Sub-Saharan Africa: The Challenge of Non-Communicable Diseases and Road Traffic Injuries

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Sub-Saharan Africa The Challenge of
Non-Communicable Diseases and Road Traffic
Injuries

• THE WORLD BANK
• Patricio V. Marquez
• Human Development Sector LeaderWorld Bank
  Country Office in Ghana
• 10th Anniversary Conference of GHIS
• Accra, November 4, 2013

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Outline

• The changing context and health profile
• How can the disease silo trap be avoided?
• How can NCDs be effectively addressed in
  resource-constrained countries?
• Take-away messages

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Changing health profile a double or triple
burden of disease and injuries

• While progress has been achieved in reducing
  premature mortality from communicable, maternal,
  neonatal, and nutritional causes, these
  conditions still account for 3 out of 4 premature
  deaths.
• At the same time, deaths from NCDs and road
  traffic injuries have emerged as leading causes
  of years of life lost.
• NCDs are expected to become the leading cause of
  ill health and death by 2030, influenced by rapid
  urbanization, change in diet, change in risk
  factors from poverty to behavior, and
  improvements in the control of CDs that increase
  life expectancy.

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NCDs and RTIs already account for almost a third
of deaths in the region
Proportion of deaths by cause in SSA, 2010
Source Global Burden of Disease study, IHME 2013

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Africa already has highest death rate from NCDs
Age-standardized Mortality Rates by Cause, WHO
Regions, 2008
Source World Health Statistics 2013, World
Health Organization
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Ghana compared with WHO African Region
Age-standardized Mortality Rates by Cause, 2008
Source World Health Statistics 2013, World
Health Organization
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Proportion of Deaths by Age Group (Years) in SSA,
2010
NCDs Biggest killers among adults gt 45 years
Source Global Burden of Disease study, IHME 2013

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Further shift expected in relative disease burden
Burden of Disease ( total DALYs) by Groups of
Disorders and Conditions, SSA, 2008 and 2030
Source Global Burden of Disease study 2004
update (2008) (estimates pending new projections
from GBD/IHME 2013)
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Shifts in the leading causes of disease burden
(DALYs) for males in Ghana, 1990-2010
Source Global Burden of Disease study, IHME 2013

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Shifts in the leading causes of disease burden
(DALYs) for females in Ghana , 1990-2010
Source Global Burden of Disease study, IHME 2013

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The contribution of different risk factors to
disease burden is shifting towards those for NCDs
Top 10 global risk factors ranked by Attributable
Burden of Disease for Sub-Saharan African
Regions, 2010
Source Global Burden of Disease study, IHME 2013

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How to effectively address NCDs in SSA?
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Align health strategy with SSAs future to make
a stronger case for investing in health

• To improve competitiveness and employment a
  healthy and skilled workforce is critical.
• To reduce vulnerability and increase resilience
  among the population and in society universal
  health coverage, both financial protection and
  access to quality services, needed to deal with
  cumulative effects of health shocks.
• Domestic social spending needs to be increased,
  particularly in mineral-rich countries, in tandem
  with building institutions and systems and
  drawing on the contributions of multiple sectors,
  to generate good health outcomes.

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Potential risks of setting up yet another
vertical program in resource-constrained
countries need to be acknowledged and overcome,
with integration and resource-sharing where
feasible

• There are four ways that this might be achieved
• Capitalize on links between conditions
• Focus on common functions (prevention, treatment,
  care) rather than disease categories
• Implement proven, cost-effective interventions
• Capitalize on existing resources and capabilities

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Capitalize on the inter-linkages between
conditions and on their common determinants

• Not much attention has been paid to the extent to
  which CDs contribute to the NCD burden and to the
  potential common intervention strategies in SSA.
• Shared underlying social conditions poverty,
  poor nutrition
• Co-morbidities with both CDs and NCDs co-existing
  in the same individual
• Presence of one condition increases risk or
  impact of the other e.g. smoking increases risk
  TB and impacts on HIV progression
• Treatment of one condition increases risk of
  another e.g. ART for HIV increases metabolic
  syndrome
• Presence of one condition can be barrier e.g.
  stigma of HIV may impede participation in health
  promotion opportunities

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A third of cancers in Africa are related to
infection, and other risk factors are shared with
NCDs
Cancer sites Infectious agents Other risk factors of high public health relevance
Breast Hormonal/ reproductive factors, obesity, physical inactivity, alcohol
Cervix HPV Tobacco
Liver HBV, HCV Aflatoxins (produced by Aspergillus moulds), alcohol
Prostate
Lymphomas (non-Hodgkin and Burkitt) EBV, malaria, HIV (indirect), HCV
Colon and rectum Diet, obesity, physical inactivity, alcohol, tobacco
Kaposi sarcoma HIV (indirect), HHV8
Oesophagus Tobacco, alcohol
Lung Tobacco
Stomach Helicobacter pylori (bacterium) Diets low in fruit and vegetables and high in salt, tobacco
Bladder Schistosoma haematobium (fluke) Tobacco, occupational exposure
Source Adapted from Parkin 2006 Sylla Wild
2012
Abbreviations HPV Human papilloma virus EBV
Epstein-Barr virus HBV hepatitis B virus HCV
hepatitis C virus HHV8 human herpes virus 8
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Shared determinants between NCDs and risk factors
related to poverty
NCDs Condition Risk factors related to poverty
Cardiovascular Hypertension Idiopathic, treatment gap
Cardiovascular Pericardial disease Tuberculosis
Cardiovascular Rheumatic valvular disease Streptococcal diseases
Cardiovascular Cardiomyopathies HIV, other viruses, pregnancy
Cardiovascular Congenital heart disease Maternal rubella, micronutrient deficiency, idiopathic, treatment gap
Respiratory Chronic pulmonary disease Indoor air pollution, tuberculosis, schistosomiasis, treatment gap
Endocrine Diabetes mellitus Undernutrition
Endocrine Hyperthyroidism and hypothyroidism Iodine deficiency
Neurological Epilepsy Meningitis, malaria
Neurological Stroke Rheumatic mitral stenosis, endocarditis, malaria, HIV
Renal Chronic kidney disease Streptococcal disease
Musculoskeletal Chronic osteomyelitis Bacterial infection, tuberculosis
Musculoskeletal Musculoskeletal injury Trauma
Source Adapted from Bukhman Kidder, Partners
in Health 2011
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Maternal and child health has potential long-
term consequences for NCDs

• Poor maternal nutrition before and during
  pregnancy together with smoking during pregnancy
  contributes to poor intrauterine growth,
  resulting in low birth weight, which in turn
  predisposes infant to metabolic disorders and NCD
  risk in later life.
• Gestational obesity is a strong predictor of
  future health, both of the mother, who may
  develop diabetes and CVD later in life, and the
  child, who also becomes at risk.
• Problem is compounded by poverty and HIV/AIDS and
  TB e.g., low birth weight and malnutrition are
  more frequent in HIV-infected children.

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Focus on common functions (prevention, treatment,
care) rather than disease categories

• Growing cross-fertilization of care approaches
  between CDs and NCDs
• Care models from HIV/AIDS and TB are being
  extended/adapted for other chronic conditions
  and co-morbidities e.g., DOTS for TB for
  management of diabetes in Malawi.
• Models already exist for collaboration with TB
  control programs for syndromic guidelines in
  primary care to also benefit patients with
  non-infectious respiratory diseases such as
  asthma.
• Chronic care models more frequently used for NCDs
  are also being applied to cover infectious
  chronic diseases e.g., to integrate and improve
  quality of care for HIV, hypertension and
  diabetes are underway in Uganda, Tanzania, and
  South Africa.

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Capitalize on existing resources and capabilities

• Leveraging the resources, experience, and models
  of existing programs, such as HIV/AIDS, could
  benefit management of other chronic conditions as
  part of integrated delivery systems
• Redesigning the delivery of services around
  multidisciplinary teams to facilitate
  task-shifting among personnel and bringing care
  closer to the patient
• Common procurement and supply lines for essential
  drugs, scaling up the use of new technologies,
  such as mobile phones and integrated health
  information systems
• Linking health spending decisions to adoption of
  clinical guidelines for service provision to
  encourage coordination of care and improve the
  quality of services

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Approach for care of HIV/AIDS at primary care
district levels relevant for other chronic
conditions
Source Adapted from WHO (2004) General
principles of good chronic care
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Chronic care model for NCDs adapted for HIV/AIDS
Example USAID project in Uganda to improve care
of people with HIV/AIDS
Source Adapted from WHO (2002) Innovative care
for chronic conditions building blocks got
action global report
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Integrating HIV/AIDS and cervical cancer control
a promising high-impact entry point

• High incidence and mortality from cervical cancer
• Minimal cervical cancer screening services
  contribute to patients being diagnosed at
  advanced stages of diseases
• HIV-positive women are 4-5 times more likely to
  develop cervical cancer
• Some common underlying determinants e.g.,
  sexually transmitted infections gender violence
  links with alcohol
• Potential for integrated solutions e.g., sexual
  health promotion cervical screening integrated
  into existing service delivery platforms

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Age-Standardized Incidence and Mortality Rates
per 100,000 Population, Females, World Regions
Incidence of cervical cancer is highest in
Eastern, Western and Southern African regions
and a high proportion die
Source GLOBOCAN, International Agency for
Research on Cancer
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The Botswana Experience
Scaling up cervical cancer control

• Partnership between Ministry of Health, Pink
  Ribbon/Red Ribbon Initiative, CDC and World Bank
• Co-financed by ongoing HIV/AIDS Prevention
  Project
• Use of existing HIV/AIDS community-based clinics
• Low-cost cervical screening (see and treat
  approach)
• Scaling up from demonstration project to 5
  regions across the country
• HPV vaccination to be introduced, beginning with
  a pilot in Gaborone, targeting school age girls
• Robust ME in place to measure results and impact

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Implement proven cost-effective interventions
Effective tobacco control requires multisectoral
policies and actions

• On June 3-5, 2012, the World Bank, with Ministry
  of Finance of Botswana, Bloomberg/Gates
  Foundations, WHO and SADC, convened in Gaborone
  high-level forum The Economics of Tobacco
  Control Taxation and Illicit Trade.
• Delegations from Ministries of Finance, Trade,
  and Health of 14 SADC member countries and global
  and regional experts initiated dialogue on
  effective design and administration of excise
  taxes on tobacco to promote public health and
  share knowledge on causes and extent of illicit
  trade of tobacco and strategies to control it.
• A Community of Practice in 14 SADC member
  countries is now evolving under World Bank
  coordination with other development partners and
  funding from Bloomberg/Gates Foundations.

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The 2011-2020 UN Decade of Action on Road
Safety an entry point to deal with injuries

• Five categories or "pillars" of activities
• building road safety management capacity
• improving the safety of road infrastructure and
  broader transport networks
• further developing the safety of vehicles
• enhancing the behavior of road users
• improving post-crash care
• The World Bank, working together with WHO and
  other development partners, plays a key role in
  supporting global effort

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Countries that have successfully reduced RTIs
have adopted a safe systems approach
Elements are already in place in some African
countries but strengthening of institution and
governance capacity is needed for better
coordination of sectors
Source Adapted from OECD/ITF (2008) Towards
zero ambitious road safety targets and the Safe
System approach
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A new role for Global Health DiplomacyCollaborat
ion and sharing of knowledge and experiences
among countries

• A move away from foreign health /domestic
  health dichotomy towards global health "concept
• Interdependence of health of populations (e.g.,
  linkage of health problems with production,
  trade, and travel)
• Global transfer of health risks (e.g., tobacco
  trade, poor and unhealthy diets and globesity,
  environmental risks)
• Global transfer of opportunities (e.g.,
  translation of knowledge into new technologies,
  social action, evidence for policy)
• Developing partnerships between countries (e.g.,
  South-to-South exchanges) to share knowledge,
  experience, and good practices
• Adapting international good practices, strategic
  support, and institutional capacity building to
  turn evidence into action

Source Frenk, J. (2009)
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Take-away Messages

• Improved health and social development are
  critical investments for social transformation
  and sustained growth in SSA as they pave the road
  to accelerated poverty reduction and shared
  prosperity
• Rather than concentrating on a few diseases,
  governments and international agencies should
  prioritize building health systems that offer
  universal financial protection, along with
  improved access to and the use of quality
  services
• An effective response also needs multisectoral
  policies and actions for dealing with
  disease-related risk factors and their social,
  economic, and environmental determinants

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The importance of health in a society

• When health is absent, wisdom cannot reveal
  itself, art cannot become manifest, strength
  cannot fight, wealth becomes useless, and
  intelligence cannot be applied.
• Herophilus, 325 B.C.
• Physician to Alexander the Great

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Thank you

• pmarquez_at_worldbank.org