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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 Ghana10th Anniversary Conference of GHIS
Accra, November 4, 2013
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
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.
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
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
Source: World Health Statistics 2013, World Health Organization
Ghana compared with WHO African RegionAge-standardized Mortality Rates by Cause, 2008
Proportion of Deaths by Age Group (Years) in SSA, 2010
Source: Global Burden of Disease study, IHME 2013
NCDs: Biggest killers among adults > 45 years
Further shift expected in relative disease burden
Source: Global Burden of Disease study: 2004 update (2008) (estimates; pending new projections from GBD/IHME 2013)
Burden of Disease (% total DALYs) by Groups of Disorders and Conditions, SSA, 2008 and 2030
Shifts in the leading causes of disease burden (DALYs) for males in Ghana, 1990-2010
Source: Global Burden of Disease study, IHME 2013
Shifts in the leading causes of disease burden (DALYs) for females in Ghana , 1990-2010
Source: Global Burden of Disease study, IHME 2013
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
How to effectively address NCDs in SSA?
Align health strategy with SSA’s 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.
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
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
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
BreastHormonal/ 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
StomachHelicobacter pylori
(bacterium)Diets low in fruit and vegetables and high in salt, tobacco
BladderSchistosoma
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
NCDs Condition Risk factors related to poverty
Cardiovascular
Hypertension Idiopathic, treatment gap
Pericardial disease Tuberculosis
Rheumatic valvular disease Streptococcal diseases
Cardiomyopathies HIV, other viruses, pregnancy
Congenital heart diseaseMaternal rubella, micronutrient deficiency, idiopathic,
treatment gap
Respiratory Chronic pulmonary diseaseIndoor air pollution, tuberculosis, schistosomiasis,
treatment gap
EndocrineDiabetes mellitus Undernutrition
Hyperthyroidism and hypothyroidism Iodine deficiency
Neurological Epilepsy Meningitis, malariaStroke Rheumatic mitral stenosis, endocarditis, malaria, HIV
Renal Chronic kidney disease Streptococcal disease
MusculoskeletalChronic osteomyelitis Bacterial infection, tuberculosis
Musculoskeletal injury Trauma
Shared determinants between NCDs and risk factors related to poverty
Source: Adapted from: Bukhman & Kidder, Partners in Health 2011
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.
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.
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
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
Source: Adapted from: WHO (2002) Innovative care for chronic conditions: building blocks got action: global report
Chronic care model for NCDs adapted for HIV/AIDS
Example: USAID project in Uganda to improve care of people with HIV/AIDS
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
Age-Standardized Incidence and Mortality Rates per 100,000 Population, Females, World Regions
Source: GLOBOCAN, International Agency for Research on Cancer
Incidence of cervical cancer is highest in Eastern, Western and Southern African regions – and a high proportion die
The Botswana Experience
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 M&E in place to measure results and impact
Scaling up cervical cancer control
Implement proven cost-effective interventions
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.
Effective tobacco control requires multisectoral policies and actions
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
Countries that have successfully reduced RTIs have adopted a safe systems approach
Source: Adapted from OECD/ITF (2008) Towards zero: ambitious road safety targets and the Safe System approach
Elements are already in place in some African countries but strengthening of institution and governance capacity is needed for better coordination of sectors
A new role for Global Health DiplomacyCollaboration 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)
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
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
