Africa’s 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; King’s College, 8th June 2010

Presentation Outline

1. Africa’s chronic disease burden2. Context of the burden 3. Policy: recommendations and gaps4. Socio-cultural, economic, health policy

implications

1. Africa’s 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/communicable diseases such as tuberculosis and HIV/AIDS

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

2. Context of the burdenMultifaceted 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.

2a. PovertyChronic 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 continent’s population - lived below the absolute poverty line of US$1.25 a day. The majority of Africa’s extreme poor lives in urban slum communities. Increased CD burden in urban slums (e.g Kenyan studies)

2b. LifestyleSix 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

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)

Structural level

Policy chronic diseases or risk

factors (e.g smoking)

Fiscal Taxes: food, alcohol, tobacco

Industry and Private Business

Food industry: lower fat or sugar content of products

International collaboration

Intellectual, technical and financial capacity

Community level

Mass media Public health education via radio, tv and newspapers

Vol/advocacy orgs Education, patient support,

lobbying by interest groups Institutions (e.g churches)

Interventions:diet, physical

activity and smoking Primary healthcare Routine medical advice; QoC;

community outreach

Individual level

Behavioural Tobacco cessation, physical

activity, weight loss Pharmacological Optimal prescription mix

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

4. Implications Rising prevalence: risk, morbidity, mortality Economic implications Health systems implications National/regional development

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

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)

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

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

GhanaHS 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).

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 US$138 per diabetic patient per year 8.1% of the total budgeted health expenditure for the year and exceeded the allocated US$2 per capita health expenditure for that year.

Cameroon (2001/2002): direct medical cost of treating a diabetic patient was US$489 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.

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

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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