According to the World Health Organisation (WHO), more than 36-million people die each year from non-communicable diseases (NCDs), and nearly 80% of these are from low- to middle-income countries (LMICs).⁽²⁾ In the age of globalisation and rapid urbanisation, NCDs, which have previously been considered diseases of the wealthy, are increasingly making their presence felt - even among the poorest of the world. It is projected that by 2020, 73% of all deaths worldwide will be due to NCDs and that the burden of disease due to NCDs will rise by more than 60% in LMICs.⁽³⁾ This rise in LMICs, as in the case of Africa (particularly Sub-Saharan Africa), is occurring against the backdrop of the existing burden of communicable diseases like HIV/AIDS, malaria and tuberculosis (TB).

This paper discusses the potential consequences of this double burden to the human and economic resources of Africa. An analysis of the level of response to the rising NCD epidemic by African governments and health systems is made. The extent of research and funding towards NCDs in Africa is explored and recommendations made for ways in which to stem the tide of NCDs.

The double burden of communicable and non-communicable diseases

Many African countries, together with other LMICs, are currently undergoing an epidemiological transition from predominantly infectious to non-communicable diseases.⁽⁴⁾ This change can be attributed to changes in lifestyle like diet, physical activity, smoking and drinking habits. It could also be due to the changing demographic profile of the population. The population pyramids of African countries are becoming more cylindrical, as opposed to cone-shaped.⁽⁵⁾ Current projections show that the largest increases in NCD deaths by 2020 will be in Africa.⁽⁶⁾ By 2030, the number of deaths due to NCDs in Africa is projected to exceed the combined deaths of communicable and nutritional diseases, and maternal and perinatal deaths.⁽⁷⁾

Despite the many gains made towards the prevention and control of communicable diseases in Africa, their prevalence in African countries still remains unacceptably high. As of 2011, there were 34 million people world-wide living with HIV, and 69% of these were in Sub-Saharan Africa (SSA).⁽⁸⁾ Close to 1 in every 20 adults in SSA are living with HIV.⁽⁹⁾ In 2011, 1.4 million people died from tuberculosis (TB) and about 95% of these deaths occurred in LMICs.⁽¹⁰⁾ With HIV-positive people being more susceptible to TB, combined, these diseases have resulted in many deaths over the years. In 2010 alone, malaria was responsible for no less than 660,000 deaths, a majority of which were among African children.⁽¹¹⁾

The interaction between communicable and non-communicable diseases is increasingly placing a burden on health care systems and individual health. For instance, there is evidence that both Type 1 and Type 2 diabetes predispose one to TB infection, and that co-occurrence of these leads to quicker progression of either disease and greater deterioration of the affected individual.⁽¹²⁾ Secondly, diabetes also predisposes patients to other infections that, in turn, exacerbate hyperglycaemia.⁽¹³⁾ Though the mechanism is as yet unknown, anti-retroviral therapy (ART) has been shown to induce a condition known as metabolic syndrome, which is a cluster of metabolic abnormalities such as glucose intolerance, insulin resistance and abdominal adiposity, and high blood pressure.⁽¹⁴⁾ ART has been hailed as life-saving for those infected with HIV and is widely available in many countries. As a result, people infected with HIV are able to lead long, healthy lives, though also at risk of contracting NCDs as a direct result of their status.⁽¹⁵⁾ Two of the NCDs occurring as a result of chronic communicable diseases are cervical cancer, which stems from human papilloma virus infection, and hepatoma, which is associated with hepatitis B infection.⁽¹⁶⁾

The double disease burden, as shown above, threatens to overwhelm an already over-taxed health system. Health services in Africa are typically under-resourced and the available resources are dedicated primarily to communicable diseases. NCDs remain largely unrecognised as significant by African health and government authorities; hence the direct and indirect effects thereof are not accounted for. Although health ministries acknowledge the burden and impact of NCDs, only a few African countries have put in place chronic disease plans or policies.⁽¹⁷⁾ Due to this seeming obliviousness to NCDs or failure to allocate resources towards their management, the real impact of the direct interaction of communicable and non-communicable diseases remains unknown.

Health systems’ response to NCDs in Africa

Health systems in Africa are largely unprepared to deal with NCDs, having previously been more geared towards communicable diseases.⁽¹⁸⁾ Historically, African health systems have developed in response to acute communicable diseases, with governments prioritising and allocating funds and training opportunities towards these conditions at the expense of NCDs.⁽¹⁹⁾ Approximately 80% of health budgets in the region have been directed towards communicable diseases in the last decade.⁽²⁰⁾ Many health facilities lack basic equipment for effective diagnosis and treatment of NCDs, while specialist NCD training and knowledge is poor among health workers.⁽²¹⁾ Furthermore, many people with NCDs do not report for health services, leading to an underestimation of the actual prevalence of these conditions. In turn, this affects the allocation of funds to NCDs by governments, as they are not fully aware of the scale and impact of NCDs. While health systems are being realigned to better deal with the dual disease burden, the chronic lack of trained personnel detracts from the goal.⁽²²⁾ Most countries also face inadequate health infrastructure. For instance, the Zimbabwean health care system, due to the political and economic unrest in the country, faces lack of equipment, shortage of skilled professionals and lack of essential medicines and commodities.⁽²³⁾ In contrast, South Africa has a large public health infrastructure, but the public sector receives only 40% of all health expenditure, although catering for 80% of the population.⁽²⁴⁾ The relative neglect of NCDs by African governments may further complicate the health outcomes of African populations. NCDs usually go unnoticed and undiagnosed, often resulting in health complications among the affected individuals. Cumulatively, these could have far-reaching, negative implications for African populations and their respective health systems.

The lack of policies and strategies for the control and management of NCDs is an important factor in NCD control and prevention in Africa.⁽²⁵⁾ NCDs are not viewed as development issues despite the fact that health and development go hand in hand - which is why three of the Millennium Development Goals (MDGs) specifically address health.⁽²⁶⁾ Even though they form part of the MDGs, the economic impact of NCDs remains unacknowledged and underestimated.⁽²⁷⁾ It is projected that the total global expenditure on NCDs will have reached nearly US$ 47 trillion by 2030.⁽²⁸⁾

There is a lack of political will to implement policies on the basis of current knowledge and guidelines, to realign government funding Many donor-funded programmes are targeted at specific diseases, thus discouraging a holistic view of NCD health risks in local populations.⁽²⁹⁾ In realisation of this tendency, Chukwuma argues for a move away from fragmented approaches towards population health and towards an appreciation of systemic interactions within health systems and holistic interventions.⁽³⁰⁾ The current level of health system response is clearly inadequate to handle the rising NCD epidemic as well as the communicable disease burden.

NCD research in Africa

The role of accurate data collection and monitoring of NCDs in LMICs cannot be underestimated. Any strategic or policy initiative needs to be underpinned by solid research. However, currently, many decision-makers do not have up-to-date evidence on the actual burden of NCDs due to the scarcity of research geared towards these diseases.⁽³¹⁾

Significant developments have, nonetheless, been made in the past decade towards improving the profile of health research in Africa. These include the Abuja Declaration and Plan of Action from the African Summit on Roll Back Malaria in 2000, where concern for both interventions and research for health in Africa was raised; and the Joint European Union (EU)-Africa Strategy, adopted at the Lisbon EU-Africa Summit in 2007, which includes thematic partnerships for Science, Information Society and Space.⁽³²⁾ The Global Ministerial Forum on Research for Health held in Bamako, Mali, in 2008, also reiterated the importance of health research in Africa and, more specifically, research on NCDs.⁽³³⁾ Despite these efforts, NCDs and NCD research remain in the background in many countries, with most resources being channelled towards infectious diseases. Nonetheless, there are a number of favourable developments aimed at facilitating focus on NCDs globally. These include the provision of healthcare to affected individuals, prevention strategies and research into interventions. Key to this has been the establishment of the WHO Global Strategy for the Prevention and Control of Non-communicable Diseases (NCD Action Plan).⁽³⁴⁾ The action plan was designed to provide the United Nations member states, the WHO and the international community with a roadmap to establish and strengthen initiatives for the surveillance, prevention and management of NCDs.⁽³⁵⁾ The Plan also highlights the pressing need to invest in NCD prevention as an integral part of sustainable socioeconomic development.⁽³⁶⁾

A joint collaboration between WHO, the World Bank and three other international organisations has seen the establishment of a global NCD network (NCDnet).⁽³⁷⁾ The mission of the NCDnet is to provide support to LMICs in implementing the NCD Action Plan by coordinating responses among donors, philanthropic organisations, United Nations (UN) agencies, intergovernmental organisations, international nongovernmental organisations, media and the private sector.⁽³⁸⁾ Its primary goals are:

• To increase focus on NCD prevention and control;
• To increase financial and human resource availability;
• To facilitate multi-stakeholder global and regional action, while emphasising country-level implementation of the plan.⁽³⁹⁾

The way forward

The six objectives enjoined in the WHO NCD Action Plan summarise the priorities to be addressed by all governments in turning the tide on NCDs. These objectives are:

• To raise the priority accorded to NCDs in development work at global and national levels, and to integrate the prevention and control of such diseases into policies across all government departments.⁽⁴⁰⁾
• To establish and strengthen national policies and plans for the prevention and control of NCDs.⁽⁴¹⁾
• To promote interventions to reduce the main shared modifiable risk factors for NCDs: tobacco use, unhealthy diets, physical activity and harmful use of alcohol.⁽⁴²⁾
• To promote research for the prevention and control of non-communicable diseases.⁽⁴³⁾
• To promote partnerships for the prevention and control of NCDs.⁽⁴⁴⁾
• To monitor NCDs and their determinants and evaluate progress at the national, regional and global levels.⁽⁴⁵⁾

Response to the NCD epidemic needs to be both at the global and national levels. Developmental, control and prevention goals, such as the MDGs and the NCD Action Plan, are formulated at a global level and implemented at national level. This ensures a more concerted effort and greater opportunity for collaboration. Existing knowledge and lessons learnt from dealing with infectious disease epidemics should be fully utilised to map the way forward. High-level commitment and concrete action, which are often missing, are required to achieve the goals as set out in the NCD Action Plan.⁽⁴⁶⁾

Conclusion

There is sufficient evidence pointing towards NCDs as a significant public health concern in Africa. Despite the scarcity of NCD research in African countries, mortality and morbidity data show that this burden is increasing at unprecedented rates. The fact that the communicable disease burden is not being reversed as fast as is required means that Africa now faces a dual burden of disease. The WHO strategy paper on NCD prevention and control has been in existence for almost five years now, yet SSA countries have not been able to turn the tide on NCDs. This is despite the fact that the framework covers all the areas that need to be addressed; what is now needed is the political will among leaders in SSA to put it into practice.

Written by Mercy Manyema ⁽¹⁾

NOTES:

(1) Contact Mercy Manyema through Consultancy Africa Intelligence’s Public Health Unit ( public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) ‘Non-communicable diseases: Media centre fact sheets’, World Health Organization, September 2011, http://www.who.int.
(3) Mufunda, J., et al., 2006. Emerging non-communicable disease epidemic in Africa: Preventive measures from the WHO Regional Office for Africa. Ethnicity and Disease,16, pp. 521-526.
(4) Dhalal, S., et al., 2011. Non-communicable diseases in Sub-Saharan Africa: What we know now. International Journal of Epidemiology,40, pp. 885-901.
(5) Ibid.
(6) ‘Noncommunicable diseases: Fact sheets’, World Health Organization, September 2011, http://www.who.int.
(7) Ibid.
(8) ‘HIV/AIDS: Factsheet No 360’, World Health Organization, November 2012, http://www.who.int.
(9) Ibid.
(10) Maher, D., et al., 2010. Health transition of Africa: Practical policy proposals for primary care. Bulletin of the World Health Organisation,88, pp. 943-948.
(11) ‘Tuberculosis: Factsheet no. 104’, World Health Organisation, October 2012, http://www.who.int.
(12) Young, F., 2009. A review of co-morbidity between infectious and chronic disease in Sub Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome, and the impact of globalisation. Globalisation and Health, 5(9), http://www.globalizationandhealth.com.
(13) Maher, D., et al., 2010. Health transition of Africa: Practical policy proposals for primary care. Bulletin of the World Health Organisation, 88, pp. 943-948.
(14) Young, F., 2009. A review of co-morbidity between infectious and chronic disease in Sub Saharan Africa: TB and diabetes mellitus, HIV and metabolic syndrome, and the impact of globalisation. Globalization and Health, 5(9), http://www.globalizationandhealth.com.
(15) ‘Women, HIV, and non-communicable diseases: Making the links and moving to action’, Task Force, http://www.womenandncds.org.
(16) Maher, D., et al., 2010. Health transition of Africa: Practical policy proposals for primary care. Bulletin of the World Health Organisation, 88, pp. 943-948.
(17) De-Graft Aikins, A., et al., 2010. Tackling Africa’s chronic disease burden: From the local to the global. Globalization and Health,6(5), http://www.globalizationandhealth.com.
(18) Kengne, P.A., et al., 2009. Setting-up nurse-led pilot clinics for the management of non-communicable diseases at primary health care level in resource-limited settings of Africa. Pan African Medical Journal,3(10), pp.180-190.
(19) De-Graft Aikins, A., et al., 2010. Tackling Africa’s chronic disease burden: From the local to the global. Globalization and Health,6(5),  http://www.globalizationandhealth.com.
(20) Ibid.
(21) Ibid.
(22) Ibid.
(23) ‘Health in Zimbabwe’, Zimbabwe Network for Health - Europe, 2012, http://zimhealth.org.
(24) ‘Health care in South Africa’, SouthAfrica.info, July 2012, http://www.southafrica.info.
(25) ‘Non communicable disease prevention and control’, World Health Organisation Programmes, http://www.afro.who.int.
(26) ‘The Millennium Development Goals and non-communicable diseases’, The NCD Alliance, http://www.ncdalliance.org.
(27) ‘Non communicable disease prevention and control’, World Health Organisation Programmes, http://www.afro.who.int.
(28) ‘The global economic burden of non-communicable diseases’, World Economic Forum and Harvard School of Public Health, 2011, http://www3.weforum.org.
(29) Nugent, R. A. and Feigl, A.B., ‘Where have all the donors gone? Scarce donor funding for
non-communicable diseases,’ Centre for Global Development Working Paper 228,2010, http://www.cgdev.org.
(30) Chukwuma, A., ‘From silos to systems: Dealing with population health challenges in the world today’, CAI, 16 January 2013, http://www.consultancyafrica.com.
(31) Yach, D., et al., 2004. The global burden of chronic diseases: Overcoming impediments to prevention and control. Journal of the American Medical Association, 291(21), pp. 2616-2622.
(32) MacCarthy, M., et al., 2010. Developing the agenda for European Union collaboration on non-communicable diseases research in Sub-Saharan Africa. Health Research Policy and Systems, 8(13), http://www.health-policy-systems.com.
(33) Ibid.
(34) ‘2008-2013 Action plan for the global strategy for the prevention and control of non-communicable diseases’, World Health Organization, 2008, http://www.who.int.
(35) Ibid.
(36) Ibid.
(37) ‘Report on the progress made in implementing the 2008-2013 action plan for the global strategy for the prevention and control of non-communicable diseases (June 2008 - February 2010)’, World Health Organisation, 2008, http://www.who.int.
(38) ‘The mission, goals and objectives of the NCDnet’, World Health Organisation, 2013, http://www.who.int.
(39) Ibid.
(40) ‘2008-2013 Action Plan for the global strategy for the prevention and control of non-communicable diseases’, World Health Organization, 2008, http://www.who.int.
(41) Ibid.
(42) Ibid.
(43) Ibid.
(44) Ibid.
(45) Ibid.
(46) Ibid.