Africa’s chronic disease burden: sociocultural, 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, 8 th June 2010
Presentation Outline 1. 2. 3. 4. Africa’s chronic disease burden Context of the burden Policy: recommendations and gaps Socio-cultural, economic, health policy implications
1. Africa’s chronic disease burden p Only region where infectious diseases still outnumber chronic diseases* as a cause of death (about 69%) p 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, 2010 a). n p In some countries chronic disease burden outweighs burden of some infectious diseases (e. g Ghana, Cameroon) (de-Graft Aikins et al, 2010 b) 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) p p Malaria and anaemia are still dominant causes of morbidity and mortality particularly for children up to age fifteen. p Growing TB, HIV/AIDS burden p Chronic non-communicable diseases (of wealth and poverty) p p p HIV (prevalence 1. 9%) Water-borne diseases such as guinea worm and bilharzias are endemic in many rural communities p 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 tenyear period: from 3. 1% in 1993 to 5. 2% in 2003) Stroke n n 2003: 4 th leading cause of deaths, nationally Kumasi (KATH, 2006 -2007): p p 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 burden Multifaceted roots of the chronic disease burden: p Urbanization; p Rapidly ageing populations; p Globalization (including food market globalization); p Poverty; p Poor lifestyle practices; p Weak health systems; p A lack of political will.
2 a. Poverty Chronic disease prevalence is higher among the urban wealthy, but poor communities experience a ‘double jeopardy’ of chronic and infectious diseases: p p p 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)
2 b. Lifestyle Six risk factors, in isolation or in combination, are implicated in the major chronic diseases: p p p 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
3 a. Policy: recommendations o Priority-based interventions: focusing on double burden of infectious and chronic diseases p Three-prong approach for chronic diseases (Unwin et al, 2001) n Epidemiological surveillance [key disciplines: epidemiology, demography] n Primary prevention (preventing disease in healthy populations) [key disciplines: public health; psychology; sociology; anthropology] n Secondary prevention (preventing complications in affected communities) [key disciplines: medicine, psychology; sociology] p Overarching framework (Epping-Jordan et al, 2005; Suhrcke et al, 2006; WHO, 2005) n Multi-faceted, multi-institutional (see slide 9) n 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 Mass media level Vol/advocacy orgs Public health education via radio, tv and newspapers Education, patient support, lobbying by interest groups Institutions (e. g churches) Primary healthcare Individual level Interventions: diet, physical Routine medical advice; Qo. C; community outreach Behavioural Tobacco cessation, physical activity and smoking activity, weight loss Pharmacological Optimal prescription mix
3 b. Policy: gaps p Funding n p Policies and politics n n p 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. ) n p 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). Physicians (21); nurses (98); public health professionals (7); cardiologists (0. 4); oncologists (0. 1) (Alwan et al 2001). Conceptual framework n n Epidemiological/Medical research dominates; social science neglected Health promotion still very much KABP – has limited value in longterm behavioural change
4. Implications Rising prevalence: risk, morbidity, mortality p Economic implications p Health systems implications p National/regional development p
4 a. Implications: rising prevalence p p p Morbidity mortality prevalence has increased steadily over the last 20 years Multi-faceted roots, but… Dominant focus: lifestyle n n n p 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 n n n 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
4 b. Implications: economic p Chronic diseases affect the most economically productive age in many countries. n p In SSA, ‘healthcare is self-care’ n p Tanzania: est. onset of diabetes 44 years; average at death est. at 46 years. With PLE of 53 years, diabetes est. to reduce LE by 7 years (Mbanya and Ramiaya, 2006). 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: p Tanzania (1990 s): insulin ($156 for a one-month supply) beyond the means of the majority of Tanzanians (Chale et al, 1992); n private sector diabetes care, 25% of the minimum wage (Neuhann et al, 2001) p Ghana (2007) (de-Graft Aikins et al, 2010 b): n diabetes care per month $106 - $638; n Minimum daily wage - $2; n Av. monthly salary civil servants - $213 p Burkina Faso (2006) (Tin Su et al, 2006) : n probability of catastrophic consequences increased by 3. 3 to 7. 8 times when a household member has a chronic illness n
4 c. Implications: health systems p WHO (2007): Six HS basic building blocks n n n (1) (2) (3) (4) (5) (6) service delivery; information and evidence; medical products and technologies; health workforce; health financing; and leadership and governance. Most African health systems are weak across some or all of these basic building blocks. p The chronic disease burden constitutes a further threat to these weak health systems p
Ghana HS Building Blocks vs chronic disease burden (de-Graft Aikins et al, 2010 b; 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).
4 d. Implications: national/regional development p CD urgent developmental problem: relationships between rapid urbanization, rapid increase in ageing populations, extreme poverty, malnutrition, infectious disease and chronic diseases. p Rising burden of chronic diseases will cripple government budgets and health systems (Suhrcke et al, 2006) n n p Rising burden will reverse the gains made on the MDGs, especially MDG 1, MDG 5 and MDG 6. n n n p 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. MDG 1: chronic disease and poverty spiral MDG 5: obesity, hypertension and maternal health (Ghana: hypertension is primary cause of maternal mortality) MDG 6: co-morbid relationships between infectious and chronic diseases Political and policy inaction will have devastating costs in terms of life and welfare.
Conclusions p There will be a gap between policy and practice for the foreseeable future n n n 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 p Lack of psychological and social care services; psychiatric services not equipped to deal with mental health outcomes of physical chronic disease experiences p Burden on families, self-help groups, patient organisations p
p But innovative responses exist and constitute best practice models for primary/secondary prevention n n Mauritius, Cameroon (structural) (Awah et al, 2007; Dowse et al, 1995) South Africa (structural, community) (Suhrcke et al, 2006; WHO, 2005) p Important models from HIV/AIDS interventions in Southern and Eastern Africa (Harding & Higginson, 2004; Illife, 2006; Kalipeni et al, 2004) p 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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