Africa

1
Africas chronic disease burden
socio-cultural, economic and health policy
implications

• Ama de-Graft Aikins
• Regional Institute for Population Studies,
  University of Ghana
• LSE Health, London School of Economics
• Economic Crises and Health in Africa Meeting
  Centre for History and Economics/Centre of
  African Studies/Centre of Governance and Human
  Rights Kings College, 8th June 2010

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Presentation Outline

• Africas chronic disease burden
• Context of the burden
• Policy recommendations and gaps
• Socio-cultural, economic, health policy
  implications

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1. Africas chronic disease burden

• Only region where infectious diseases still
  outnumber chronic diseases as a cause of death
  (about 69)
• But age specific mortality rates from chronic
  diseases as a whole are higher than in virtually
  all other regions of the world, in both men and
  women (de-Graft Aikins et al, 2010a).
• In some countries chronic disease burden
  outweighs burden of some infectious diseases (e.g
  Ghana, Cameroon) (de-Graft Aikins et al, 2010b)
• Over the next ten years the continent will
  experience the largest increase in death rates
  from cardiovascular disease, cancer, respiratory
  disease and diabetes (WHO,2005)
• chronic diseases in this document refers to
  chronic non-communicable
• diseases and excludes chronic infectious/communica
  ble diseases such as
• tuberculosis and HIV/AIDS

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Ghana

• Infectious/communicable diseases (of poverty)
• Malaria and anaemia are still dominant causes of
  morbidity and mortality particularly for children
  up to age fifteen.
• Growing TB, HIV/AIDS burden
• HIV (prevalence 1.9)
• Water-borne diseases such as guinea worm and
  bilharzias are endemic in many rural communities

• Chronic non-communicable diseases (of wealth and
  poverty)
• Hypertension (28.7)
• Diabetes (prev. 6.4, Accra)
• Cancers (0.67, breast)
• Sickle cell disease (2)
• Asthma (exercise-induced bronchospasm (EIB) among
  schoolchildren (aged 9-16) in Kumasi, almost
  doubled in a ten-year period from 3.1 in 1993
  to 5.2 in 2003)
• Stroke
• 2003 4th leading cause of deaths, nationally
• Kumasi (KATH, 2006-2007)
• 9.1 of total medical adult admissions 13.2 of
  all medical adult deaths
• The stroke case fatality rate was 5.7 at 24
  hours, 32.7 at 7 days, and 43.2 at 28 days

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2. Context of the burden

• Multifaceted roots of the chronic disease burden
• Urbanization
• Rapidly ageing populations
• Globalization (including food market
  globalization)
• Poverty
• Poor lifestyle practices
• Weak health systems
• A lack of political will.

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2a. Poverty

• Chronic disease prevalence is higher among the
  urban
• wealthy, but poor communities experience a
  double jeopardy of
• chronic and infectious diseases
• Environmental pollution and degradation chronic
  respiratory disease (air pollution) and cancers
  (e-waste).
• Poor living conditions ? increased risk of
  infections and infectious diseases ? increased
  risk of chronic diseases (e.g. tuberculosis and
  diabetes, malaria and Burkitt Lymphoma).
• Under-nutrition and malnutrition maternal
  under-nutrition, low birth weight, child
  malnutrition ? obesity, atypical diabetes,
  cancers (stomach and oesophageal) and CVDs
• Psychosocial stresses ? ? poor lifestyle
  (smoking, alcohol, unsafe sex)
• Poor access to healthcare / chronic disease
  poverty spiral
• In 2005, 38803 million Africans - just over half
  of the continents
• population - lived below the absolute poverty
  line of US1.25 a day. The
• majority of Africas extreme poor lives in urban
  slum communities.
• Increased CD burden in urban slums (e.g Kenyan
  studies)

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2b. Lifestyle

• Six risk factors, in isolation or in combination,
  are
• implicated in the major chronic diseases
• poor diets (low in fruit and vegetables and high
  in saturated fats and salt),
• physical inactivity,
• obesity,
• high blood pressure,
• cigarette smoking and
• excessive alcohol consumption
• Factors individual? ? socio-cultural ? ?
  structural

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3a. Policy recommendations

• Priority-based interventions focusing on double
  burden of infectious and chronic diseases
• Three-prong approach for chronic diseases (Unwin
  et al, 2001)
• Epidemiological surveillance key disciplines
  epidemiology, demography
• Primary prevention (preventing disease in healthy
  populations) key disciplines public health
  psychology sociology anthropology
• Secondary prevention (preventing complications in
  affected communities) key disciplines medicine,
  psychology sociology
• Overarching framework (Epping-Jordan et al, 2005
  Suhrcke et al, 2006 WHO, 2005)
• Multi-faceted, multi-institutional (see slide 9)
• Innovative cost-effective (because of double
  burden of disease)

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Structural level Policy chronic diseases or risk factors (e.g smoking)
Structural level Fiscal Taxes food, alcohol, tobacco
Structural level Industry and Private Business Food industry lower fat or sugar content of products
Structural level International collaboration Intellectual, technical and financial capacity
Community level Mass media Public health education via radio, tv and newspapers
Community level Vol/advocacy orgs Education, patient support, lobbying by interest groups
Community level Institutions (e.g churches) Interventionsdiet, physical activity and smoking
Community level Primary healthcare Routine medical advice QoC community outreach
Individual level Behavioural Tobacco cessation, physical activity, weight loss
Individual level Pharmacological Optimal prescription mix
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3b. Policy gaps

• Funding
• 80 of regional health budgets - usually 10 or
  less of the national budget - has been allocated
  to communicable disease for the last decade
  (Pobee, 1993 WHO-Afro, 2006).
• Policies and politics
• Few countries have non-communicable disease
  healthcare policies or plans (Alwan et al, 2001)
• Power relations between local policymakers and
  DPs/ Donors/Funders (WHO, 2007)
• Human resources (per 100,000 popn.)
• Physicians (21) nurses (98) public health
  professionals (7) cardiologists (0.4)
  oncologists (0.1) (Alwan et al 2001).
• Conceptual framework
• Epidemiological/Medical research dominates
  social science neglected
• Health promotion still very much KABP has
  limited value in long-term behavioural change

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4. Implications

• Rising prevalence risk, morbidity, mortality
• Economic implications
• Health systems implications
• National/regional development

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4a. Implications rising prevalence

• Morbidity mortality prevalence has increased
  steadily over the last 20 years
• Multi-faceted roots, but
• Dominant focus lifestyle
• Poor diets, obesity, physical inactivity, alcohol
  overconsumption, tobacco smoking
• Culture implicated e.g reification of fat and
  female obesity
• Social processes urbanisation and sedentary work
• Future focus structural dimensions
• Food import/export policies in WA changing food
  consumption patterns linked to aggressive
  marketing of processed foods by multinational
  food companies.
• Urban/Transport policies and changing eating
  alcohol consumption practices
• Poverty and the double burden of disease

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4b. Implications economic

• Chronic diseases affect the most economically
  productive age in many countries.
• Tanzania est. onset of diabetes 44 years
  average age at death est. at 46 years. With PLE
  of 53 years, diabetes est. to reduce LE by 7
  years (Mbanya and Ramiaya, 2006).
• In SSA, healthcare is self-care
• Caregivers, care-giving and loss of productivity
• Poverty spiral chronic diseases can cause
  poverty in individuals and families, and draw
  them into a downward spiral of worsening disease
  and poverty (WHO, 2005)

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• Poverty spiral
• Tanzania (1990s)
• insulin (156 for a one-month supply) beyond the
  means of the majority of Tanzanians (Chale et al,
  1992)
• private sector diabetes care, 25 of the minimum
  wage (Neuhann et al, 2001)
• Ghana (2007) (de-Graft Aikins et al, 2010b)
• diabetes care per month 106 - 638
• Minimum daily wage - 2
• Av. monthly salary civil servants - 213
• Burkina Faso (2006) (Tin Su et al, 2006)
• probability of catastrophic consequences
  increased by 3.3 to 7.8 times when a household
  member has a chronic illness

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4c. Implications health systems

• WHO (2007) Six HS basic building blocks
• (1) service delivery
• (2) information and evidence
• (3) medical products and technologies
• (4) health workforce
• (5) health financing and
• (6) leadership and governance.
• Most African health systems are weak across some
  or all of these basic building blocks.
• The chronic disease burden constitutes a further
  threat to these weak health systems

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Ghana
HS Building Blocks vs chronic disease burden (de-Graft Aikins et al, 2010b Bosu, 2010) HS Building Blocks vs chronic disease burden (de-Graft Aikins et al, 2010b Bosu, 2010)
1. Service delivery Secondary, tertiary oversubscribed primary/rural care poor.
2. Information and evidence Epidemiology poor medical/social science based largely in urban south.
3. Medical products and technologies Unavailability/high cost of medicines lack of technologies (e.g diagnostic equipment)
4. Health workforce Poor chronic disease knowledge (asthma, cancers, diabetes) lack of psychological/social services
5. Health financing NHIS but high cost of CD care a growing burden on the system.
6. Leadership governance Weak donors not interested in CDs (Bosu, 2010).
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4d. Implications national/regional development

• CD urgent developmental problem relationships
  between rapid urbanization, rapid increase in
  ageing populations, extreme poverty,
  malnutrition, infectious disease and chronic
  diseases.
• Rising burden of chronic diseases will cripple
  government budgets and health systems (Suhrcke et
  al, 2006)
• Tanzania (1989/90) government spent approx
  US138 per diabetic patient per year ? 8.1 of
  the total budgeted health expenditure for the
  year and exceeded the allocated US2 per capita
  health expenditure for that year.
• Cameroon (2001/2002) direct medical cost of
  treating a diabetic patient was US489 ? 3.5 of
  the national budget for that year.
• Rising burden will reverse the gains made on the
  MDGs, especially MDG1, MDG5 and MDG6.
• MDG1 chronic disease and poverty spiral
• MDG5 obesity, hypertension and maternal health
  (Ghana hypertension is primary cause of maternal
  mortality)
• MDG6 co-morbid relationships between infectious
  and chronic diseases
• Political and policy inaction will have
  devastating costs in terms of life and welfare.

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Conclusions

• There will be a gap between policy and practice
  for the foreseeable future
• Competing interests - concrete material
  investment in (acute/chronic) communicable
  disease (malaria, HIV/AIDS, TB) vs rhetorical
  investment in chronic non-communicable diseases.
• The power of international donors/policymakers
• Financial, human resource, conceptual barriers
  real
• 80 funding to infectious disease
• Lack of psychological and social care services
  psychiatric services not equipped to deal with
  mental health outcomes of physical chronic
  disease experiences
• Burden on families, self-help groups, patient
  organisations

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• But innovative responses exist and constitute
  best practice models for primary/secondary
  prevention
• Mauritius, Cameroon (structural) (Awah et al,
  2007 Dowse et al, 1995)
• South Africa (structural, community) (Suhrcke et
  al, 2006 WHO, 2005)
• Important models from HIV/AIDS interventions in
  Southern and Eastern Africa (Harding Higginson,
  2004 Illife, 2006 Kalipeni et al, 2004)
• These innovative responses have required pooling
  expertise, resources and commitment of some or
  all of these groups lay communities, pluralistic
  health professionals, multidisciplinary
  researchers, health policymakers, industry,
  governments, development partners and donors.

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