Haemorrhage of Gross Domestic Product from Disability-Adjusted-Life-Years Among 15-59 Year Olds in Kenya

Methods: This study employs the lost output or human capital approach (HCA) to convert the DALYs lost from all causes into their monetary equivalents. The magnitude economic haemorrhage from each disease was obtained by multiplying the per capita non-health GDP in International Dollars by the total number of DALYs lost in a specific age group (15-29 years, 30-49 years, 50-59 years). Per capita non-health GDP equals per capita GDP minus total health expenditure in 2015. Data on DALYs and per capita total health expenditure were obtained from the World Health Organization and per capita GDP data was from IMF databases.


Background
Kenya's population was estimated at 46,034,000 people in 2015 [1].In the same year the country lost a total of 21,854,898 Disability-Adjusted-Life-Years (DALYs) from all causes.Out of that total DALY loss, 59% were from communicable, maternal, perinatal and nutritional conditions; 30% from non-communicable diseases (NCDs); and 11% from intentional and unintentional injuries.About 54% and 46% the total DALYs lost occurred in male and female gender respectively.
The large loss in DALYs has been attributed to weaknesses in national and local health systems responsible for providing quality health services [2,3]; systems that assure access to other basic needs (food, water, sanitation, education, clothing, shelter) or social determinants of health [4,5]; and national health research system that produces knowledge and facilitates its use in development of discoveries and innovations aimed at addressing health and socioeconomic needs [6,7].
Various studies have attempted to estimate the productivity losses attributable to premature mortality from one or a group of disasters, diseases and health conditions in the WHO African Region (AFR).A study conducted in 2004 used regression modelling to estimate the impact of disaster-related mortality on gross domestic product (GDP) in AFR [8].Kirigia et al [9] estimated the effects of maternal mortality on GDP in AFR using econometric production function modelling.Kirigia et al [10] used cost-of-illness (COI) method to estimate the economic burden of diabetes mellitus in AFR.Kirigia et al [11] used COI approach to estimate the economic burden of cholera in AFR.Okorosobo et al [12] used a combination of methods to estimate the economic burden of malaria in five AFR countries.Orem et al [13] used production function approach to estimate the impact of malaria morbidity on GDP in Uganda.Kirigia et al [14] used COI approach to estimate the indirect cost of maternal deaths in AFR.Kirigia et al [15] used COI approach to estimate the cost of child mortality in the AFR.
Kirigia et al [16] estimated the indirect cost associated with deaths from the Ebola Virus disease in West Africa.Kirigia and Muthuri [17] estimated productivity losses associated with tuberculosis deaths in AFR.Kirigia et al [18] estimated the indirect cost of maternal deaths in the AFR.Kirigia et al [19] estimated indirect cost of non-communicable diseases deaths in the AFR.Those studies have two main limitations.First, they all estimated the productivity losses attributable to premature deaths but omitted the economic impact of non-fatal disability resulting from various diseases or health conditions.Second, none of those studies estimated the productivity losses of premature mortality from all causes.Third, except for Kirigia et al [20] study on the indirect cost of DALYs lost among the elderly in Kenya, no other study in Kenya has attempted estimate the GDP losses emanating from DALYs lost.
The objective of this study was to estimate nonhealth gross domestic product (GDP) losses associated with DALYs lost among 15-59 year-old in Kenya in 2015.

Study area and population
The study reported in this paper focusses on all DALYs lost among 15-59 year olds in Kenya, i.e.

The lost output or human capital approach
This study employs the lost output or human capital approach (HCA) to convert the DALYs lost in Kenya in 2015 from all causes into their monetary equivalents.The approach was first used in 1699 [21], and its theoretical underpinnings honed in subsequent studies [22,23,24,24].The availability of data on DALYs, total health expenditure per capita and GDP per capita for Kenya influenced our choice of HCA.The per capita GDP of Kenya is equals total expenditure (i.e.consumption expenditure, investment, government expenditure and net exports) divided by total population.Our hypothesis is that DALY losses from any disease haemorrhages incomes of households and firms (and hence consumption expenditure), savings (and hence resources available for investment), taxes and service fees (and hence revenues available for government spending), and numbers of export producers (and hence quantity of exports).
The Murray [25], Struijk et al [26] and WHO [27] global heath estimates technical papers details DALY methods and data sources.The NHGDPHA linked with k th disease among persons of a specific age group equals non-health GDP per capita times total DALYs lost from k th disease.Kenya's discounted NHGDPHA attributable to k th disease was calculated using the equations (1) to (4): Where: NHGDPPC Int$ : is per capita non-health GDP in purchasing power parity (PPP), obtained by subtracting per capita total health expenditure (PCTHE) from per capita GDP (GDPPC Int$ ) [14][15][16][17][18][19][20]; DALY 15-29 is the number of DALYs lost from k th disease among those aged 15-29 years in Kenya in 2015; DALY 30-49 is the number of DALYs lost from k th disease among those aged 30-49 years in Kenya in 2015; and DALY 50-59 is the number of DALYs lost from k th disease among those aged 50-59 years in Kenya in 2015.Discount factor was not introduced in equation ( 2) to (4) because DALY estimates contained in the WHO Global Health Observatory are already discounted at a rate of 3% [27].

Data Analysis
The Excel Software developed by Microsoft (New York) was used to estimate equations (1) to (4).

Results
Kenya sustained a loss of 9,405,184 DALYs among 15-59 years olds in 2015.That DALY loss caused a haemorrhage in GDP of Int$ 29,788,392,419.About 43% of the economic loss was sustained by the 15-29 year-old; 43.7% by the 30-49 year-old; and 13.3% by the 50-59 year-old.

GDP haemorrhage from communicable diseases and nutritional conditions indirect costs
About Int$ 14,482,888,888 (48.6%) of total GDP haemorrhage was caused by communicable diseases and nutritional conditions (CDs).This loss was due to four categories of causes.First, 3,403,288 DALYs were lost from infectious and parasitic diseases, which was equivalent to Int$10,779,561,469 (74%) (Figure 1).Eighty-five percent of this loss was from HIV/AIDS, diarrhoea diseases, parasitic and vector diseases, tuberculosis, and meningitis.Second, 297,097 DALYs were lost from respiratory infections, which was equivalent to Int$ 940,973,619 (Figure 2).
Ninety-three percent of the loss emanated from lower respiratory infections.Third, maternal and neonatal conditions led to a loss of 560,389 DALYs, equivalent to Int$ 1,774,881,139.Fourth, nutritional deficiencies resulted in 311,778 DALYs lost, which was equal to Int$ 987,472,662.Eighty-four percent of the latter loss was from iron-deficiency anaemia and 11% from protein-energy malnutrition.
First, malignant neoplasms (Cancers) haemorrhaged 648,090 DALYs, which was equal to Int$ 2,040,790,854.Five cancers accounted for 42.3% of the productivity losses, including cervix uteri cancer, breast cancer, oesophagus cancer, lymphomas and multiple myeloma, and mouth and oropharynx cancers (Figure 4).
Second, other neoplasms, diabetes mellitus and endocrine/blood/immune disorders led to a loss of 248,457 DALYs causing a haemorrhage of Int$ 786,920,661, i.e. 7.1% of the total GDP loss in Kenya (Table 1).
Third, mental and substance use disorders resulted in 696,354 DALY loss, which caused a haemorrhage in GDP of Int$ 2,205,514,227 (19.8%).About 79.4% of the GDP loss resulted from depressive disorders, bipolar disorder, schizophrenia, alcohol use disorders, and anxiety disorders (Table 2).Fourth, 236,062 DALYs were lost from neurological conditions translating to Int$ 747,663,702 GDP loss, i.e. 6.7% of losses related to NCDs (Table 3).Epilepsy and migraine accounted for 87.8% of neurological conditions.Fifth, 105,261 DALYs were lost from neurological conditions translating to Int$ 333,384,904 GDP loss, i.e. 3% of losses related to NCDs (Table 4).Other hearing loss, uncorrected refractive errors, and other vision loss accounted for 77.9% of GDP losses attributed to sense organ diseases.
Sixth, 435,584 DALYs were lost from cardiovascular diseases haemorrhaging Int$1,379,595,271, i.e. 12.4% of the total losses related to NCDs (Table 5).Hypertensive heart disease, ischaemic heart disease and stroke were responsible for 73% of cardiovascular diseases related GDP losses.
Seventh, 145,343 DALYs were lost from respiratory diseases haemorrhaging GDP by Int$ 460,335,371, i.e. 4.1% of total NCD productivity losses.About 32%, 59% and 9% of those losses resulted from chronic obstructive pulmonary disease, asthma and other respiratory diseases respectively.
Eighth, 362,392 DALY loses stemmed from digestive diseases, which in turn accounted for Int$ 1,147,779,998, i.e. 10.3% of NCD-related economic losses (Table 6).About 70.8% of the digestive disease GDP loss was caused by peptic ulcer disease, cirrhosis of the liver, and paralytic ileus and intestinal obstruction.

GDP haemorrhage from injuries
Twelfth, 1,317,485 DALYs lost were from injuries, which haemorrhaged Int$ 4,172,781,137 of GDP, i.e. 14% of the grand total productivity losses from all causes (Figure 5).About 73.8% of the losses were from unintentional injuries; and the remaining 26.2% from intentional injuries.Sixty-four percent of the unintentional injuries GDP losses were from road injury and exposure to mechanical forces.Ninety-six percent of the intentional injuries GDP losses resulted from self-harm and interpersonal violence.

Discussion
The 9,405,184 DALYs lost among 15-59 years olds are estimated to have haemorrhaged equivalent to 21% of Kenya's GDP in 2015.In other words, if Kenya could avert all the DALYs lost in 2015, it could increase its GDP by 21%.Kenya could potentially avert majority of the GDP losses from communica-ble and non-communicable diseases and injuries by implementing pertinent policies and strategies agreed upon at the United Nations General Assembly, World Health Assembly, African Union and WHO Regional Committee for Africa.

Global and regional policies and strategies for combatting communicable diseases HIV/AIDS
In May 2016, the Sixty-ninth World Health Assembly (WHA) endorsed the Global Health Sector Strategy for HIV (2016-2021) [30] that envisions zero new HIV infections, zero HIV-related deaths and zero HIV-related discrimination in a world where people living with HIV are able to live long and healthy lives [30,31].Its goal is to end the AIDS epidemic as a public health threat by 2030, within the context of ensuring healthy lives and promoting well-being for all at all ages [31].The strategy has five strategic directions: strategic information for focussed action and accountability, essential interventions for impact, delivering for quality and equity, financing for sustainability and financial risk protection, and innovation to bridge knowledge and technological gaps for acceleration [31].The 62 nd WHO Regio- nal Committee for Africa resolution AFR/RC62/ R2 adapted the global HIV strategy to the African region context to facilitate implementation of the global strategy [32].

Diarrhoeal diseases
The Thirty-first WHA resolution WHA31.44 of 1978 urged Member States to implement effective interventions for prevention and case management of diarrhoeal diseases in the primary health care context [33].The 1987 Fortieth WHA resolution WHA40.34 underscores that prevention of diarrhoeal diseases entails improving nutrition, promoting breast-feeding, access to and use of safe water, personal hygiene (including hand washing with soap), sanitation, and immunization against measles [34].It also adds that an effective diarrhoeal diseases control programme must include careful planning, adequate health manpower training and information, effective communication as well as education on health, sanitation, nutrition promotion, adequate production, distribution and social marketing of oral rehydration preparations, and appropriate supervision, monitoring and evaluation [34].The 2011 Sixty-fourth WHA resolution WHA64.15called upon Member States to mobilize sufficient technical and financial resources for coordinated and multi-sectoral measures for preparation, prevention and control of cholera [35].The 2017 cholera outbreaks in Kenya's Nairobi capital city clearly indicates that there is need for implementing sectoral and inter-sectoral interventions (health education, personal hygiene, potable water, improved sanitation, environmental conditions and cultural practices) to prevent recurrence of diarrhoeal diseases [36].

Parasitic and vector diseases
The Seventieth World Health Assembly in 2017 through its resolution WHA70.16,adopted the Global Vector Control Response 2017-2030, which envisions a world free of human suffering from vector-borne diseases [37].According to the WHA resolution and strategy, Kenya's national vector control strategy and operational plan(s) should, among others, feature needs assessment and resource mobilization plan; training of relevant staff from national and County ministries of health in public health entomology; establishment of functional national institutional network(s) to support education and training in public health entomology; and development of a national agenda for basic and applied research on entomology and vector control.In order significantly reduce the burden and threat of vector-borne diseases, Kenya's strategic vector control plan will need to be supported by four pillars: inter-and intra-sectoral action and collaboration; engaging and mobilizing communities; enhancing vector surveillance and monitoring and evaluation of interventions; and scaling up and integrating tools and approaches [38].

Tuberculosis
The Sixty-Seventh WHA, in 2014, through resolution WHA67.1 adopted the global strategy and targets for tuberculosis (TB) prevention, care and control after 2015 [39].The strategy envisions a world without TB.It targets ending the global TB epidemic by 2035 through a reduction in TB deaths by 95% and in TB incidence by 90%, and elimination of associated catastrophic costs for TB-affected households.The strategy has three pillars: integrated, patient-centred care and prevention (early diagnosis of TB, treatment of all people with TB, management of HIV/TB co-morbidities, preventive treatment of persons at high risk, and vaccination against TB); bold policies and supportive systems (adequate resources for TB care and prevention, engagement of stakeholders, social protection, and universal health coverage policy and regulatory frameworks); and intensified research and innovation (development and uptake of new tools, optimization of implementation) [40].

Meningococcal meningitis
The WHO strategy for the control of epidemic meningitis is based on three key pillars: surveillance (to detect the first cases, identify the pathogen as well as the serogroup of the meningococcus); treatment and care (providing prompt, appropriate, accessible and affordable treatment with antibiotics and care); and vaccination (large-scale vaccination of population groups that are at risk) [41].

Global and regional policies and strategies for battling non-communicable diseases
Following the adoption of the UN General Assembly (UNGA) decisions [42,43,44], WHA resolutions [45,46,47,48], and WHO Regional Committee for Africa resolutions [49,50,51] related to NCDs, WHO specified 10 indicators which the Director-General will use to report [52], by the end of 2017, to the UNGA on the progress achieved in the implementation of the time-bound commitments included in the 2014 Outcome Document [53].By end of 2015, Kenya had fully achieved the following: formulated national NCDs targets and indicators; developed national integrated NCD policy/strategy/action plan; developed public awareness on diet and/or physical activity; articulated guidelines for the management of major NCDs; and legislated tobacco advertising ban.The country had partially achieved the indicators on: risk factor surveys, health warnings tobacco demand-reduction measure, and harmful use of alcohol reduction measures, such as availability of regulations, advertising and promotion bans, and pricing policies.The following indicators had not been achieved: NCD mortality data surveillance; taxation and smoke-free policies tobacco demand-reduction measures; unhealthy diet reduction measures (salt/ sodium policies, saturated fatty acids and trans-fats policies, marketing to children restrictions, and marketing of breast-milk substitutes restrictions); and drug therapy/counselling for high risk persons [52].
The 2030 Agenda for Sustainable Development aims to reduce premature deaths from NCDs by one-third by 2030 (SDG target 3.4), strengthen implementation of the WHO Framework Convention on Tobacco Control (FCTC) (3.a), strengthen the prevention and treatment to reduce the harmful use of alcohol (3.5), support the research and development on medicines for NCDs that primarily affect developing countries (3.b), and achieve universal health coverage (3.8) [54].This historic decision to include NCDs within the scope of SDGs is grounded in the commitments made at two highlevel meetings of the UNGA in 2011 and 2014 to track the exponential increase in prevalence of NCDs and its impact on development, make prevention the cornerstone of the global response, and strengthen national health systems capacities tackle NCD epidemic [44,53].

Kenya national policies and strategies for combatting communicable and noncommunicable diseases
Kenya's national health policy goal is to attain the highest possible health standard in a manner responsive to the population needs through provision of equitable, affordable and quality health and related services to all Kenyans [55].Its policy objectives are to eliminate communicable diseases; halt and reverse rising burden of NCD's; reduce the burden of violence and injuries; provide essential health services; minimize exposure to health risk factors; and strengthen collaboration with private and health-related sectors.Kenya national health sector strategic plan (NHSSP) expounds on the strategies for realizing those policy objectives [56].It explains how investments would be increased and efficiently utilized to strengthen health system building blocks (organization of services, health workforce, health infrastructure, health products and technologies, health information and research, health finance, and leadership and governance) at community, primary, county and national levels to provide unfettered access to an Essential Package of Health Services to all Kenyans in need.However, Kenya's current total health expenditure per capita of US$68 [29] is far much lower than the USD US$ 271 total cost per person needed to achieve health SDG 3 [57].

Global and regional policies and strategies for preventing injuries
Road traffic injuries and Interpersonal violence alone account for 55.6% of violence-related productivity losses.Due to great concern about health losses attributable to road traffic accidents the UNGA adopted eight resolutions on improving global road safety between 2003 and 2014 [58][59][60][61][62][63][64][65].The 2010 resolution proclaims the period 2011-2020 as the Decade of Action for Road Safety, with a goal of stabilizing and then reducing road traffic fatalities [60].It called upon member states to implement road safety activities, particularly in the areas of road safety management, road infrastructure, vehicle safety, and road user behaviour, among others.
The UNGA has also adopted conventions and resolutions for curbing other forms of injuries.The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) asserts the rights of women and elimination of all forms of discrimination [66].The UNGA A/RES/48/104 asserted women's right to life and called upon governments to budget adequate resources for implementing action plans to eliminate all forms of violence against women [67].By resolution A/RES/54/134, the UNGA designated 25 November as the International Day for the Elimination of Violence against Women [68].
This political momentum culminated in UNGA adoption of its resolution A/RES/70/1 of 25 September 2015 entitled "Transforming our world: the 2030 Agenda for Sustainable Development" [54].The Goal 3 on ensuring healthy lives and promoting well-being for all at all ages has a target 3.6, which aspires to halve the number of global deaths and injuries from road traffic accidents by 2020 [54].
Thus, there is political commitment at the UNGA Heads of State level to curb injuries.What about at the WHA?
The UNGA in 2004 designated WHO the coordinator on road safety issues [63].WHO accepted the responsibility through resolution WHA57.10 [69].Subsequently, in 2007, the WHA adopted resolution WHA60.22 calling upon Member States to strengthen emergency care systems to improve provision of trauma and emergency care [70].The WHA resolution WHA69.7 of 2016 urged Member States to implement the Brasília Declaration on Road Safety [71]; commit to implement the Decade of Action for Road Safety 2011−2020 and the Global Plan for the Decade of Action for Road Safety 2011−2020 [72]; develop and implement a national strategy and action plan; adopt and enforce laws on the key risk factors (speeding, drinking alcohol and driving; non-use of motorcycle helmets, seat-belts and child restraints; distracted or impaired driving), improve the quality of road safety data; and improve prevention and emergency medicine training programmes [73].
The Sixty-seventh WHA, in 2014, adopted resolution WHA67.15 that urges Member States to develop comprehensive and effective multi-sectoral response to interpersonal violence against women, girls and children [74].The Sixty-Ninth WHA, in 2016, adopted resolution WHA69.5 urging Member States to implement the WHO global plan of action to strengthen the role of the health system within a national multi-sectoral response to address interpersonal violence against women, girls and children [75].Thus, there is expressed commitment among global ministers of health to tackle injuries in countries.Is there commitment at Africa continent level prevent injuries?
At the Continental level, the African Union has a Road Safety Charter [76] and an African Road Safety Action Plan [77].In order for African countries to fully implement the action plan, the First Ordinary Session of the African Union Specialized Technical Committee, recommended that Member States create and/or strengthen their Lead Road Safety Agencies, involve private sector and civil society organizations, build a critical mass of skilled road safety experts, modernize management of national database on road safety, strengthen human and financial resources of emergency services of hospitals, develop national monitoring frameworks, enhance sensitization on Road Safety, sustainably finance national road safety programme, celebrate the African Road Safety Day on 18 th November, and appoint high-level political Road Safety Champions [78].
In order to curb domestic violence, the African Union adopted the Protocol to enshrining the Rights of Women in Africa.The protocol calls upon State Parties to enact and enforce laws to prohibit all forms of violence against women including unwanted or forced sex whether the violence takes place in private or public [79].Thus, political commitment also exists within the African Union to curb all forms of injuries.
Does commitment exist among ministers of health in Africa?The WHO Regional Committee for Africa has over the years adopted a number of resolutions aimed at injury prevention and control.Resolution AFR/RC53/R3 urges Member States to adopt and implement national policies and programmes on injury and violence prevention and control [80].Resolution AFR/RC53/R4 called upon Member States to accelerate the implementation of interventions aimed at eliminating all forms of violence and harmful traditional practices [81].Resolution AFR/RC58/R1 called upon Member States to consider in women's health policies, the prevention of early and forced marriages, gender-based violence and all forms of discrimination against women, and adopt and enforce relevant legislation [82].Resolution AFR/RC63/R4 called upon member states to intensify action aimed at eliminating violence against women, gender discrimination, sexual coercion, early marriage and harmful tradi-tional practices such as female genital mutilation [83].There seems to be expressed commitment among ministers of health in the AFR.

Kenya national policies and strategies for preventing injuries
Since this paper is on indirect cost of DALYs lost in Kenya, is there commitment to tackle injuries?At the national level, Article 26 of Kenya's Constitution asserts every person's right to life; and Article 29 assures the right to security of the person, including the right not to be subjected to any form of violence from public or private sources [84].The country has a National Transport Safety Authority (NTSA) whose functions are to implement policies relating to road transport and safety; plan, manage and regulate the road transport system; and ensure the provision of safe, reliable and efficient road transport services [85,86].Kenya has a comprehensive road safety action plan [87].The country also has a Prohibition of Female Genital Mutilation (FGM) Act No. 32 of 2011 prohibiting the practice of FGM and safeguarding against violation of a person's mental or physical integrity through the practice of FGM [88].In addition, Kenya has an Act of Parliament aimed at providing protection and relief of victims of domestic violence [89].The existing legal framework and plans of action for preventing intentional and unintentional injuries have not been fully implemented due to inadequacy of inter-sectoral resources allocated for the purpose [90].

Limitation of this study
This study has a number of limitations.First, the focus of the current study was on productivity losses attributable to DALYs lost in Kenya in 2015.Thus, the study omitted direct health systems costs, e.g., health workforce time, medicines, diagnosis, health facility buildings and equipment.
Second, the DALY index has been criticized for age weighting (giving more weight to DALYs lost among people in economically productive age bracket), discounting, and using the highest average life expectancy in the world instead of each country's average [91,92].Furthermore, given Kenya's weak vital registration system for births and deaths, estimations of years of life lost are based on a combination of second-best approaches.
Third, the study uses GDP per capita to monetarily value DALYs lost.The GDP has been criticized for omitting contributions of full-time home-makers (e.g.housewives), for not reflecting inequalities in income distribution, and for valuing leisure activities at zero [93][94][95][96].
Fourth, if the HCA strictly is applied, the DALYs lost by the unemployed and full-time homemakers would be valued at zero [23,97,98].In order to alleviate the impact of this limitation, the current study valued all the DALYs lost using the same per capita GDP, without adjusting for employment rates.

Conclusion
Annually Kenya suffers considerable GDP haemorrhage due to non-fatal disability and premature mortality among the 15-59 year olds, i.e. the most productive age bracket in Kenya's population.Majority of the health and economic haemorrhage from all causes can be averted using available proven promotive, preventive, curative and rehabilitative interventions.On paper, there exists political commitment at global, continental, regional and national levels to stem the tide of DALY haemorrhage.However, the political commitment does not seem to have translated into allocation of adequate budget for implementing existing policy and legal frameworks and action plan(s) to tackle the root causes DALY losses [3].Thus, the need for evidence-based advocacy among national and county governments, private sector (industry) and external development partners to increase and use all available health development resources more efficiently to strengthen performance of health systems [2,99,100,101,102], national health research and innovation system [6,7], and other systems that tackle social determinants of health (e.g.education, food, water, sanitation and shelter) [4] cannot be overemphasized.STD: Sexually transmitted diseases UNGA: United Nations General Assembly WHA: World Health Assembly WHO: World Health Organization WHO/AFRO: World Health Organization Regional Office for Africa Kenya's non-health GDP haemorrhage (NHGDPHA) associated with DALYs lost from k th disease (or health condition) is the sum of the NHGDPHA due to DALYs lost from k th disease among people aged 15-29 years (NHGDPA 15-29 ), 30-49 years (NHGDPA 30-49 ), and 50-59 years (NHGDPA[50][51][52][53][54][55][56][57][58][59]

Figure 2 :
Figure 2: GDP haemorrhage from respiratory infections, maternal and neonatal conditions, and nutritional deficiencies among 15-59 year olds in Kenya in 2015 (Int$).

Table 2 .
GDP haemorrhage from DALYs lost from mental and substance use disorders among 15-59 yearolds in Kenya in 2015 (Int$).

Table 8 .
GDP haemorrhage from musculoskeletal diseases, congenital anomalies, and oral conditions among 15-59 year-olds in Kenya in 2015 (Int$)
congenital anomalies GDP losses were from congenital heart anomalies; and 45.7% of oral condition losses were from periodontal diseases (Table8).