; 3.1% from diabetes mellitus; 5.9% from endocrine, blood and immune disorders; 12.5% from mental and substance use disorders; 6.0% from neurological conditions; 3.3% from sense organ diseases; 16.5% from cardiovascular diseases; 5.1% from respiratory diseases; 8.3% from digestive diseases; 3.4% from genitourinary diseases; 2.7% from skin diseases; 4.2% from musculoskeletal diseases; 13.1% from congenital anomalies; 0.8% from oral conditions; and 0.2% from sudden infant death syndrome (Figure 3). About 56.6% of NCD-related monetary value of DALY losses resulted from cardiovascular diseases, malignant neoplasms, congenital anomalies and mental and substance abuse disorders.

Almost 82.0% of the monetary value of INJ DALY losses resulted from unintentional injuries and the remaining 18.0% from intentional injuries (Figure 4). Almost 39.7% of unintentional injury monetary value of DALY losses emanated from road injuries. Fifty-four percent of monetary value of unintentional injury

DALY losses were from interpersonal violence. Road injuries and interpersonal violence together account for 42.2% of the total EAC monetary value of DALY losses from violence.

About Int$ 132,718,749,155 (65.1%) of the total monetary value of DALYs lost in EAC in 2015 resulted from the SDG3 health conditions listed in Table 2. If the disease targets in Table 2 were fully attained, the SDG3-related monetary value of DALYs lost would be reduced by Int$ 62,554,855,010 (47.13%).