Transcript The Challenge of NCDs in Sub-Saharan Africa

Sub-Saharan Africa:
The Challenge of Non-Communicable
Diseases and Road Traffic Injuries
THE WORLD BANK
Patricio V. Marquez
Human Development Sector Leader
World Bank Country Office in Ghana
10th Anniversary Conference of GHIS
Accra, November 4, 2013
Outline
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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
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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
Ghana compared with WHO African Region
Age-standardized Mortality Rates by Cause, 2008
Age-standardized mortality rates by cause (per 100,000
population)
900
800
700
600
500
Africa
400
Ghana
300
200
100
0
Communicable,
maternal, perinatal,
nutritional causes
Noncommunicable
Source: World Health Statistics 2013, World Health Organization
Injuries
NCDs: Biggest killers among adults > 45 years
Proportion of Deaths by Age Group (Years) in SSA, 2010
Source: Global Burden of Disease study, IHME 2013
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)
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
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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
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There are four ways that this might be achieved:
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Capitalize on links between conditions
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Focus on common functions (prevention, treatment, care)
rather than disease categories
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Implement proven, cost-effective interventions
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Capitalize on existing resources and capabilities
Capitalize on the inter-linkages between
conditions and on their common determinants
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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.
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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
Hormonal/ reproductive factors, obesity, physical inactivity,
alcohol
Breast
Cervix
HPV
Tobacco
Liver
HBV, HCV
Aflatoxins (produced by Aspergillus moulds), alcohol
Prostate
Lymphomas (nonHodgkin and Burkitt)
EBV, malaria, HIV
(indirect), HCV
Colon and rectum
Kaposi sarcoma
Diet, obesity, physical inactivity, alcohol, tobacco
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
Shared determinants between NCDs and risk
factors related to poverty
NCDs
Condition
Risk factors related to poverty
Hypertension
Idiopathic, treatment gap
Pericardial disease
Tuberculosis
Rheumatic valvular disease
Streptococcal diseases
Cardiomyopathies
HIV, other viruses, pregnancy
Congenital heart disease
Maternal rubella, micronutrient deficiency, idiopathic,
treatment gap
Chronic pulmonary disease
Indoor air pollution, tuberculosis, schistosomiasis,
treatment gap
Diabetes mellitus
Undernutrition
Hyperthyroidism and hypothyroidism
Iodine deficiency
Neurological
Epilepsy
Stroke
Meningitis, malaria
Rheumatic mitral stenosis, endocarditis, malaria, HIV
Renal
Chronic kidney disease
Streptococcal disease
Chronic osteomyelitis
Bacterial infection, tuberculosis
Musculoskeletal injury
Trauma
Cardiovascular
Respiratory
Endocrine
Musculoskeletal
Source: Adapted from: Bukhman & Kidder, Partners in Health 2011
Maternal and child health has potential longterm consequences for NCDs
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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
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Growing cross-fertilization of care approaches between CDs and NCDs:
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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.
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Models already exist for collaboration with TB control programs for
syndromic guidelines in primary care to also benefit patients with noninfectious respiratory diseases such as asthma.
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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
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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
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Redesigning the delivery of services around multidisciplinary teams to
facilitate task-shifting among personnel and bringing care closer to the
patient
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Common procurement and supply lines for essential drugs, scaling up the
use of new technologies, such as mobile phones and integrated health
information systems
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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
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
Integrating HIV/AIDS and cervical cancer
control: a promising high-impact entry point
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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
Incidence of cervical cancer is highest in Eastern, Western
and Southern African regions – and a high proportion die
Age-Standardized Incidence and Mortality Rates per 100,000 Population, Females, World Regions
Source: GLOBOCAN, International Agency for Research on Cancer
The Botswana Experience
Scaling up cervical cancer control
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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
Implement proven cost-effective interventions
Effective tobacco control requires multisectoral policies and actions
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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.”
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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.
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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.
The 2011-2020 UN Decade of Action on
Road Safety: an entry point to deal with injuries
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Five categories or "pillars" of activities:
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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
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
A new role for Global Health Diplomacy
Collaboration and sharing of knowledge and experiences among countries
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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
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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
Thank you
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