Most countries in Sub-Saharan Africa (SSA) are presently going through an epidemiological transition with the rising burden of non-communicable diseases (NCDs), in addition to the huge disease burden from poorly controlled communicable diseases and childhood illnesses.1

Karadon: Most countries in Sub-Saharan Africa (SSA) are presently going through an epidemiological transition with the rising burden of non-communicable diseases

Globally, death and disability from NCDs are rising fastest in SSA and it was projected in 2011 that the rise in NCDs will outpace reduction in communicable diseases leading to a double burden of disease, which we see today.2

NCDs lead to 41 million deaths annually, accounting for 76% of global mortality. About 15 million of the deaths will occur prematurely (between the ages of 35-69 years) and 85% of these deaths will occur in low- and middle-income countries (LMICs).3

A clear relationship is evident between premature NCD mortality and country income levels. In 2016, 78% of all NCD deaths and 85% of premature adult NCD deaths, occurred in LMICs. Adults in LMICs face the highest risk of dying from an NCD. In 2016, the World Health Organization (WHO) estimates of NCDs accounting for all deaths by country, were 27% in Kenya, 29% in Nigeria, 37% in Cote d’Ivoire, 35% in Cameroon, 42% in Senegal and 51% in South Africa.3

The rise in NCDs has been attributed to the increase in risk factors such as an ageing population, adoption of unhealthy western diets, increasing prevalence of hypertension, smoking, obesity, physical inactivity, and alcohol consumption.

Increasing urbanisation with rural to urban migration and the attendant stress of slum-dwelling also plays a part. Studies have shown an increasing burden of cardiovascular disease (CVD), diabetes, chronic respiratory diseases, cancers, and an increase in mental health disorders.4,5

The majority of the NCD deaths in 2018 are related to CVDs accounting for 17.9 million deaths annually, followed by cancers (9 million), respiratory diseases (3.9million) and diabetes (1.6 million) and these account for 80% of the premature deaths.3

At the beginning of the last century, CVDs were responsible for fewer than 10% of all deaths worldwide. Today, there is a striking difference with the figure approximately 30%.6

Some 86% of the burden now occurs in developing countries and more than 50% occurs in those under 70 years of age.7 This has placed an added strain on the fragile health care systems and infrastructure in most countries on the African continent.

Cardiovascular disease burden in SSA

Africa is home to more than one billion people and is one of the major contributors to the global burden of CVD.8 In 2013, nearly one million deaths were attributable to CVD in SSA, constituting 38.3% of non-communicable disease deaths and 11.3% of deaths from all causes in the region.9

SSA contributed 5.5% of global CVD deaths. This accounts for an almost two-fold increase (81%) in the number of CVD related deaths since 1990, from 529 880 deaths in 1990 to 958 713 deaths in 2003 (95% uncertainty intervals [UI]).9

There were more deaths due to CVDs in women (512 269) than in men (445 445) and more deaths from stroke (409 840) than ischaemic heart disease (258 939). Deaths for all components of CVDs also increased.9

Given the overwhelming burden of non-cardiac-related infectious diseases (including malaria and the broader epidemic of HIV/AIDS), CVDs are often overlooked as a matter of health importance. Some urban communities in SSA are characterised by the increase of chronic diseases and the emergence of diseases closely related to hypertension.10

The prevalence pattern of the CVDs is distinctly different in SSA compared with the rest of the world: infectious and inflammatory causes are relatively more common and atherosclerosis relatively less common.8

As parts of SSA urbanise and life expectancy increases, a larger share of the population may develop higher CVD rates, along with the persistence of the lower CVD rates in poorer rural areas.8

In SSA, the epidemiology of CVD may differ across certain groups of the population. Different exposure to known and unknown risk factors, unhealthy lifestyles (prevalence of smoking, obesity, and alcohol consumption) and access to healthcare and environmental conditions, including traditional customs could be the main reasons.10, 11

From a regional perspective, some contrast among regions in Africa may exist and the epidemiology of CVD could therefore differ. Historically the lipid profiles of African individuals were considered largely favourable, reflecting traditional lifestyles that include high levels of physical activity and diets low in fat, which resulted in low rates of atherosclerotic disease.10

Diabetes

Diabetes is one of the most common NCDs globally. It is the fourth or fifth leading cause of death in most high-income countries and there is substantial evidence that it is epidemic in many economically developing and newly industrialised countries. About 77% of people with diabetes live in LMICs.12

This in itself is very likely underestimated, as the majority of cases may go undiagnosed since many patients are unaware that they may have diabetes. Genetics, some environmental factors and viral infections have been shown to increase the risk of type 1 diabetes. Type 2 diabetes risk factors due to an increased western lifestyle in SSA include, but are not limited to: family history of diabetes, being overweight, unhealthy diet, physical inactivity, ageing, and poor nutrition during pregnancy.12

Despite national guidelines, protocols and treatment algorithms being available in many countries, they are still not effectively implemented in all countries across SSA. Without effective prevention and management programmes, the number of people with diabetes globally is expected to rise from 387 million people in 2014 to 592 million people by 2035.12

Inadequate primary healthcare and inadequate availability of oral anti-diabetic medication and insulin result in poor control and inevitable complications, both microvascular and microvascular.

Respiratory diseases

Chronic respiratory diseases pose a major public health problem, with an estimated 3.91 million deaths in 2017, accounting for 7% of all deaths worldwide. Between 1990 and 2017, the total number of deaths due to chronic respiratory diseases increased by 18.0%, from 3.32 million in 1990 to 3.91 million in 2017.13

The contribution of risk factors including smoking, environmental pollution and a high body mass index to mortality and disability-adjusted life-years supports the need for urgent efforts to reduce exposure to risk factors. Regions with a low socio-demographic index were found to have the greatest burden of disease.13

In 2017, 21 600 deaths were due to pneumoconiosis. The age-standardised mortality rate of pneumoconiosis varied with the highest being from 1.76 per 100 000 people in Papua New Guinea to the lowest in Moldova of 0.0041 per 100 000 people. African countries such as Swaziland, Lesotho, Madagascar, Central African Republic, Somalia, and South Africa had an age-standardised mortality rate of pneumoconiosis above 0.5 per 100 000 people.13

Cancer

Cancer is the second leading cause of death globally, accounting for an estimated 9.6 million deaths or one in six deaths in 2018, with approximately 70% of deaths occurring in LIMCs.14

Lung, prostate, colorectal, stomach and liver cancer are the most common types of cancer in men, while breast, colorectal, lung, cervical and thyroid cancer are the most common types of cancer in women.14

The cancer burden continues to grow globally, exerting tremendous physical, emotional and financial strain on individuals, families, communities and health systems.14

Large numbers of cancer patients globally do not have access to timely quality diagnosis and treatment. Many health systems in LMICs are least prepared to manage this burden.14

Late-stage presentation and inaccessible diagnosis and treatment are common. In 2017, only 26% of low-income countries reported having pathology services generally available in the public sector. Less than 30% of low-income countries reported availability of treatment services compared to 90% in high-income countries.14

In countries where health systems are strong, survival rates of many types of cancers are improving due to accessible early detection, quality treatment and survivorship care. That being said, only one in five LMICs have the necessary data to drive cancer policy.14

In 2018, the cancer incidence and mortality statistics across Africa as per the Globocan data showed that the incidence of cancer in both sexes had the highest new cases in Eastern Africa (332 177), followed by Northern Africa (283 219), Western Africa (229 459), Southern Africa (114 582) and Middle Africa (95 735).15

The number of deaths across Africa in 2018 was highest in Eastern Africa (230 968), followed by Northern Africa (178 754), Western Africa (153 332), Middle Africa (68 763) and Southern Africa (61 670).15

Mental health

Mental health and wellbeing are central to reducing the global burden of NCDs, as emphasised by the WHO’s mental health action plan for 2013-2020. Diabetes, CVD, cancer and respiratory diseases commonly co-occur with both common mental disorders such as depression and anxiety disorders and severe mental illnesses such as schizophrenia and bipolar disorder.16

Epidemiological studies have found significant associations within and across countries between CVD and common mental disorders. In the World Mental Health Surveys, odds ratios for the association of heart disease with mental disorders were 2.1 for mood disorders, 2.2 for anxiety disorders and 1.4 for alcohol misuse or dependence across countries.16

A dose-response association was seen between the increasing number of mental disorders and heart disease and there were strong associations between early-onset common mental disorders and adult-onset heart disease, as well as between early childhood adversities and adult-onset heart disease.16

Although mental disorders are associated with greater disability than physical conditions, they are less likely to receive treatment across the globe. This may partly reflect higher levels of stigmatisation experienced by those with mental disorders compared with people with physical conditions. Risk factors for NCDs such as tobacco use, unhealthy diet, physical inactivity, and harmful alcohol use commonly cluster in people with mental disorders, where they may have multiplicative effects.16

Challenges

While there has been profound progress made in the health of populations over the last three decades, (including in SSA with improved life expectancy), the rise of NCDs threatens to reverse these gains and stall social and economic developments.17

While the evidence is consistent on the growing health and economic consequences of NCDs in SSA, specific efforts aimed at addressing NCD prevention and control remain less than optimum and country-level progress of implementing evidence-backed cost-effective NCD prevention approaches such as tobacco taxation and restrictions on marketing of unhealthy food and drinks is slow.17

Similarly, increasing interest to employ multi-sectoral approaches (MSA) in NCD prevention and policy is impeded by policymaker inertia, as well as limited knowledge on the mechanisms of MSA application in NCD prevention, their co-ordination, and potential successes in SSA.17

In 2001, African Union (AU) heads of state pledged to allocate at least 15% of annual expenditure to health under the Abuja Declaration. As of 2014, most countries are below the Abuja AU Declaration. Government health prioritisation does not seem to be associated with national income or level of government revenues in the African region.18

Higher per capita income countries such as Algeria, Botswana, Equatorial Guinea, Gabon, Mauritius, Seychelles, and South Africa (above US$10 000 per capita PPP) do not systemically give higher priority to health in their public spending.18

In contrast, a few lower-income countries including Ethiopia, Gambia, and Malawi and Swaziland allocate more than 15% of their public spending to the health sector, as can be seen in Figure 1.18

When states become richer, public spending on health as a proportion of total public expenditure does not systematically increase, and in most cases, public expenditure on health is not responsive to increased state revenues, as should be the case.18

Figure 1: Government health prioritisation and GDP per capita, 201418

Donor funding for health is still important in many LMICs, with 20 LMICs in SSA relying on donor funding for more than one-fifth of their health spending.19

Most of these funds, however, are targeted at mitigating communicable disease, maternal and infant mortality thereby deepening the neglect of NCDs in these countries.20

Poor health insurance coverage has led to catastrophic spending for healthcare in many SSA countries and the rubrics of assessing health care delivery using under-five and maternal mortality has also contributed to the neglect of NCDs. The poor health insurance coverage and out-of-pocket payment for health services have resulted in late presentations and poor outcomes associated with NCDs.20

The menace of poor quality and counterfeit drugs constitutes another major issue for public health in SSA.21 As a consequence of this, treatment failures may adversely affect patient treatment outcome.22 More research is needed in this area to institute measures to fight against those counterfeiting drugs.23

The Covid-19 pandemic, which started in December 2019, is associated with more severe disease, higher morbidity, and mortality in patients with underlying CVD and CVD risk factors.24-27

Mortality, though low (2%-3%) in the general population, rises to 10% in patients with underlying CVDs.27 Hypertension and diabetes are the most common CV risk factors seen in patients with severe disease.28,29

Outcomes in Covid-19 have been shown to be worse in patients with underlying CVD or CV risk factors and people living with NCDs are at higher risk of severe Covid-19-related illness and death.30

The outcomes will probably be worse in SSA because of the rising burden of NCDs and low levels of optimal management due to both personal and systemic problems in the healthcare delivery system. This was especially evident in South Africa, which had the highest number of Covid-19 infections in Africa.31

Patients with co-morbidities suffered worse outcomes and higher mortality rates. The influence of the high burden of communicable diseases like TB and HIV on CVD in LMICs requires further research. An awareness of the problems due to the associations seen between chronic and infectious disease in SSA should be top of mind in order to manage patients more efficiently, in light of Covid-19 and CVD on the continent.31

Most countries in SSA have very fragile health systems struggling to cope with the double burden of disease, both communicable and rising NCDs. According to the WHO, prevention and treatment services for NCDs have been severely disrupted since the Covid-19 pandemic began.30 The additional burden of the Covid-19 could lead to the total collapse of the systems.

The Covid-19 pandemic has also caused health services in many countries to be either partially or completely disrupted with regards to hypertension treatment, treatment for diabetes and diabetes-related complications, cancer treatment and CV emergencies.30

The postponement of public screening programmes such as breast and cervical cancer is also widespread. Unsurprisingly, there appears to be a correlation between levels of disruption to services for treating NCDs and the evolution of the Covid-19 outbreak in a country.30

Poor infrastructure, as well as undertrained and poorly motivated personnel together with a shortage of staff, exist at many of the primary health centres across SSA. These primary health centres lack the basic infrastructure to deal with NCDs.

The lack of properly functioning sphygmomanometers, glucometers, weighing scales and strips for urinalysis is a reality here. These, together with a lack of models for chronic care, has led to secondary and tertiary centres, which in many countries may be centres of excellence, being inundated with the burden of routine follow-up for NCDs. The non-availability and often high cost of medicines and investigations for NCD, is also a challenge in SSA.

Research priorities

Research on NCDs in Africa has been limited to predominantly small case series in addition to population studies, mainly on risk factors. A number of epidemiologic studies have been done in the recent past, mainly from hospitalised patients.32

Higher-level research including cohort studies, randomized controlled trials and implementation science lags behind. Despite the rising prevalence of CVD in SSA, the lack of research constitutes a significant challenge for the countries in the region. Worldwide scientific publishing activity over the past decade indicates that most countries in SSA have very low levels of publication.32

In 2004, 31 of the world’s 193 countries produced 97.5% of the world’s most cited papers. South Africa, at number 29, was the only SSA country on this list.33

There has however been a significant improvement in health research in the WHO African Region since 2000. The per cent share of first authors from Africa contributing to worldwide research publications per year increased from 0.7% in 2000, to 1.3% in 2014, with South Africa, Nigeria and Kenya contributing to 52% of the publications.34

In a recent paper, Ettarth showed that the number of publications involving multiple SSA countries accounts for less than 10% of the total number of multi-country publications that included at least one SSA country, with a low level of collaboration between French-speaking and English speaking countries in the region.35

Primordial prevention, early detection and appropriate treatment are key components of the response to NCDs. To alter the trajectory of NCD epidemiology, research must be one of the main goals in order to fill the important knowledge gap. This will provide thorough and reliable data on the magnitude of the disability burden of NCDs in SSA.36

Important efforts are needed to curb the burden of NCDs in the region, starting with the provision of reliable epidemiological estimates of NCDs and their drivers in order to appropriately inform prevention and control strategies.36

Such efforts will aid in informing national health systems on how to design and implement effective interventions for specific NCDs and prioritise the resources required by countries.36

Opportunities

The Covid-19 pandemic is a wake-up call for governments in SSA to re-strategise and retools healthcare policies and delivery systems using a more holistic (including NCD prevention and care) people-centric approach that is indigenous in collaboration with the other sectors that impact the health of the population.37,38

There is also an opportunity for health systems analysis to evaluate the best ways of integrating NCD care into primary health care that already has established pathways for communicable diseases. This would require some basic equipment like functioning sphygmomanometers, weighing scales, glucometers and urinalysis strips. These basic tools will ensure adequate follow-up at the primary care level without the patients travelling long distances to the tertiary or secondary centres.38,39

Another advantage will be the reduction in the cost of transportation, which is a major part of the cost of care in SSA. Policy proposal that has been advocated to improve the primary care response will include improving data on communicable diseases and NCDs, implementing a structured approach to improved primary care delivery and ensuring the quality of clinical care, aligning the response to health transition with health system strengthening.38,39

Proper integration of services at the primary care level leveraging on lessons learnt from the management of HIV would reduce cost and redundancy in delivering care for patients with NCDs.40,41

This is also an opportunity for up-skilling personnel at the primary care level and community health workers. Continuous professional development using online training and leveraging the available technologies will reduce the cost of up-skilling the health workers in rural areas.42

Development of standard operating procedures (SOPs), charts, algorithms for screening, simple treatment guidelines, follow-up, referral and teleconsulting facilities so that specialists can assist the rural healthcare workers with the evaluation of difficult cases, will enable safe task shifting and sharing.42

The high cost of medicines and medical equipment could be better managed through waivers on import duties for medication and medical equipment. There should be a concerted effort towards local and/or regional production of essential medicines for NCDs, making use of harmonisation of drug approvals available in the region, as well as improved supply chain management.

This has become more crucial with the experience of disruption in drug shipment and supplies during the Covid-19 pandemic and border closures. In addition, local production of some of the basic medications for NDCs will reduce the cost of prescriptions and improve uptake and adherence.

There is also the added advantage of economic growth and employment opportunities in these countries. This will reduce the cost of these essential elements in the management of CVDs in the SSA region. Where this is not feasible, there should be some subsidy for medications used to treat NCDs.

Some governments in SSA have begun taking action to reduce the rise in risk factors by implementing policies such as the taxation of tobacco, alcohol and unhealthy food items. This could be more broadly implemented across the region.

Health systems can support people by providing universal healthcare and mental health services, screening services, brief interventions targeting NCD risk factors in primary care and access to affordable drugs for the prevention and control of NCDs.

This will ultimately be beneficial to the general population, more so during the Covid-19 pandemic where many people are facing unemployment, career/financial stressors, low social engagement, divorce or poor emotional resilience.43

The challenges and opportunities in the management of NCDs in SSA are summarised in Table 1.

Table 1: Summary of challenges and opportunities

Recommendations

There are multiple factors accounting for the rapid rise in NCDs across SSA. The answer to the increase in NCDs is multi-faceted and must include education and awareness as well as effective interventions and research. Money must be spent wisely and the best impact of these campaigns must be assessed.

Governments should assume a holistic view of health and strengthen inter-sectoral collaboration between ministries of health, agriculture, housing, education and urban development. These different aspect impact health and healthcare delivery both directly and indirectly.

It is time for our governments to honour their commitments to achieve universal health coverage by increasing insurance coverage for the general population, whilst ensuring that coherent NCD policies are available at a national level.

Health systems can support patients by providing universal healthcare and mental health services, screening services, brief interventions targeting NCD risk factors in primary care and access to affordable drugs for the prevention and control of NCDs.43

There needs to be increased budgetary allocation to health with goal-oriented and integrated spending to improve the health care delivery system addressing both the communicable and NCDs.44

The departments of health in SSA countries need to understand the challenge of the NCDs on the fiscus and how this will continue to escalate if appropriate primary care interventions and management are not instituted timeously. This will cost much more if preventative care is not effective.

The major NCDs (CVD, diabetes, chronic respiratory diseases, cancer and mental disorders) are often associated with older age groups, but the evidence suggests that they affect people of all ages.43

The government’s NCD preventive policies should also address the youth and adolescents so that the risk factors are tackled early, timely and in an appropriate manner. This is important because 15 million deaths attributable to NCDs occur between the ages of 30- and 69 years. Taking early, appropriate, timely and collective action is important if we are to reduce premature mortality related to NCDs by a third by 2030.43

NCDs are set to overtake communicable, maternal, neonatal and nutritional diseases as the leading cause of disability and mortality in the region over the next decade. Policymakers must recognise that the inability to control NCDs is a major barrier to the attainment of Sustainable Development Goals 1, 2 and 3.36

Conclusion

NCDs are a major contributor to disability and mortality in the SSA region. Precise, swift action is needed from a public health perspective on prevention and treatment modalities.  This is possible through multi-sectoral approaches, the collaboration of governments, departments of health, medical societies, academia, private sector and civil societies in order to address the burden of disease. 

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The scientific writer is Kiasha Naicker of Karadon (Pty) Ltd.  The scientific writer was sponsored by Pfizer Laboratories (Pty) Ltd.