79293 The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa AN OVERVIEW Patricio V. Marquez Jill L. Farrington WORLD BANK REPORT NUMBER: 79293 SUGGESTED CITATION: Marquez, P. V., Farrington, J. L. (2013) “The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa. An Overview�. Washington, DC.: The World Bank. ON THE COVER: Ntando Futhela, Sokuqala st., Khayamandi, Stellenbosch, South Africa, 2010 / 04 / 15, 18:23 ‘I was 12 years when I got this bicycle. I’m now 16. I like riding my bike. I ride to Koelenhof, I live there. And I go to school on this bike every day. I have no brakes. I stop with my foot.’ FROM: “Bicycle Portraits� by Stan Engelbrecht and Nic Grobler, Cape Town, South Africa. CONTACT EMAIL ADDRESS: info@bicycleportraits.co.za WEBSITE: http://www.bicycleportraits.co.za/ ABOUT: “Bicycle Portraits is a photographic study of South Africans who rely on their bicycles every day, revealing who rides, why they ride, and of course why so few South Africans choose the bicycle as a primary mode of transport. With more than 500 portraits compiled over three years and 10,000 cycled kilometers, the project cul- minates in three published volumes as a portrait of a nation through it’s commuter subculture – uncovering all manner of societal, historical and cultural nuances never imagined. Bicycle Portraits celebrates the noblest ma- chines ever dreamt up, and those who ride them. Stan Engelbrecht and Nic Grobler cycled everywhere to meet the bold individuals photographed for this project – people who choose to ride a bicycle in the face of cultural and social stigma, crime and dangerous roads ... They did not photograph people who ride purely for exercise or recreation, but instead searched for those who use bicycles as an integral tool in their day-to-day existence. They learnt that in South Africa, especially in the cities, very few people use bicycles to get around. It became clear that as major centers develop, there is still a trend to structure cities for cars, not people.� Acknowledgement Special contribution to the production of the report was made by Ms. Jessica Morgan, who designed the cover of the report, and Ms. Chandrani Raysarkar, who coordinated the overall design and printing of the report. THE CHALLENGE OF NON-COMMUNICABLE DISEASES AND ROAD TRAFFIC INJURIES IN SUB-SAHARAN AFRICA: AN OVERVIEW Patricio V. Marquez and Jill L. Farrington with inputs Huihui Wang, Sheila Dutta, and Alberto Gonima June 2013 A Working Paper Africa Human Development Sector Unit The World Bank ABSTRACT This report draws on a comprehensive review of the place communicable diseases as priorities. Instead, literature and on input from policy makers, research- given resource constraints, and some shared deter- ers, and practitioners to address four questions: (1) minants, characteristics, and interventions, there is How is the growing burden of non-communica- scope for an integrated approach focusing on func- ble diseases (NCDs) and road traffic injuries (RTIs) tions (prevention, treatment, and care) rather than changing the epidemiology of Sub-Saharan Africa? on disease categories. Examples are cited of potential (2) What determines and drives this burden, and opportunities to integrate and add NCD prevention what are the commonalities with communicable dis- and treatment into existing services and programs. eases? (3) What is the rationale for public interven- Proven, cost-effective, prevention interventions are tion? (4) How could resource-constrained govern- clearly needed, many of which (such as tobacco and ments approach NCD prevention and treatment and alcohol taxes, road safety measures, and fuel-efficient road safety in a comprehensive, effective and efficient ventilated cookstoves) require action beyond the way? The data show that action against NCDs and health sector. These can deliver broader development RTIs in Sub-Saharan Africa is needed, together with benefits in addition to their benefits for health. Se- continued efforts to address communicable diseases lective, evidence-based actions to reduce NCDs and and maternal and child health as well as to reach the RTIs would address the changing disease burden in Millennium Development Goals (MDGs). The re- Africa and achieve a more sustainable improvement port suggests that NCDs/RTIs should not be tackled in health outcomes, more efficient use of resources, separately as a vertical program, nor should they dis- and better equity across patients and populations. iii TABLE OF CONTENTS Abstract........................................................................................................................................................................iii Table of Contents......................................................................................................................................................... v List of Figures.............................................................................................................................................................. vi List of Tables...............................................................................................................................................................vii List of Boxes...............................................................................................................................................................vii Acknowledgements.................................................................................................................................................... ix List of Acronyms......................................................................................................................................................... xi Executive Summary.................................................................................................................................................... 1 1. Introduction............................................................................................................................................................. 7 The Nature of the Problem and Rationale for the Report................................................................................ 7 2. Burden of NCDs and RTIs................................................................................................................................... 11 2.1. A Health Perspective.................................................................................................................................... 11 2.2. Economic and Social Development Consequences ............................................................................... 19 3. The Drivers and Determinants of NCDs............................................................................................................ 21 3.1. NCD Risk Factors......................................................................................................................................... 21 3.2. Drivers of NCD Trends............................................................................................................................... 25 3.3. Socio-Economic Determinants and Distributions.................................................................................. 27 3.4. Commonalities between NCDs and Other Disease Groups.................................................................. 29 4. The Rationale for Public Intervention ............................................................................................................... 31 4.1. Economic Rationale .................................................................................................................................... 31 4.2. Human Capital Rationale............................................................................................................................ 33 4.3. Development Rationale............................................................................................................................... 34 5. A Comprehensive, Integrated Approach to NCDs and Road Safety ............................................................. 35 5.1. Policy Approach........................................................................................................................................... 35 5.2. Population-Level Prevention...................................................................................................................... 37 5.3. Clinical Services for Individual-level Prevention.................................................................................... 46 5.4. Therapies – Treatment, Care, and Rehabilitation.................................................................................... 48 5.5. Strengthening Health Systems.................................................................................................................... 50 5.6. Addressing Information and Research Gaps............................................................................................ 66 5.7 Role of Public and Private Employers and Businesses ............................................................................ 69 6. Conclusion............................................................................................................................................................. 71 References................................................................................................................................................................... 73 Map IBRD 39854...................................................................................................................................................... 91 v List of Figures Figure 1: Proportion of Deaths by Cause in SSA, 2010.................................................................................... 11 Figure 2: Projected Burden of Disease (percentage of Total DALYs) by Groups of Disorders and Conditions, SSA, 2008 and 2030............................................................. 12 Figure 3: Age-Standardized Mortality Rates by Cause, WHO Regions, 2008................................................ 14 Figure 4: Proportion of Deaths by Age Group (Years) in SSA, 2010............................................................... 14 Figure 5: Epidemiological Transition for CVD in Developing Countries...................................................... 15 Figure 6: ASMR by Cause in Countries of SSA, 2008....................................................................................... 15 Figure 7: ASMR by NCD Cause, WHO Regions, 2008..................................................................................... 17 Figure 8: Distribution of Road Traffic Deaths by Type of Road User in SSA Countries.............................. 19 Figure 9: Projected Disease Burden (DALYs) in SSA for Children Aged 5-15 Years, 2008-2030............... 19 Figure 10: The Double Burden of Under-Nutrition and Overweight in SSA: Share of Recent Mothers Who are Underweight or Overweight (Most Recent Data Available Since 2000)......... 23 Figure 11: Current Use of Tobacco Products among African Youth, 13-15 Years, 2005-2010...................... 24 Figure 12: Population of SSA, 2010........................................................................................................................ 26 Figure 13: Projected Age-Specific Increase in Male and Female Populations in SSA, 2010 to 2030 ............ 27 Figure 14: Conceptual Framework for Understanding Health Inequities, Pathways and Entry Points....... 28 Figure 15: The Safe System Model for Road Safety.............................................................................................. 42 Figure 16: General Availability of Cancer Therapies in the Public Health System in SSA............................. 49 Figure 17: Availability of NCD Medicines in the Public Health System in SSA.............................................. 54 Figure 18: WHO Model of Primary Care and its Place within a Larger Network........................................... 57 Figure 19: Innovative Care for Chronic Conditions Framework....................................................................... 59 Figure 20: Units of Care for Endemic NCDs in Rural Rwanda.......................................................................... 60 Figure 21: Approach to Chronic Care at Primary Care and District-Level Facilities for HIV/AIDS, Relevant for Managing Other Diseases and Conditions............................................. 61 Figure 22: Systemic Use of Data for Road Safety Planning, Monitoring, and Evaluation.............................. 68 vi List of Tables Table 1: Top 15 Leading Causes of YLL in Each Region of SSA, 2010.......................................................... 13 Table 2: ASMR by Cause and Country for SSA, 2008..................................................................................... 16 Table 3: Common Cancers in SSA: Infectious and Other Risk Factors........................................................ 17 Table 4: Top 15 Risk Factors Ranked by Attributable Burden of Disease for SSA Regions, 2010............. 22 Table 5: Prevalence of Weekly Heavy Drinking Episodes among Drinkers in the Past 12 Months by Sex – WHO Region and the World, 2005............................................... 25 Table 6: Examples of NCDs Linked to Conditions of Poverty*...................................................................... 29 Table 7: ODA Funding for Health and Disease Areas per 2008 DALY......................................................... 34 Table 8: Principles to Guide Action on NCDs and RTIs................................................................................. 36 Table 9: Population-Level Priority Interventions for NCDs Relevant to SSA (by Incremental Cost-Effectiveness)................................................................................................... 38 Table 10: Components of a Community-Based Program for NCD Prevention............................................ 45 Table 11: Priority Interventions for NCDs Relevant to SSA Involving Clinical Services at Population- or Individual-Level (by Incremental Cost-Effectiveness)........................................... 46 Table 12: Illustrative HIV/AIDS Program Innovations..................................................................................... 62 List of Boxes Box 1: Collaborative Framework for the Care and Control of TB and Diabetes...................................... 30 Box 2: The Economic and Social Impact of NCDs in the Russian Federation and in China.................. 32 Box 3: Regional Response to Tobacco............................................................................................................. 39 Box 4: The Imperative of the 2011-2020 UN Decade of Action on Road Safety in Africa...................... 42 Box 5: Cervical Cancer Screening................................................................................................................... 48 Box 6: Palliative and End-of-Life Care for AIDS, Cancer and Other Conditions.................................... 50 Box 7: Country Responses to NCD Challenges............................................................................................. 51 Box 8: Integration of the Health Sector in Botswana.................................................................................... 52 Box 9: East African Community Medicines Regulatory Harmonization Project..................................... 56 Box 10: Integrated Care for Communicable Diseases and NCDs in Primary Care.................................... 58 Box 11: Quality Improvement Lessons for HIV Improve Care for O ther Chronic Conditions in Uganda................................................................................................... 60 Box 12: Cross-Fertilization of Care for Chronic Conditions......................................................................... 62 Box 13: Supporting PLWH Self-Management Leads to Expanded Services in Tanzania.......................... 64 Box 14: Healthier Workplaces = Healthy Profits............................................................................................. 70 vii ACKNOWLEDGEMENTS This report was prepared by a team led by Mr. Patri- Social Change, Partners in Health, Dr. Doyin Olu- cio V. Marquez, Lead Health Specialist, Eastern and wole, Executive Director, Pink Ribbon Red Ribbon Southern Africa Region (AFTHE), World Bank, that Initiative, George W. Bush Institute, and Dr. Robert included Dr. Jill L. Farrington, Honorary Senior Lec- Beaglehole, former Director, Department of Chronic turer, Nuffield Centre for International Health and Disease and Health Promotion, WHO and convener Development, Leeds, UK and former Coordinator, of four Lancet NCD series. NCDs, WHO Europe, who served as the principal World Bank: Dr. Olusoji Adeyi, Sector Manager, researcher/writer; Ms. Huihui Wang, Health Econ- AFTHE, Eastern and Southern Africa; Ms. Trina omist, AFTHE, World Bank, Mr. Alberto Gonima, Haque, Sector Manager, AFTHW, Africa West and Consultant, Health Care Management and Informa- Central; Dr. Maryse B. Pierre-Louis, Lead HNP Spe- tion Systems, and Ms. Sheila Dutta, Senior Health cialist, Public Health Cluster; Mr. Sameh El-Saharty, Specialist, World Bank, who provided inputs for se- Senior Health Policy Specialist, South Asia Region; lected sections, and Ms. Joy de Beyer, World Bank Dr. Shiyong Wang, Senior Health Specialist, Middle Institute, who provided editorial support. Mr. Colin East and North Africa (MNSHD) Region; Mr. John Douglas edited the final version of the report. C. Langenbrunner, Lead Economist, HNP Anchor; The team benefitted from the valuable comments Mr. Jean J de St Antoine, Former Acting Health, and suggestions made by a group of distinguished Nutrition , and Population Sector Manager, Africa experts on draft versions of the report, as follows: Region; Dr. Joana Godinho, Sector Manager, Health, Nutrition and Population, Latin America and Carib- Africa Region: Dr. Shenaaz El-Halabi, Deputy Per- bean Region; Mr. Chris Lovelace, Lead Health Spe- manent Secretary, Ministry of Health of Botswana; cialist, AFTHE; Mr. Deon Filmer, Lead Economist, Prof. Krisela Steyn, School of Medicine, University Human Development Department, Africa Region; of Cape Town; Prof. Diane McIntyre, Health Eco- Dr. Gaston Sorgho, Lead Health Specialist, Human nomics Unit, University of Cape Town; Dr. Magda Development Department, Africa Region; Dr. Hum- Robalo, WHO Resident Representative in Namibia; berto Albino Cossa, Senior Health Specialist, AF- and Dr. Karen Voetsch, US CDC/Botswana. THE; Ms. Karima Seleh, Senior Health Economist, AFTHE; Mr. Saul Walker, Health Specialist, AFTHE; International: Sir George Alleyne, former Direc- Mr. Ronald Mutasa, Health Specialist, AFTHE; Mr. tor of PAHO/WHO; Prof. Martin McKee, London Jean-J Frere, Senior Health Specialist (ret.), and Mr. School of Hygiene and Tropical Diseases; Dr. Ka- Willy de Geyndt, Lead Health Specialist, East Asia lipso Chalkidou, UK National Institute of Health and the Pacific (ret.), and now Adjunct Professor, and Clinical Excellence; Prof. Rob Moodie, Univer- International Health Department, Georgetown Uni- sity of Melbourne’s Nossal Institute of Global Health; versity Medical Center. Prof. Miriam Rabkin, Columbia University Mailman School of Public Health; Dr. Suzanne Gaudreault, Administrative support was also provided by Ms. USAID/Quality Assurance Project; Dr. Gene Bukh- Yvette Atkins, Senior Program Assistant, AFTHE man, Director, Harvard Medical School and Pro- and Ms. Samia Benbouzid, Program Assistant, gram in Global Non-Communicable Disease and AFTHE. ix LIST OF ACRONYMS AIDS Acquired Immune Deficiency ICCC Innovative Care for Chronic Conditions Syndrome ICT Information Communication AMRH African Medicines Regulatory Technology Harmonization IHD Ischemic Heart Disease APC Adult per capita consumption IPMS Integrated Patient Management System ART Anti-Retroviral Therapy LBW Low birth weight ASMR Age-standardized mortality rate LMIC Low-and middle-income countries BMI Body mass index MDG Millennium Development Goal BNAPS Botswana National HIV/AIDS Prevention Support (oproject) MMR Maternal Mortality Ratio CCM Chronic Care Model MOH Ministry of Health CDC Centers for Disease Control and NCD Non-Communicable Disease Prevention NGO Non-Governmental Organization CHF Congestive Heart Failure COPD Chronic Obstructive Pulmonary NMRAs National Medicine Regulatory Disease Authorities CRD Chronic Respiratory Disease PEPFAR United States President’s Emergency Plan for AIDS Relief CSO Civil Society Organization PLWH People Living with HIV and AIDS CVD Cardiovascular Disease DALY Disability Adjusted Life Year PPP Public Private Partnership DOTS Directly observed therapy, short-course R&D Research and development DM Diabetes Mellitus RBF Results-based financing EAC East African Community RHD Rheumatic Heart Disease EBV Epstein-Barr Virus RTI Road Traffic Injury EHR Electronic health records SADC Southern Africa Development FCTC Framework Convention on Tobacco Community Control SSA Sub-Saharan Africa/Sub-Saharan GAVI Global Alliance for Vaccines Initiative African GDP Gross Domestic Product TB Tuberculosis GMRH Global Medicines Regulatory THE Total expenditure on health Harmonization Multi-Donor Trust Fund UN United Nations HALE Global Health Life Expectancy UNAIDS Joint United Nations Program on HIV/ HbA1C Hemoglobin A1C (‘glycosylated AIDS hemoglobin’) VIA Visual inspection with acetic acid HBV Hepatitis B Virus (cervical cancer screening) HCV Hepatitis C Virus WHO World Health Organization HHV8 Human Herpes Virus 8 YYL Years of Life Lost HIV Human Immunodeficiency Virus HPV Human Papilloma Virus xi “Countries will take different paths towards universal health coverage. There is no single formula. However, today, an emerging field of global health delivery science is generating evidence and tools that offer promising options for countries…. For decades, energy has been spent in disputes opposing disease-specific ‘vertical’ service delivery models to integrated ‘horizontal’ models. Delivery science is consolidating evidence on how some coun- tries have solved this dilemma by creating a ‘diagonal’ approach: deliberately crafting priority disease-specific programs to drive improvement in the wider health system…. Whether a country’s immediate priority is dia- betes; malaria control; maternal health and child survival; or driving the ‘endgame’ on HIV/AIDS, a universal coverage framework can harness disease-specific programs diagonally to strengthen the system.� Dr. Jim Kim, President of the World Bank, World Health Assembly Geneva May 21, 2013 EXECUTIVE SUMMARY The rising burden of non-communicable diseases governments approach NCD prevention and treat- (NCDs) – including cardiovascular diseases (CVDs), ment and road safety in a comprehensive, effective diabetes mellitus, cancers, and chronic respiratory and efficient way? diseases – poses a growing health challenge for Af- rica; this is compounded by the rise in road traffic The Growing Burden of injuries (RTIs). Yet, in contrast to communicable NCDs and RTIs diseases, Africa’s epidemic of NCDs and RTIs re- mains largely hidden. NCDs and RTIs are already a significant problem for SSA, causing almost a third of deaths in the region as This report approaches NCDs and RTIs within the a whole: for some countries, such as Mauritius and context of existing work on communicable diseases the Seychelles, and some populations, such as those and maternal and child health, to consider whether over 45 years, NCDs are already the leading cause common challenges, drivers, and potential solutions of death. For all four SSA sub-regions, strokes and provide opportunities to build on existing resources RTIs are already among the top 15 causes of years of and experience and capitalize on their inter-linkages. life lost, along with ischemic heart disease, diabetes It shows that effective, proven, cost-effective inter- mellitus and hypertensive heart disease in Southern ventions to control NCDs and RTIs are available and SSA. NCDs are at least as common among the poor possible – even in the region’s resource-constrained as they are among the more affluent. Moreover, Af- environment. rica has the highest RTI death rate per population This report aims to answer four questions, draw- in the world, with pedestrians and other vulnerable ing on a comprehensive review of the literature and road users suffering most. Among young men, RTIs on input from policy makers, researchers and practi- are already the leading cause of premature death tioners: (1) How is the growing burden of NCDs and after HIV/AIDS. RTIs disproportionately affect the RTIs changing the epidemiology of Sub-Saharan Af- poor, whose limited access to emergency care may rica (SSA)? (2) What determines and drives this bur- mean worse outcomes. den, and what are the commonalities with commu- NCD and RTI trends point to the need to act. The nicable diseases? (3) What is the rationale for public largest relative increase in NCD deaths globally in intervention? (4) How could resource-constrained the next decade is expected to occur in Africa, where 1 2 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa NCDs will become the leading cause of death by decreased physical activity and increased cardio- 2030. The burden from cancer alone is expected to vascular risk, while air pollution is an emerging more than double between 2008 and 2030. By 2015, issue. The risk of crashes and injury increases with RTIs are expected to be the number one killer of a poorly regulated transport sector, the lack or non children aged 5-15 in Africa. Yet, although funding -use of seat belts, hazardous road environments, to developing countries for NCDs grew sixfold from poor maintenance of vehicles and roads, and defi- 2001 to 2008, it still comprised less than 3 percent cient monitoring and enforcement. of overall global development assistance for health. • Over the last 20 years, SSA has seen a shift in the NCDs and RTIs are preventable causes of pre- attributable burden of disease of risk factors away mature mortality and morbidity. They reduce pro- from risks for communicable diseases in children ductivity and consume resources that could other- towards those for NCDs in adults. A nutrition wise be used for social and economic development. transition is underway, with an increase in female Health-care needs for chronic conditions and dis- obesity in some population groups; and lifestyles abilities resulting from NCDs and RTIs increase practices are changing. Tobacco use among young pressure on existing fragile health systems, and im- people has increased, particularly of products pose large health and social care costs. NCDs can in- other than cigarettes. Harmful alcohol consump- flict substantial financial and psychosocial burdens tion is a common risk factor for both NCDs and on individuals and their families, particularly where RTIs (a well as for intimate partner violence and treatment costs are mostly paid out-of-pocket and HIV), and is expected to increase with further are lifelong. economic development – Africa already has the NCDs and RTIs also have consequences for sus- highest prevalence of heavy episodic drinking of tainable development. Some of the changes in life- any region. style practices that increase NCDs and RTIs, such Close relationships exist in cause, course and out- as increased car use, are also linked to greenhouse come between NCDs, communicable diseases, and emissions and climate change. maternal, perinatal, and nutritional conditions. There are common underlying social conditions, Drivers, Determinants and such as poverty and unhealthy environments, and Commonalities commonalities across disease groups in causation, co-morbidity, and care needs. Frequently, both com- Communicable diseases have long been the leading municable diseases and NCDs co-exist in the same causes of death and the disease burden in SSA – and individual, and one can increase the risk or impact in many countries still are – but rising incomes, pop- of the other, as happens for example with diabetes ulation growth and ageing, globalization, rapid ur- and tuberculosis. Maternal health and practices, banization and changing lifestyle practices are shift- the intra-uterine environment and low birth weight ing the disease pattern. In particular: may have long-term consequences for developing • Africa’s population is growing rapidly enough to chronic diseases. Interventions to improve maternal double within a generation. The high proportions and child health – such as reducing malnutrition and of young people, in combination with the rela- exposure to smoke – are also integral components of tively early age at which some chronic conditions a continuum of preventive measures for NCDs. manifest themselves, exacerbates the situation. The proportion of elderly persons is projected to The Rationale for Public Intervention double in many African countries between 2000 From an economic perspective, government inter- and 2030, accounting for a substantial proportion vention is justified as a means to achieve a net im- of the projected increase in cancer. provement in social welfare. That is, it is justified • SSA is urbanizing faster than any other region. when private markets fail to function efficiently Living in an urban environment is associated with or when the social objectives of equity in access to An Overview 3 health services are otherwise unlikely to be attained. A Comprehensive, Effective and Global evidence suggests the following sources of Efficient Approach market failure that could justify government inter- In considering responses, this report is comprehen- vention for tackling the risk factors that give rise sive but intentionally not prescriptive. It systemat- to NCDs: (1) ‘externalities’ where society or family ically considers a range of functions (prevention, members bear health or social costs of an individu- treatment, care) and systems that cut across disease al’s unhealthy behaviors, for example alcohol-related categories to highlight what can be done. To iden- crime and the harm to health caused by second-hand tify what has been done and what works, it draws smoke; (2) ‘non-rational’ behavior, recognizing that on evidence and examples from within and beyond people, particularly children, often do not act in SSA. It deliberately stops short of recommending their own best interests and may require protection, what countries should do, in the belief that tailored, for example restrictions on marketing of unhealthy country-led approaches need to follow on from this report, taking account of the needs, capacity, and foods to children, or laws requiring use of seat belts; context of each country. (3) what is termed ‘imperfect’ information – that is, where insufficient information is available for people Drawing on the rich material available, it is possi- ble to identify a range of effective policy measures. to make informed choices; and (4) time-inconsis- Core messages that emerge from this knowledge are tent preferences where people pursue instant grat- as follows: ification at the expense of long-term best interests. Highly effective and cost-effective interventions for (i) Ensure synergies between MDGs and the prevention and control of NCDs and RTIs have NCDs to maximize resource envelopes been identified. Their implementation has been cal- Action against NCDs and RTIs in SSA is needed culated to be well justified in economic terms by po- now, and must take place alongside continued ef- tential welfare gains and averted economic losses. forts to address communicable diseases and mater- Besides the economic rationale, human capital and nal and child health, and to reach the MDGs. One overall economic and social development consider- set of actions cannot wait for the other. Neverthe- ations need to be taken into account. People need less, there are opportunities to take advantage of the commonalities between these disease groups and to be healthy, educated, and adequately housed and build on existing work. For instance, leveraging the fed in order to be more productive and better able resources, experience and models of existing HIV/ to contribute to society. Unequal progress in health AIDS programs could benefit other chronic con- Millennium Development Goals (MDGs) in low-in- ditions; and a greater emphasis on strengthening come countries seems to be significantly related to health systems through universal coverage, stronger HIV and NCD burdens in a population, and the ris- primary health care, integrated chronic care deliv- ing burden of NCDs threatens to reverse the gains ery, and community-based interventions is likely to already made on MDGs, especially those relating to be valuable for any condition. It is important to ac- poverty, education, and child and maternal health knowledge and address the potential risks of setting up yet another vertical program in resource-con- Africa spends a relatively low share of national in- strained countries – and to promote integration and come on health and social services. With additional resource-sharing where feasible. investment, programs to build human capital, such as education and nutrition, can also benefit NCD (ii) Put primary focus on prevention prevention and control, as can social protection and and population-based actions safety nets. Transport systems play their part: im- Globally, a set of cost-effective ‘best buys’ has been provements can significantly increase school atten- identified for prevention of NCDs and RTIs. These dance, as well as contributing to injury reduction. are typically population-wide interventions, imple- 4 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa mentable at little additional cost, which focus on consequences for patients and their families. At the prevention of common modifiable risk factors. They same time, screening programs, for example for include proven measures to reduce tobacco and al- cancer, can raise awareness of early signs and symp- cohol use, such as increased taxation; a ban on ad- toms of those cancers amenable to early diagnosis, vertising, promotion and sponsorship; protection and increase the quality and coverage of effective from exposure to tobacco smoke; and drink-driving evidence-based treatment using standardized proto- counter-measures. As overweight/obesity emerges cols – thus can increasing survival rates. Where fa- as an issue, measures are also being put in place to cilities are limited, non-laboratory tools are needed regulate other ‘unhealthy commodities’ such as ul- to support such screening and assess risk cheaply tra-processed, energy-dense, nutrition-poor food and quickly. Where the majority of cancer is di- and drink. To prevent RTIs, law-enforcement needs agnosed late, improvement in quality of life can be to be combined with public awareness campaigns achieved relatively inexpensively by improving ac- and education to increase seatbelt use and helmet cess to pain management and supportive care close wearing, and to reduce speeding and drink-driving. to home – palliative and home-based care programs Legislation and regulation can also protect against already in place for HIV/AIDS are transferrable to some occupational and environmental hazards such other conditions. as outdoor air pollution, industrial waste and con- tamination of drinking water and soil, which can ex- (iv) Adapt and strengthen health systems acerbate asthma or be linked to carcinogenic agents. Together with other disease groups, NCDs and RTIs It should be noted that policy makers need to avoid face constraints across all main components of a the potential negative consequences that some pop- health system, but solutions can be shared across ulation-based actions might create. For example, it programs and initiatives, and be part of a wider sys- is important to ensure that measures to alleviate un- temic improvement. der-nutrition do not have deleterious consequences for over-nutrition. And while developing a health- Common problems faced by disease groups in- supporting environment that facilitates walking and clude the heavy reliance on external financing and cycling can be part of a pro-growth and pro-poor the shortfall in total health expenditure per capita. transport strategy, such an environment should also Health-care infrastructure is insufficient across all be safe and protect vulnerable road users. tiers of service delivery – not just facilities but also laboratory and diagnostic systems and capabili- (iii) Promote ‘treatment as prevention’, and ties – while primary care is limited in many places. effective care The severe shortage and imbalanced distribution of Health services can implement a number of proven, trained health workers is not just an obstacle to tack- targeted preventive measures – at relatively low ling NCDs but also to the delivery of good quality cost – for CVD, diabetes, chronic respiratory dis- clinical services in general, jeopardizing achieve- eases and cancer, and acute and chronic conditions. ment of the MDGs and improvement of the overall These measures include multidrug treatment for in- health of the poor. Moreover, all the main health and dividuals at high risk of a cardiovascular event; drug disease programs draw from the same data sources treatment of myocardial infarction; glycemic control and share common challenges of weak information and foot care for people with diabetes; and several systems, limited civil registration, and unreliable vi- highly cost-effective interventions to combat cancer, tal statistics – which make it difficult to assess dis- such as Hepatitis B vaccination for liver cancer pre- ease burden and create a compelling political case vention, HPV vaccination for cervical cancer control, for action. and male circumcision to reduce high-risk HPV. The chronic, life-long nature of many NCDs Prompt emergency care for RTIs and acute NCD heightens some of these issues. The limited finan- events can save lives, reduce the incidence of short- cial and social protection against the high costs of term disability and dramatically improve long-term health-care can mean that a life-long condition or An Overview 5 disability from RTI can throw a family further into people with the condition themselves. Finally, the poverty. Health systems are particularly challenged application of ICT in health (eHealth), for example by care of chronic conditions which require a com- through telemedicine and distance learning, has plex response over an extended time period. While the potential to facilitate better health care delivery medicines, such as insulin for diabetes, are essen- in situations where health services and human re- tial in NCD prevention and treatment, their qual- sources for health are scarce. ity, safety and effective use are not assured and they Some of these solutions have already been devel- make up a substantial part of the direct costs of care oped or implemented by other disease groups, and for chronic diseases. Evidence shows that availabil- NCDs and RTIs can benefit from this work. For ity may be worse for medicines for chronic diseases example, many existing programs, such as TB con- than for acute diseases, and that under-funding, trol, aim to strengthen primary care in low-resource poor planning, and inefficient procurement, supply, countries; there are opportunities for improvemed storage and distribution systems within the public NCD care to ‘piggy-back’ existing efforts, by in- sector may exacerbate the problem. Health service tegrating services when an individual is seen by a delivery systems in low- and middle-income coun- health worker. There is broad experience in imple- tries (LMIC) are typically more suited to providing menting chronic care models for HIV/AIDS in Af- episodic care for acute conditions; models for deliv- rica, and this may be transferable to NCDs. Systems ery of care for chronic conditions may be unfamiliar for communicable diseases can be adapted, and ex- and hindered by shortcomings of the system. isting health surveys and surveillance instruments Some of the potential solutions would benefit all can be expanded to measure NCDs and their risk disease groups. Universal health coverage aims to factors. Rather than pursuing separate solutions, ensure that everyone has access to effective health therefore, there are opportunities for initiatives to services when needed, without incurring financial share resources and benefits. hardship; some countries have made significant progress in developing financial systems towards (v) Revisit governance for health this goal. Shifting from originator medicines to ge- Weak governance impedes work to improve health neric products could achieve substantial savings systems effectiveness and health outcomes generally. without loss of quality, and a GAVI-like capacity at With the greater emphasis on prevention and the the regional or global level could usefully negotiate, recognition that many of the solutions for NCDs and make bulk purchases, and distribute vaccines, med- RTIs lie outside of the health sector, broad partner- icines and test kits. A health care delivery system ships across a range of sectors are needed. Political that has been designed to decentralize and integrate will, active civil society organizations, and research chronic care across health care provider boundaries support are all significant contributors to success. can span a spectrum of diseases with similar care Furthermore, underlying social determinants such needs, assisted by simplified protocols and treat- as inequitable distribution of power, money and ment plans. Decision support tools for health-care other resources have implications for prevention and professionals can improve their adherence to guide- care strategies, and both health and non-health sec- lines, standardized case management and patients’ tors have roles to play in addressing these. There is outcomes. Performance-based funding can be used an opportunity to revisit the roles and terms of ref- to incentivize providers towards public health goals, erence of Ministries of Health to allow them to play and more efficient use of resources with reductions an oversight role of coordinating actions from other in waste, errors and corruption could help gain sectors to deliver health outcomes. There are encour- ‘more health for the money’. Innovative strategies to aging signs, for example with civil society organiza- expand health system capacity include ‘task-shifting’ tions emerging to hold governments to account, and in clinical settings so that appropriate tasks are del- increased recognition that population health is not egated to the lowest cadre of health worker with the the outcome of a single ministry but requires a wide ability to perform the task effectively – and even to range of actors and a synergetic set of policies. 6 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa The Way Forward measures, and fuel-efficient ventilated cookstoves) require action beyond the health sector. These can The burden of NCDs and RTIs is growing fast, even deliver broader development benefits in addition to as SSA continues to grapple with high burdens of their benefits for health. Selective, evidence-based communicable diseases, maternal and child health, actions to reduce NCDs and RTIs would address and HIV. Much of the disease and disability from the changing disease burden in Africa and achieve a NCDs and RTIs could be prevented by effective, cost-effective, proven interventions. There are strong more sustainable improvement in health outcomes, rationales for government action on NCDs and RTIs, more efficient use of resources, and better equity alongside continued efforts to achieve the MDGs. across patients and populations. The extensive literature reviewed, together with In conclusion, it should be clear that controlling the views of many of the African and international NCDs and RTIs is a key public health issue in Af- experts consulted for this report, suggest that sepa- rica. Ensuring an effective response, however, is a rate, special NCD programs may not be optimal or particularly difficult challenge in countries facing a feasible in resource-constrained contexts. Moreover, double or triple burden of disease, and with low na- given the shared determinants and characteristics of tional income levels and weak health care systems. several diseases, there seems scope for an integrated As argued here, and fully consistent with the health approach focusing on functions (prevention, treat- improvement and poverty alleviation objectives ment and care) rather than on disease categories. of World Bank work in the health sector, efforts to The report has identified examples of potential op- address this challenge in Africa should be part of a portunities to integrate NCD prevention and treat- broader multisectoral effort, including programs to ment into existing services and programs that would strengthen health systems. This effort will need to build on resources and experience already in place be supported by national governments, public and – and would capitalize on the inter-linkages among private employers and businesses, civil society and communicable diseases, NCDs, maternal and child the international community over the short and me- health. Also needed are proven, cost-effective, NCD dium terms. It is hoped, therefore, that this report and RTI prevention interventions, many of which will contribute to advancing the discussion on this (such as tobacco and alcohol taxes, road safety topic in Africa and beyond in the years to come. “The kola nut was given to him to break, and he prayed to the ancestors. He asked them for health and children. ‘We do not ask for wealth because he that has health and children will also have wealth. We do not pray to have more money but to have more kinsmen’.� Chinua Achebe, “Things Fall Apart� 1. INTRODUCTION There is growing optimism about Africa1 [1]. Since Against this backdrop, there is a growing health the turn of the century, Africa’s growth has been challenge for Africa, spurred on in part by its own robust (averaging 5-6 percent GDP growth a year), successes. Population growth and ageing, globaliza- making important contributions to poverty reduc- tion, and rapid urbanization – with improvement in tion. Over the last decade, six of the world’s ten fast- roads [4] and infrastructure – are contributing to a est-growing nations were African. The GDP growth fast-rising burden of non-communicable diseases rate for the region as a whole was an estimated 4.6 (NCDs) and road traffic injuries (RTIs). These are percent in 2012, about the same as Asia. As world rapidly overtaking the long-standing communicable trade slowed in recent years, Africa was the only re- diseases such as malaria, tuberculosis (TB), and the gion that posted double-digit growth in exports and Human Immunodeficiency Virus and Acquired Im- imports. The current boom is underpinned by sound mune Deficiency Syndrome (HIV/AIDS ) [5]. macro policies, political stability, and regional inte- gration efforts. Unlike in some rich countries, public The Nature of the Problem and debt levels in most of Africa are sustainable. Rationale for the Report Yet the continent cannot rest on its laurels; deep NCDs are expected to become the leading cause of development challenges persist [2]. Non-sustainable death in Africa by 2030 – and already are for some resources, such as minerals, are the main drivers of African nations. In 2008, they caused 2.8 million growth. Job creation has not matched need – un- deaths in Africa, and almost two-thirds (62 percent) employment, particularly of youth and women, re- of deaths in people over 45 years of age [6]. RTIs are mains high. Social and human development indi- largely killers of the young, including many child pe- cators remain poor. Poverty reduction has lowered destrians [7]. Globally, the four main NCDs are car- the US$1.25 a day poverty rate from 57.9 percent in diovascular disease (CVD) such as strokes and heart 1999 to 47.5 percent in 2008, but results vary widely attacks; cancers; diabetes mellitus; and chronic respi- across resource-rich and resource-poor countries. ratory diseases (CRDs) such as asthma and chronic Access to quality health care and education is patchy, obstructive pulmonary disease (COPD). They share there is a large deficit in infrastructure and human many common risk factors and underlying determi- capital (poor learning outcomes, skills deficit, lag- nants, some of which also contribute to RTIs. Mental ging health indicators), and many African countries illness, neuropsychiatric conditions and other en- are not likely to meet the Millennium Development demic NCDs add to the burden. The care of chronic Goals (MDGs) by 2015 [3]. conditions and disabilities resulting from NCDs and 1 The main focus of this document is Sub-Saharan Africa, but the RTIs threatens to overwhelm existing fragile health scope in the different sources used for its preparation varies and is systems and send the costs of health and social care not always clear. A definition of region and income groups is avail- able from: http://www.who.int/healthinfo/global_burden_disease/ soaring – and families and individuals further into definition_regions/en/index.html. poverty in the face of inadequate social protection. 7 8 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa Both NCDs and RTIs are receiving global atten- The challenge presents risks for an already re- tion. The United Nations (UN) High-level meeting source-constrained situation: how to respond in a on NCD Prevention and Control in September 2011 way that does not further deepen any divide between was only the second time that disease has been high- communicable and NCDs, or add new vertical pro- lighted in this way, the first being AIDS a decade grams that are potentially in competition for scarce earlier [8]. The year 2011 also marked the beginning resources, but which instead could capitalize on the of the UN Decade of Action for Road Safety 2011- commonalities among disease groups, in causation, 2020 [4]. At the World Health Assembly in May co-morbidity, and care. 2012, Member States agreed to adopt a global target Development is multi-dimensional – social, eco- of “25 by 25� – for a 25 percent reduction in prema- nomic, environmental – and the challenges, and ture mortality2 from NCDs by 2025 [9]. They also their solutions, are interlinked [6]. To sustain and placed a new Global Action Plan and Monitoring increase growth in an inclusive and equitable way, Framework for NCDs under consideration [10-11]. Africa’s governments need to adopt long-term de- NCDs and RTIs are largely preventable causes of velopment strategies, increasing investments in premature mortality and morbidity and a package high-quality education, health, and infrastructure. of cost-effective measures has been identified [12- To the same end, they must find ways of addressing 13]. It has been estimated that implementing a core the threat posed by NCDs and RTIs which build on package of ‘best buys’ for NCDs would cost less than existing resources and experience and take account US$1 per day in low-income countries, and less than of the many commonalities between communicable US$3 per day in middle-income countries – with diseases, NCDs, maternal and child health, and de- three dollars expected in return for every dollar in- velopment. vested in NCDs [14]. Achieving a 50 percent reduc- This report is not a World Bank policy paper nor tion in RTI fatalities in Africa by 2020 would save an is it an academic review of the literature. Instead, estimated one million lives and 10 million serious it seeks to stimulate new ways of thinking and ap- injuries, with an estimated social benefit of around proaches to health and development, specifically to US$340 billion [15]. tackling NCDs and RTIs, within the context of SSA. NCDs and RTIs are a hidden yet growing health It is grounded in evidence and in practical experi- challenge for Africa. The report aims for a broader ence, drawing upon a broad and extensive review of understanding of NCDs and RTIs within Afri- the data and literature and benefitting from the in- ca’s health and development context, and explores sights and experience of policymakers, analysts, and shared drivers and potential integrated solutions. It managers in the field.3 essentially seeks to answer four questions: While the report is comprehensive, it is intention- (1) How is the growing burden of NCDs and RTIs ally not prescriptive. It systematically considers a changing the epidemiology of SSA? range of functions (prevention, treatment, care) and (2) What determines and drives this burden, and systems that cut across disease categories to high- what are the commonalities with communica- light what can be done. To find what has been done ble diseases? and works, it harvests from evidence and examples from within and beyond SSA. It deliberately stops (3) What is the rationale for public intervention? short of advocating what countries should do in the (4) How could resource-constrained governments belief that more tailored, country-led approaches approach NCD prevention and treatment and need to follow that take account of individual coun- road safety in a comprehensive, effective, and try need, capacity, and context. efficient way? The report is intended for policymakers and tech- nical staff at the national and international level, 2 ‘Premature mortality’ in this context refers to mortality between the ages of 30 and 70 years of age due to cardiovascular disease, cancer, diabetes or chronic respiratory disease. 3 See Acknowledgements section, for list of experts consulted. An Overview 9 working within government institutions and inter- from the health, economic, and social perspectives. national bodies in health and in related sectors such Second, it explores their underlying drivers and de- as finance, trade, agriculture, transport, and envi- terminants, and commonalities with other diseases. ronment. It is expected, therefore, that this report Third, it examines the rationale for public interven- will contribute to advance the discussion on this tion from the economic, human capital, and devel- topic in Africa and beyond in the years to come. opment perspectives. Fourth, it suggests possible The report is organized in four main sections, in elements of a comprehensive, effective and appro- line with the four main questions already posed. priate response to NCDs and RTIs in SSA. First, it summarizes the burden of NCDs and RTIs 2. BURDEN OF NCDs AND RTIs This section considers the question, “How is the Nine of the world’s 22 high-burden countries for growing burden of NCDs and RTIs changing the ep- TB are African (Democratic Republic of Congo, idemiology of SSA?�. It covers: Ethiopia, Kenya, Mozambique, Nigeria, South Af- • An overview of the health perspective in the re- rica, Uganda, Tanzania, and Zimbabwe) [19]. Six gion, including: African countries (Nigeria, Democratic Republic of Congo, Burkina Faso, Mozambique, Cote d’Ivoire, – The relative burden of disease in Africa; and Mali) account for 60 percent of malaria deaths – The rising epidemic of NCDs and RTIs; in the world [20], and malaria was the leading cause – The types of disease that reflect the stage of a of DALYs lost in Central and Western SSA in 2010 country’s development; and [16]. Nigeria is one of only three polio-endemic countries in the world (with Pakistan and Afghan- – An examination of specific NCDs (CVDs, can- istan). cers, diabetes, chronic respiratory diseases and others) and RTIs; as well as Close to 60 percent of global maternal deaths occur in SSA which has the highest maternal mortality ratio • A look at the consequences of NCDs and RTIs on (MMR) in the world [21]. The main specific causes the economic and social development of SSA. are unsafe abortion, sepsis, hemorrhage, obstructed labor, and hypertensive disorders. Africa has a high 2.1. A Health Perspective stunting rate – 40 percent of children under five years old are underweight for their age – and the rate is fall- The Relative Burden of Disease in Africa ing much more slowly than in other regions [22]. For some time, much of the health focus in the SSA Little attention has been paid to the extent to region has been understandably directed towards which these conditions contribute, directly or in- communicable diseases, maternal, perinatal, and directly, to the growing burden of NCDs. In this nutritional causes of mortality and morbidity. These context it must be remembered, for example, that all remain among the leading five causes of disabili- ty-adjusted life years (DALYs) for the sub-regions of FIGURE 1: Proportion of Deaths by Cause in SSA in 2010, accounting for 67-71 percent of DALYs SSA, 2010 in Eastern, Western, and Central SSA [16]. TB, HIV/ AIDS, and malaria were responsible for 22 percent Tuberculosis 6% 4% 3% of all deaths in SSA in 2010, other communicable HIV/AIDS 12% diseases account for another 23 percent. These fig- Malaria ures are already slightly exceeded by the 25 percent Other communicable 25% 13% diseases share of deaths caused by NCDs (Figure 1). Maternal, perinatal and nutritional causes HIV was the leading cause of DALYs in Southern Noncommunicable and Eastern SSA in 2010 [16]. In recent years, the 15% diseases 23% dramatic increase in anti-retroviral therapy (ART) Road tra c injuries coverage, helped by increases in safer sex and con- Other injuries dom use, have contributed to a decline in HIV inci- dence in the region[18]. Source: Authors from [17] 11 12 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa some tropical diseases and infections of poverty By 2010, cerebrovascular disease, diabetes and cause heart disease [23]; TB worsens outcomes for COPD already ranked as the 7th, 8th and 9th highest diabetes [24]; stunting is associated with increased causes of DALYs in Southern SSA [16]. A further risk of obesity in later life [22, 25]; and many infec- shift in relative disease burden is expected: by 2030, tious agents such as hepatitis B (HBV), human pa- the disease burden (in DALYs) for HIV/AIDS, ma- pilloma virus (HPV), and HIV are associated with laria, and other infectious and parasitic conditions increased risk of cancer [26-27] – about one third is expected to be significantly lower, with the four of cancers in Africa are infection-related, double main NCDs becoming pre-eminent (Figure 2) [28]. the world average [27]. FIGURE 2: Projected Burden of Disease (percentage of Total DALYs) by Groups of Disorders and Conditions, SSA, 2008 and 2030 Intentional injuries Injuries Other unintentional injuries RTIs Other NCDs NCDs Neuropsychiatric disorders 4 NCDs (CVD, cancer, respiratory diseases, diabetes) Nutritional de ciencies Perinatal conditions Communicable, maternal, perinatal, nutritional Maternal conditions Respiratory infections Other infectious and parasitic diseases Malaria HIV/AIDS Tuberculosis 2030 2008 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% Source: Authors from [28]4 Projected DALYs by cause for 2008, 2030 - standard DALYs (3 percent discounting, age weights) – Baseline scenario. 4 At the time of preparation of this report, projections of mortality and burden of disease were not available through the Global Burden of Disease study 2010 [17] so an earlier version [28] was used for Figures 2 and 9. An Overview 13 A Rising Epidemic of NCDs and RTIs NCDs are becoming a significant burden in SSA, the top 15 causes of years of life lost (YLL) for all and RTIs are rapidly emerging as a major cause of four SSA regions, joined by ischemic heart disease death and disability. By 2010, cerebrovascular dis- (IHD), diabetes mellitus (DM), and hypertensive eases (stroke) and road injuries were already within heart disease in Southern SSA (Table 1) [29]. TABLE 1: Top 15 Leading Causes of YLL in Each Region of SSA, 2010 Global Southern Eastern Central Western   rank SSA SSA SSA SSA 1 Ischemic heart disease 11 17 16 17 2 Lower respiratory infections 2 3 4 2 3 Cerebrovascular disease (stroke) 7 14 13 12 4 Diarrhoeal diseases 3 4 2 3 5 Malaria 14 2 1 1 6 HIV/AIDS 1 1 5 4 7 Pre-term birth complications 6 5 6 7 8 Road injury 12 11 11 9 10 Neonatal encephalopathy (incl. birth asphyxia/trauma) 9 9 10 10 11 Tuberculosis 5 8 8 11 12 Sepsis 18 7 12 5 14 Congenital anomalies 13 15 7 15 15 Protein-energy malnutrition 29 6 3 6 18 Meningitis 19 10 9 8 19 Diabetes mellitus 8 26 26 24 20 Interpersonal violence 4 18 17 23 23 Fire, heat, and hot substances 23 16 19 13 27 Hypertensive heart disease 15 38 39 46 28 Maternal disorders 20 13 15 14 34 Exposure to mechanical forces 10 28 22 40 40 Syphilis 31 12 14 18 Ranking legend 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36 + Source: Authors from [17, 29] 14 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa Compared to other regions of the world in 2008, Africa was estimated to have the highest age-standard- ized mortality rate for NCDs (779 per 100,000 population) and for injuries including RTIs (107 per 100,000 population) (Figure 3) [30]. Globally, NCD deaths are expected to increase by a further 17 percent in the next 10 years, with the largest increase expected in Africa (27 percent) [31]. FIGURE 3: Age-Standardized Mortality Rates by Cause, WHO Regions, 2008 900 Age-standardized mortality rates by cause 800 700 (Per 100 000 population) 600 500 400 300 200 100 0 Africa Americas South-East Asia Europe Eastern Mediterranean Western Paci c WHO Region Communicable diseases, maternal and perinatal conditions, nutritional de ciencies Noncommunicable diseases Injuries Source: [32] NCDs occur at younger ages in SSA than else- FIGURE 4: Proportion of Deaths by Age Group where: for example, the average age of death from (Years) in SSA, 2010 CVD is at least 10 years younger than in developed countries [33]. Half of the deaths caused by NCDs 100% in Africa occur in people under 70 years of age [6], 90% and NCDs are already the leading cause of death 80% Other injuries 70% in people aged over 45 years (Figure 4). The NCD Road tra c injuries 60% death rate among women in Africa is twice as high Noncommunicable 50% diseases as the rate in high-income countries [31]. Maternal, perinatal, 40% nutritional causes 30% Communicable diseases 20% 10% 0% 0-4 yrs 5-14 yrs 15-44 yrs 45 yrs Source: Authors from [17] An Overview 15 Types of Disease Reflect Stage of Development FIGURE 6: ASMR by Cause in Countries of SSA, 2008 The relative burden and types of NCDs that are pres- 6% Mauritius 7% 88% ent reflect to some extent the stage of epidemiological Seychelles 19% 75% 6% transition of a country or its population (Figure 5). In Sao Tome and Principe 30% 65% 5% countries at the earliest stages of development, circu- Cape Verde 26% 65% 9% latory diseases due to nutritional deficiency or infec- Eritrea 28% 63% 9% tions (such as rheumatic heart disease) predominate. Madagascar 35% 60% 5% As countries develop, circulatory diseases related to Comoros 35% 59% 6% Gambia, The 39% 55% 5% hypertension (such as hemorrhagic stroke) become Senegal 41% 54% 5% more common. With high-fat diets, sedentary life- Mauritania 41% 53% 6% styles, and increased tobacco use, mortality from 6% Benin 41% 53% atherosclerotic CVD (such as IHD) predominates, Rwanda 42% 52% 6% especially in those below the age of 50 years [34]. The Togo 45% 51% 4% prevalence of and complications from diabetes also Guinea 42% 51% 7% increase during this disease transition. Differences Gabon 42% 51% 6% can co-exist within countries – for example rural Ethiopia 41% 51% 8% versus urban populations – and obesity can be seen Ghana 43% 50% 6% Namibia 41% 49% 10% alongside under-nutrition even in the same house- Congo 42% 49% 9% hold [35]. Trends in these risk factors in SSA, and Liberia 49% 48% 4% their drivers, are discussed further in Section 3. 44% 8% Kenya 48% Figure 6 shows the relative burden of communica- Uganda 43% 47% 10% ble disease, NCDs, and injuries by country in SSA, Nigeria 48% 47% 4% 6% as measured by age-standardized mortality rate Guinea-Bissau 47% 47% Cote d'Ivoire 45% 47% 9% (ASMR). The number of countries in which NCDs Cameroon 47% 47% 6% and injuries dominate may surprise many readers. 47% 6% Burkina Faso 47% Table 2 shows ASMR by country for the main Angola 46% 47% 6% NCDs focused on in this report (cancer, CVD, diabe- Niger 51% 46% 3% tes, and chronic respiratory diseases), with countries Zambia 46% 45% 8% United Republic of Tanzania 47% 45% 7% organized by World Bank Income Group (WBIG). Mozambique 47% 45% 8% Mali 51% 45% 4% Democratic Republic of the Congo 48% 44% 8% FIGURE 5: Epidemiological Transition for CVD in 49% 7% Burundi 44% Developing Countries 49% 8% Malawi 43% Chad 51% 43% 6% 80 Tobacco, Obesity/Lipids/DM Central African Republic 51% 42% 7% 70 Public Health, (IHD, Stroke) Nutrition, Hypertension Botswana 51% 42% 7% 60 Starvation (Hem. Stroke) Sierra Leone 55% 40% 5% & Infection 50 (RHD) 53% 9% Swaziland 38% 40 South Africa 58% 38% 4% 30 Lesotho 59% 35% 7% 20 Prevention Zimbabwe 69% 28% 3% Treatment 10 (IHD, Stroke, CHF) Communicable diseases, maternal and Noncommunicable Injuries 0 perinatal conditions, nutritional de ciencies diseases Pestilence Receding Degenerative Delayed and Famine Pandemics and Man-made Degenerative Diseases Diseases Source: [32] Life expectancy (years) Percentage of deaths due to CVD Source: [36] 16 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa TABLE 2: ASMR by Cause and Country for SSA, 2008 Age-standardized mortality rate by cause (ages 30-70 years, per 100 000 population) Cardiovascular Chronic Countries in SSA All causes Cancer disease and respiratory arranged by World Bank Income Group of death diabetes conditions Upper-middle income Angola 1685 130 459 110 Botswana 1633 66 293 70 Gabon 1251 117 325 80 Mauritius 774 110 440 29 Namibia 1889 73 524 84 Seychelles 867 199 265 32 South Africa 2259 193 307 68 Lower-middle income Cameroon 1846 122 473 115 Cape Verde 772 144 235 55 Congo, Rep. 1468 113 391 95 Cote d’Ivoire 2567 104 651 166 Ghana 1452 151 359 93 Lesotho 2748 109 443 108 Nigeria 1632 148 377 90 Sao Tome and Principe 654 169 183 40 Senegal 1133 152 307 73 Swaziland 3109 117 551 136 Zambia 2395 166 527 135 Low income Benin 1528 161 413 102 Burkina Faso 1497 143 377 94 Burundi 1893 161 391 91 Central African Republic 2275 121 483 116 Chad 1841 130 461 111 Comoros 1194 140 393 92 Democratic Republic of the Congo 1765 138 399 95 Eritrea 952 119 306 73 Ethiopia 1863 132 473 115 Gambia, The 1618 183 500 118 Guinea 1906 177 542 137 Guinea-Bissau 2007 166 522 128 Kenya 1495 178 276 69 Liberia 1760 149 378 89 Madagascar 1058 154 289 69 Malawi 3147 163 634 125 Mali 1262 171 292 71 Mauritania 1265 147 362 85 Mozambique 2167 143 498 125 Niger 1057 129 246 57 Rwanda 1174 158 290 68 Sierra Leone 1675 133 383 92 Togo 1562 143 370 89 Uganda 1959 191 421 111 United Republic of Tanzania 1733 113 341 86 Zimbabwe 3046 157 206 51 Source: [32] Cardiovascular Diseases CVDs are the second most common cause of adult Surveys find a hypertension prevalence rate of 25– deaths in SSA and, in some countries such as Mau- 35 percent in the adult population aged 25–64 years ritius and the Seychelles, already the leading cause [38] with treatment rates relatively low, contribut- [37]. The age-standardized mortality rate for CVD ing to the high rates of stroke reported [6, 39]. The and diabetes is highest for the African region (Fig- burden of disease from CVD is projected to double ure 7). Table 2 shows the relative burden of the main from 1990 to 2020 [40]. NCDs of focus in this report. An Overview 17 FIGURE 7: ASMR by NCD Cause, WHO Regions, 2008 2000 All Causes Cancer Cardiovascular Disease and Diabetes Chronic Respiratory Conditions 1800 Age-standardized adult mortality rate by cause (ages 30-70 years per 100,000 population) 1600 1400 1200 1000 800 600 400 200 0 Africa Americas South-East Asia Europe Eastern Mediterranean Western Paci c WHO Region Source: [32] Cancers The burden from cancer is expected to more than sarcoma, and cancer of the liver. The lifetime risk of double between 2008 and 2030, with new cases ris- cancer in females (0-64 years) in Africa is only 30 ing from 681,000 to 1.6 million and deaths rising percent lower than the risk in developed countries from 512,000 to 1.2 million over that period [6]. but their risk of dying is almost twice as high [41]. Risk factors for cancer can be infectious and/or non The regions in the world with the highest risk for -infectious (Table 3). The most common cancers for cervical cancer are Western and Eastern Africa [42]. men in Africa are HIV-associated Kaposi’s sarcoma, The growing use of tobacco and occupational and and cancer of the liver, prostate, and bladder; and for environmental risks such as air pollution and expo- women they are cancer of the cervix, breast, Kaposi’s sure in mining, add to the cancer burden [43-44]. TABLE 3: Common Cancers in SSA: Infectious and Other Risk Factors Cancer sites, in rank Infectious Other risk factors of high order of incidence agents public health relevance Hormonal/reproductive factors, obesity, Breast physical inactivity, alcohol Cervix HPV Tobacco Aflatoxins (produced by Aspergillus moulds), Liver HBV, HCV alcohol Prostate Lymphomas EBV, malaria, (non-Hodgkin and Burkitt) HIV (indirect), HCV Colon and rectum Diet, obesity, physical inactivity, alcohol, tobacco Kaposi sarcoma HIV (indirect), HHV8 Oesophagus Tobacco, alcohol Lung Tobacco Helicobacter pylori Diets low in fruit and vegetables and high in salt, Stomach (bacterium) tobacco Bladder Schistosoma haematobium (fluke) Tobacco, occupational exposure Source: Adapted from [27, 44] Abbreviations: HPV Human papilloma virus; EBV Epstein-Barr virus; HBV hepatitis B virus; HCV hepatitis C virus; HHV8 human herpes virus 8. 18 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa Diabetes has even been a call for a “5 by 5� approach in Af- An estimated 14.7 million people were living with rica, adding a focus on neuropsychiatric disorders diabetes in SSA in 2011 (3.8 percent of the popula- as the ‘5th NCD’ and transmissible agents as the ‘5th tion), and rising prevalence was expected to affect risk factor’ [55]. For some countries such as Rwanda 28 million people by 2030 [45]. Over 90 percent of with populations early in the epidemiological tran- cases are Type 2 diabetes [46] but this may be due in sition, NCDs are not dominated by any one condi- part to early mortality for those with type 1 diabe- tion; instead each NCD is relatively uncommon thus tes who have insufficient access to insulin, syringes, making an individual, disease-specific approach and monitoring equipment [47]. Children in the even less useful [56]. region with Type 1 diabetes often go undiagnosed; While it is outside the scope of this report to go some may even be misdiagnosed as having AIDS. into detail on these other conditions, it is worth not- Surveys during the period 2003–2009 found that ing that an individual may carry multiple co-mor- between 5 and 15 percent of the population of indi- bidities, or risk factors for other conditions, and that vidual countries have diabetes [48]. Almost one in these may impact overall outcomes and thus need two Mauritians aged 25-74 years has either diabetes to be taken into account in disease management. or impaired glucose metabolism (pre-diabetes) [49]. For example, a review of patients with heart fail- Around three-quarters (78 percent) of people with ure in Cameroon found that over half had at least diabetes in Africa are undiagnosed [45], and the one co-morbidity, and around a third had multiple proportion of people with diabetes having compli- co-morbidities, such as renal impairment, COPD, cations is high [50]. diabetes, and gout [57]. A survey of over 700 resi- dents aged over 50 years in South Africa found that Chronic Respiratory Diseases a quarter had hypertension with one or more other chronic diseases [58]. There is limited information available about the prev- alence of chronic respiratory diseases in SSA, but RTIs conditions appear to be under-recognized, under-di- agnosed, and under-treated [51]. Asthma appears Despite being the least motorized region, SSA has to be on the increase, particularly in urban regions, the highest road traffic death rate in the world, pro- and COPD has become an increasing health problem portional to its population: an estimated 24.1 people due to tobacco smoking and exposure to biomass fuel per 100,000 population are killed in road crashes emissions [52]. Environmental pollution, occupa- each year [59]. The number of road traffic deaths is tional exposure, and high levels of TB infection may predicted to rise by at least 80 percent by 2020 [60]. also increase the prevalence of these diseases [51]. Just seven countries account for almost two-thirds (64 percent) of all road deaths in the region (Demo- Other NCDs cratic Republic of Congo, Ethiopia, Kenya, Nigeria, South Africa, Tanzania, and Uganda), with Nigeria While much international attention has focused on and South Africa having the highest fatality rates four main NCDs (CVD, cancer, CRD, diabetes), (33.7 and 31.9 deaths per 100,000 per year respec- and these are the main focus of this report, African tively) [61]. health leaders have also voiced concern about other chronic conditions, such as mental health disorders, Vulnerable road users—pedestrians, cyclists, and haemoglobinopathies such as sickle cell disease, oral users of motorized two-wheelers—constitute more and eye diseases, and violence and injuries. This is than half of all those killed on roads (Figure 8). In because of their burden on health and development all four SSA regions more than 40 percent of road in the African region and for their shared risk fac- injury deaths are amongst pedestrians [16]. tors and/or care need [6, 53-54]. Indeed, by 2010 By 2015, RTI are expected to have become the major depressive disorders were already the 10th number-one killer of children aged 5-15 in Africa, highest cause of DALYs in Southern SSA [16]. There outstripping Malaria and HIV/AIDS [62] (Figure 9). An Overview 19 For young men, RTI are the second leading cause 2.2. Economic and Social of premature death after HIV/AIDS. Economically Development Consequences active young people are most at risk of road injury – in South Africa over half of pedestrian deaths were As the leading cause of death in low- and middle-in- people aged 20-44 years. Road crashes are estimated come countries (LMIC), NCDs have costs for indi- to cost African countries between 1 and 3 percent of viduals and families, health systems and economies, their Gross National Product each year [63]. and also for sustainable development. The two main factors accounting for the macroeconomic impacts are productivity loss—nearly 30 percent of NCD-re- FIGURE 8: Distribution of Road Traffic Deaths by lated deaths in low-income countries occur in peo- Type of Road User in SSA Countries ple under 60 years of age [64]—and costs of treat- ment, which pose particular challenges in LMIC Other – 5% where resources and health systems are already 2 and 3 Wheelers – 7% overstretched. Although the biggest economic burden is currently Cyclists – 7% in high-income countries, the burden will rise in the Pedestrians – 38% developing world as economies enlarge and popula- tions grow and age [65]. Rising NCD mortality rates are expected to reduce economic growth in devel- Occupants – 43% oping countries [66]. A review of LMIC in 2007 es- timated total losses in economic output during the period 2006–15 from coronary heart disease, stroke, and diabetes alone; namely, US$1.88 billion in South Africa, US$1.17 billion in Nigeria, US16 million in Source: [59, 61] Note that the small difference in the percentage of pedestrians between this source Ethiopia, and US15 million in Democratic Republic and [17], cited in the text above, results from differences in the countries included. of Congo [67]. The estimated economic cost (direct and indirect) of diabetes alone in the African region in 2000 was I$25.51 billion5 (at purchasing power FIGURE 9: Projected Disease Burden (DALYs) in SSA parity) [68]. Total costs attributed to CVD in the Afri- for Children Aged 5-15 Years, 2008-2030 can region were US$11.6 billion, of which 41 percent represented loss of productivity costs [65]. A review 6000000 of over 7,000 employees in Namibia found that high 5000000 blood glucose and diabetes had the largest effect on absenteeism, greater than being HIV positive [69]. 4000000 NCDs and the risk factors that fuel them can in- 3000000 flict substantial financial and psychosocial burdens 2000000 on individuals and their families, particularly where 1000000 treatment costs are paid mostly out-of-pocket. In 0 the poorest households of some countries, 15 per- 2008 2015 2030 cent of disposable income is spent on tobacco [31]. Tuberculosis HIV/AIDS Malaria Road tra c injuries One study in Sudan showed that for a family with a diabetic child, 65 percent of their family’s annual Source: Authors from [28] health expenditure was spent on their child’s dia- Projected DALYs by age, sex, and cause for 2008, 2015, 2030 – standard DALYS (3 percent discounting, age weights) – Baseline scenario. betic care [70]. A study of how households in Afri- 5 I$ refers to International dollar which is a hypothetical unit of cur- rency that has the same purchasing power parity that the U.S. dol- lar had in the United States at a given point in time. 20 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa can countries cope with high out-of-pocket health This burden is disproportionate: poor populations expenditure found that households with the highest and low-income countries have a greater burden of levels were at least 10 percent more likely to borrow related disease per unit of alcohol consumption than and sell assets than those without such expenditure, high-income populations and countries [73]. and this effect was greatest in Congo, Ethiopia, and The changes in lifestyle behaviors that lead to an Ghana where the likelihood rose to 38-40 percent increase in NCDs, such as a diet more reliant on [71]. Average out-of-pocket costs for treatment of meat and processed foods and a reduction in physi- injury (including RTIs) in Ghana was found to be cal activity with increased use of cars, are also linked US$31 per injury in an urban area and US$11 in a to increasing greenhouse gas emissions and to cli- rural area [72], at a time when average monthly per mate change [74-75]. In turn, climatic factors have capita income was only US$86. Coping strategies af- a negative impact on health; for example, asthma is ter injury included intra-family labor reallocation, likely to increase with the related increase in air pol- borrowing money, and selling belongings. lution [76]. So reducing risk factors for NCDs can The consequences of alcohol abuse have large have wider social and economic benefits in addition costs for society in health care costs and social harm. to improving health. 3. THE DRIVERS AND DETERMINANTS OF NCDs Changes in the magnitude and distribution of the blood pressure6 in the WHO African Region, at 36.8 risk factors and determinants for NCDs, alongside percent (34.0-39.7 percent) of adults aged 25 years demographic change and economic development, and over, was highest of any region [79]. In Southern are driving the trends in the disease burden [24, 35, SSA in 2010, alcohol use was the leading risk factor, 77]. In considering the question, “What determines followed by high blood pressure and high body mass and drives the NCD and RTI burden, and what are index, with smoking also in the top five. the commonalities with communicable diseases?� this section covers: Nutrition Countries in SSA are undergoing a nutrition transi- • NCD risk factors in SSA (nutrition, tobacco, alco- tion [80]. More than half of them are still at an early hol, and physical activity and travel); stage, experiencing a high prevalence amongst chil- • The drivers of NCD trends (growing urbanization dren of stunting or being underweight for their age, and the impact of demographic changes); a low prevalence of overweight and obesity amongst • Socio-economic determinants and distributions; women, and low intakes of energy, protein, and fat. and For a few countries, changes in dietary patterns are affecting health outcomes in a large portion of • Commonalities between NCDs and other risk the population; for example, South Africa, Ghana, groups. Gabon, Cape Verde, and Senegal have relatively high levels of obesity/overweight, and low levels of 3.1. NCD Risk Factors underweight in women, as well as high intakes of Over the period 1990-2010 globally and in Sub energy and fat. In several countries, overweight and -Saharan Africa, there has been a shift in the contri- obesity have reached substantial proportions with bution of different risk factors to the disease burden levels of 30-50 percent amongst adults and higher in away from risks for communicable diseases in chil- women [81]. Among a sample of recent mothers in dren towards those for non-communicable diseases 31 SSA countries more women were overweight or in adults [78]. Leading risk factors for SSA regions obese than underweight (Figure 10) [82]. in 2010 can be found in Table 4. In 2010 in Central, Where measured, cholesterol levels are generally Eastern, and Western SSA, childhood underweight, low except for the wealthier countries such as Mauri- household air pollution from solid fuels, and subop- tius, where elevated cholesterol levels have been seen timal breastfeeding continue to be leading causes of in 30 percent of the population [49]. A high intake disease, but their contribution to the disease burden of sodium is common in SSA, with salt being used to has fallen substantially since 1990. A much larger preserve food and add taste [83], but salt intake gen- share of the disease burden can be attributed to risk erally does not make the 15 top-ranked risk factors factors for NCDs and injury, most notably alcohol for attributable disease burden in SSA regions. use and high blood pressure. Since 1980 mean blood pressure has been stable or been increasing in most 6 Systolic blood pressure (SBP) of 140mmHg or above or dia- African countries: by 2008, the prevalence of raised stolic blood pressure (DBP) of 90mmHg or above. 21 22 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa TABLE 4: Top 15 Risk Factors Ranked by Attributable Burden of Disease for SSA Regions, 2010 Global Southern Eastern Central Western   rank SSA SSA SSA SSA 1 High blood pressure 2 6 5 6 2 Tobacco smoking, including second hand smoke 5 7 12 10 3 Alcohol use 1 5 6 5 4 Household air pollution from solid fuels 7 2 2 2 5 Diet low in fruits 8 8 11 13 6 High body mass index (BMI) 3 14 18 15 7 High fasting plasma glucose 6 10 13 11 8 Childhood underweight 9 1 1 1 9 Ambient particulate matter pollution 25 16 14 7 10 Physical inactivity and low physical activity 11 15 15 16 11 Diet high in sodium 13 21 17 18 13 Iron deficiency 10 4 4 4 14 Suboptimal breastfeeding 4 3 3 3 17 Diet low in vegetables 15 23 23 20 19 Drug use 12 19 24 22 23 Intimate partner violence 14 18 20 23 25 Unimproved sanitation 18 9 8 9 29 Vitamin A deficiency 17 11 7 8 31 Zinc deficiency 21 13 10 14 34 Unimproved water source 27 12 9 12 Ranking legend 1-5 6-10 11-15 16-20 21-25 26-30 Source: Authors from [17, 78] Global economic policies in agriculture, trade, in- Fruit and vegetable consumption varies consid- vestment, and marketing have played a part in chang- erably among and within countries but is generally ing what people eat, by altering the quantity, type, low, with few individuals consuming recommended cost, distribution, and desirability of foods available levels [88]. Dietary diversity is often lacking in many [84-85]. Globalization gives access to greater food di- SSA countries. Diets traditionally consist of cereal versity but also convergence towards more homoge- or root staples with very few micronutrient-rich nous diets (“McDonaldization�). As countries de- sources [82]. One study found that a large propor- velop, dietary differences between rich and poor are tion of young children across a group of countries further exacerbated as the latter tend to adopt a poor were exposed to no more than two food groups [89]. quality ‘obesogenic’ diet, with ultra-processed prod- ucts that are typically energy dense and high in un- Diversion of resources from food production to healthy dietary fat, free sugars, and sodium [86-87]. cash crop exports by African governments, in order An Overview 23 FIGURE 10: The Double Burden of Under-Nutrition and Overweight in SSA: Share of Recent Mothers Who are Underweight or Overweight (Most Recent Data Available Since 2000) Ethiopia Madagascar Chad Burkina Faso Eritrea Congo Democratic Republic Mozambique Guinea Niger Uganda Mali Benin Malawi Rwanda Zambia Liberia Tanzania Senegal Nigeria Kenya Congo (Brazzaville) Sierra Leone Cameroon Gabon Zimbabwe Ghana Namibia Sao Tome and Principe Lesotho Mauritania Swaziland 0 10 20 30 40 50 % recent mothers Overweight/Obese (BMI>25) Underweight (BMI<18.5) Source: [82] based on MEASURE DHS, ICF International. 2012: Stat Compiler: www.statcompiler.com to pay debt and achieve macroeconomic adjustment to tobacco use [91]. More than 40 million people are targets, has not helped food security [82]. Further- current smokers in Africa [31]. According to WHO more, international investors have acquired the rights estimates, adult daily smoking prevalence ranges to use large tracts of land in SSA, and they have in- from 3 percent in Ethiopia to 22 percent in Sierra vested mainly in non-food products such as biofuels, Leone [92]. The poor are most likely to smoke, what- industrial cash crops, and game reserves [90]. ever the income level of the country. Tobacco use is expanding in Africa and the age Tobacco of initiation is decreasing, increasing people’s years Tobacco is a risk factor for four of the 10 main causes of exposure and risk levels. This is reflected in in- of death in Africa [31], with 3 percent (5 percent creased tobacco use prevalence among young peo- males; 1 percent females) of all deaths attributable ple, particularly of products other than cigarettes. 24 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa The rate of smoking among young girls is becoming smoke. For example, in 2007 in Uganda, 5.5 percent similar to boys [6] (Figure 11). of students were currently smoking tobacco (males Around one in ten adolescents smoke cigarettes, 6.6 percent; females 4.0 percent), and 13.9 percent around one in ten use other tobacco products, and were currently using other tobacco products [93]. half of all adolescents are exposed to second-hand Tobacco companies are shifting their focus from the west to developing nations, and marketing heav- ily in Asia and Africa. This is particularly because as FIGURE 11: Current Use of Tobacco Products incomes rise, cigarettes are likely to become more af- among African Youth, 13-15 Years, 2005-2010 fordable. Smoking is promoted as a sign of indepen- Botswana dence and success for women. The tobacco industry Burkina Faso also takes advantage of a country’s need for eco- Burundi nomic development, promoting reliance: Botswana Cameroon Cape Verde has recently started cigarette manufacturing, even Central African Republic providing incentives to companies to increase em- Chad ployment opportunities [94]. Comoros Congo Africa is home to some of the most tobacco-de- Cote d'Ivoire pendent economies in the world: in Malawi, 2 mil- Democratic Republic of the Congo lion people rely on growing tobacco for their live- Eritrea lihood, and in Nigeria British American Tobacco Gambia, The presents itself as a significant stakeholder in the Ghana rural economy [95]. Where nutrition is a threat to Guinea Guinea-Bissau public health there is a tradeoff between tobacco Kenya growth and food production, and this may in time Lesotho lead to conflict over land: in the Democratic Repub- Liberia lic of Congo, cassava is no longer available in some Madagascar places due to tobacco plantations, and has to be im- Malawi Mali ported from Uganda [94]. Mauritania Mauritius Alcohol Mozambique Namibia In SSA 2.2 percent of all deaths and 2.5 percent of Niger all DALYs are related to alcohol, and consumption Nigeria is rising throughout the region [73, 96]. Africa’s total Rwanda adult per capita consumption (APC) of 6.15 liters is Senegal similar to the world average, but levels differ greatly Seychelles across countries [97]. Around one-third (31.4 per- Sierra Leone South Africa cent) of the alcohol consumed is ‘unrecorded’, often Swaziland being home-brewed. Beverages other than wine, Togo beer, and spirits, such as fermented maize or millet, Uganda are mainly consumed in SSA (48.2 percent of APC), United Republic of Tanzania with beer accounting for around a third (34.1 per- Zambia Zimbabwe cent) of APC. 0.0 10.0 20.0 30.0 40.0 The African region has the highest prevalence of % population heavy episodic (“binge�) drinking globally, present in around a quarter (25.1 percent) of those drink- Currently using any Currently using any tobacco products - female % tobacco products - male % ing, and including nearly one-third (30.5 percent) of Source: [32] [92] men (Table 5). While seven out of 10 adults in the An Overview 25 TABLE 5: Prevalence of Weekly Heavy Drinking Episodes among Drinkers in the Past 12 Months by Sex – WHO Region and the World, 2005 WHO region Women (%) Men (%) Average Total (%) Africa 16.2 30.5 25.1 Americas 4.5 17.9 12.0 Eastern Mediterranean 17.9 24.9 24.7 Europe 4.6 16.8 11.0 South-East Asia 12.9 23.0 21.7 Western Pacific 1.3 11.6 8.0 WORLD 4.2 16.1 11.5 Source: [97] region abstain from alcohol, those that do drink do Physical Activity and Travel so in a harmful way that increases risk particularly Overall physical activity levels are relatively high of acute consequences: almost two-thirds of the al- in Africa, with most either work-related or trans- cohol-attributable disease burden relates to injuries port-related. This is especially so in rural areas, but [6], and heavy-episodic drinking is linked with un- levels of physical inactivity have been shown to rise safe sex leading to STIs and HIV transmission [98]. with urbanization [102-104]. The presence of alcohol as a contributory factor to In most African cities, most residents walk or road crashes is likely to be under-reported in Africa, use public transportation for daily routine activi- due to lack of detection technology, and unspeci- ties. Cycling is usually negligible in large cities, but fied reporting, due to limited use of standard cod- may reach 20 percent of daily journeys in smaller ification, logistics, and enforcement. Nevertheless, a cities [105]. Poor law enforcement combined with study in Nigeria over the period 1996-2000 found poor road infrastructure, and high traffic mix and alcohol to be a factor in 50 percent of police report little separation of vulnerable road users from high accidents [99]. speed motorized traffic, contribute to the high rate There is a strong relationship between economic of crashes and fatalities [59]. A poorly-regulated wealth and alcohol consumption for low-income private sector may be the major supplier of public countries: as GDP rises, the overall volume that is transport, and the risk to passengers of collision consumed increases, and the proportion of abstain- and injury involving public buses is increased by ers decreases [73]. Consumption of commercial- lack of seat belts, overcrowding, and hazardous road ly-produced alcohol is expected to rise as economic environments: in Ghana, the majority (58 percent) conditions improve in African countries [100]; while of crashes in urban areas involved buses and mini- other regions have experienced stable consumption buses, with most of those injured being their passen- trends, an increase has been noted in the African gers or pedestrians [63, 106]. and Southeast Asian regions. With Western mar- kets more or less saturated, low-income countries 3.2. Drivers of NCD Trends and emerging markets with large populations such as South Africa and Nigeria, and even Malawi and Growing Urbanization Uganda, are being targeted by global alcohol cor- SSA is urbanizing faster than any other continent, porations [101]. Adolescents and young adults are and in the Northern and Southern sub-regions over a particular target, for example through sponsorship half the total population already live in urban ag- of sports [96]. glomerations [107]. Rapidly-growing cities can be 26 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa major assets for a nation’s development – the 40 billion in 2010 to 1.56 billion in 2030, with around percent of Africa’s population that now lives in cities 85 percent of his population living in SSA [119]. Fig- produces 80 percent of its GDP – but if not properly ure 12 shows the population distribution by age for or fairly steered they can lead to major social and the region in 2010. economic challenges [108]. SSA follows South and East Asia in having the third largest number of slum FIGURE 12: Population of SSA, 2010 dwellers worldwide, with slum conditions, such as lack of access to basic services, impacting most neg- atively on the poorest people, particularly women 80 - 84 and children [109-110]. As people move away from 70 - 74 villages, traditional family- or community-based 60 - 64 safety nets are breaking down, and governments 50 - 54 Age (years) are recognizing the need to set up or extend social 40 - 44 protection systems to protect vulnerable households 30 - 34 from sudden shocks to offset poverty [111]. 20 - 24 Living in an urban environment is associated with 10 - 14 raised blood pressure, blood sugar, and BMI, par- 0-4 10 8 6 4 2 0 2 4 6 8 10 ticularly for recent settlers, with increased blood % population (Male = blue; female = red) pressure becoming apparent within months of mi- grating from rural to urban areas [40, 104]. Urban Source: [119] (medium variant) residents have a 1.5- to fourfold higher prevalence of diabetes than their rural counterparts, and have in- All SSA countries but one (Mauritius) are con- creased cardiovascular risk [34, 112]. Urbanization, sidered either high- or medium-fertility countries; income, sedentary lifestyles, and alcohol consump- nearly half have an estimated fertility level above tion independently contribute to higher BMI [113], five children per woman. There are signs of a fertility and changes in dietary habits, stress, and uptake of transition to lower rates but this is fairly unpredict- smoking among women raise cardiovascular risk able in SSA countries, and depend on the level of [114-115]. development, socio-economic factors such as levels Pollution is an emerging issue in urban centers. It of education, female employment, and urbanization, is caused by emissions from industry, motor vehi- as well as more ‘proximate’ determinants such as cles, and households, and exacerbated by the use of contraceptive use [120]. Countries with the highest trucks for long-distance transportation in the pres- population growth rates struggle to meet the social, ence of poor railway systems [116]. The use of obso- economic, and health needs of their people, and face lete vehicles is a major contributor to air pollution, increasing environmental stress and competition for and poor maintenance of vehicles and monitoring land and water resources [109]. and enforcement systems also contribute to crashes Africa is the ‘youngest’ region in the world. A de- [63, 117]. Urbanization is associated with increased mographic shift which sees half of the increase in asthma prevalence in South Africa and other parts world population over the next 40 years in Africa of SSA. Unsafe working conditions, out-of-date could be favorable in economic terms, while pop- technology, and poor regulation contribute to occu- ulations age elsewhere in the world [1]. However, pational lung diseases [118]. youth already comprise up to 60 percent of the un- employed in the region. Investments in education The Contribution of Demographic Change and health are needed to provide skills for jobs, and Africa is undergoing rapid population growth and to enhance protection against preventable diseases it is likely to double within the coming generation. that affect productivity and the negative impact of Projections are for a population increase from 1.02 unemployment on health [121]. An Overview 27 Life expectancy has stagnated or gone down in exception of Southern SSA due to adult mortality many African countries, reflecting worsening so- from HIV/AIDS. cial and economic conditions, and the impacts of Chronic conditions occur in younger age groups AIDS and related diseases especially in Southern more commonly in SSA than in developed countries Africa [109]. Nevertheless, large gains in life expec- [83]. High burdens of CVD are attributable not just tancy have occurred since 1990 in some SSA coun- to the epidemiological transition, but also to the rel- tries; most notably, increases of 12-15 years for atively early age at which CVD manifests in combi- men and women in Angola, Ethiopia, Niger, and nation with the large population of individuals who Rwanda are due to HIV-control strategies and a re- are young or middle aged [34]. duction of childhood diseases [122]. All four SSA regions had at least a 10 percent decline in adult The number of elderly persons in SSA is pro- mortality from 2004 to 2010, particularly in East- jected to double between 2000 and 2030 (Figure ern and Southern SSA. 13). Advancing age is associated with increased risk of a number of chronic diseases [124], more so for Global healthy life expectancy (HALE) in- people living with HIV and AIDS (PLWH) [125]. creased over the period 1990-2010, mainly Population growth and ageing alone are driving a through reductions of child and adult mortality substantial part of the projected increases in cancer rather than through reductions in disability [123]. by 2030. Nevertheless, health and wellbeing in older For similar reasons, overall HALE also rose in the age is determined more by chronic disease status SSA regions (East, West, and Central), with the and co-morbidity than by age [126]. FIGURE 13: Projected Age-Specific Increase in Male 3.3. Socio-Economic Determinants and Female Populations in SSA, 2010 to 2030 and Distributions Increased prevalence of both communicable and 85+ NCDs in disadvantaged populations is caused by 80-84 the same social conditions [127-128]. Poverty and 75-79 the challenges of poverty, such as overcrowding, 65-69 insanitary environments, malnutrition, infections, 60-64 and psychosocial stress, play a critical role in the rise of NCDs in poor and rural communities [114, 129]. 55-59 Differential exposures throughout a person’s life- 50-54 time result in a range of consequences and outcomes 45-49 (Figure 14) – Africa may have some specific insights 40-44 to contribute on these linkages. 35-39 As noted before, Africa’s growth has been robust 30-34 (averaging 5-6 percent GDP growth a year) since 25-29 the turn of the new century, making important con- 20-24 tributions to poverty reduction. Income inequality, 15-19 however, remains high and SSA has some of the highest income inequalities in the world. Neverthe- 10-14 less, there has been a trend toward improvement in 5-9 female male several countries [82, 131] 0-4 Wealthy communities experience a higher risk of 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Factor increase in population size 2010 to 2030 chronic diseases, while poor communities experi- ence a higher risk of communicable diseases and a Source: Authors from [119] (medium variant) double burden of communicable diseases and NCDs 28 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa FIGURE 14: Conceptual Framework for Understanding Health Inequities, Pathways and Entry Points Social context Age Economic development, urbanization, globalizationa Social strati cationa Lifetime exposure to advertising of fast foods, tobacco, vehicle use, Social deprivationa disposable income, urban infrastructure, physical inactivity, high calorie intake, Unemployment Differential high salt intake, high saturated fat diet, tobacco usec, lack of control over exposure Illiteracy life and work, high deprivation neighborhoods Deprived neighborhoods Adverse intrauterine life Raised cholesterol, raised blood sugar, raised blood pressure, overweight, Less access to: Differential obesityb, lack of access to health information, health services, social support • Health services vulnerability and welfare assistance, poor health care-seeking behavior • Early detection • Health foodsb Differential Higher incidence, frequent recurrences, Povertya outcomes higher case fatality, comorbiditiesb Overcrowding Poor housing Differential High out-of-pocket expenditure, poor adherence, lower survival, loss of Rheumatic heart disease consequences employment, loss of productivity and income, social and nancial consequences, Chagas disease entrenchment in poverty, disability, poor quality of lifeb Determinants a. Government policies influencing social capital, infrastructure, transport, agriculture, food b. Health policies at macro, health system and micro levels c. Individual, household and community factors: use of health services, dietary practices, lifestyle Source: [130] [132]. NCDs are at least as common in the poor as in lower respiratory infections) and women (COPD) the more affluent sector of society [83] and the ob- [118, 135]. When women have less say in household served increase in hypertension and obesity accom- decisions than men, household food security deteri- panying wealth bodes badly for the consequences of orates, access to health care lags and child nutrition future socio-economic development [133]. suffers [82]; better female education improves child Some lifestyle factors are more common for under-nutrition. Violence against women, particu- women and others for men: for example, smoking larly sexual, can increase their risk of sexually trans- is still mainly a risk factor for men; whereas obe- mitted diseases including HPV and the later devel- sity is predominantly a risk factor for women [114]; opment of cervical cancer. more women than men abstain from alcohol con- SSA has the highest concentration of fragile and sumption; and higher proportions of men engage in conflict-affected states [121]. Post-conflict environ- heavy episodic drinking [97]. Gender inequality and ments can increase NCD risks in a number of ways: power relationships are reflected in the distribution for example, psychological distress is associated with of diseases and risk factors [129], and specific roles the taking up of harmful behaviors; and tobacco, al- place women at risk for some NCDs in a number of cohol, and food companies can take advantage of ways [134]; for example, in most SSA countries, 90 weakened trading and regulatory systems [136]. percent of rural households depend on biomass fuel There are lessons to be learnt of how the tobacco for cooking and heating, and the indoor air pollution industry has used chaotic conditions in countries generated affects principally young children (acute elsewhere to exploit legislative loopholes [137] or An Overview 29 employ business practices that fall short of interna- needed. Some of the commonalities have been al- tional standards [138]; for example, by using flawed luded to in the preceding section, and are summa- economic arguments to persuade cash-starved or rized below: naïve governments of the economic rewards from their investment. i) There are some: shared causal pathways, partly related to stage in epidemiological The burden of RTI falls disproportionately on the transition, with many shared determinants poor and vulnerable road users [63]. The poorest between NCDs and communicable diseases, communities often live alongside the fastest roads, such as under-nutrition and poor sanitation; their children may need to negotiate the most dan- shared risk factors, such as alcohol for NCDs gerous routes to school, and they may have poorer and injuries and poverty; and shared causative outcomes from injuries due to limited access to agents, such as untreated infections linked post-crash emergency health care [60]. to cancers and some CVDs [27, 139] (Table 6). Rapid urbanization together with an in- 3.4. Commonalities between NCDs crease in diabetes prevalence is likely to make and Other Disease Groups TB control more difficult; and an increase in The usual epidemiological grouping of conditions smoking could substantially increase TB cases into communicable diseases, maternal, perinatal, and deaths in coming years [140]; and diseases from nutritional causes, NCDs, and in- ii) Several conditions (co-morbidities) can co-ex- juries perhaps makes less sense in SSA given some ist in one person which has consequences for of the close relationships among them, which in their management and implications for taking turn have implications for the appropriate response a person-centered approach [24]; TABLE 6: Examples of NCDs Linked to Conditions of Poverty* Condition Risk factors related to poverty Hypertension Idiopathic, treatment gap Pericardial disease Tuberculosis Rheumatic valvular disease Streptococcal diseases Cardiovascular Cardiomyopathies HIV, other viruses, pregnancy Maternal rubella, micronutrient deficiency, idiopathic, Congenital heart disease treatment gap Indoor air pollution, tuberculosis, schistosomiasis, Respiratory Chronic pulmonary disease treatment gap Diabetes mellitus Undernutrition Endocrine Hyperthyroidism and hypothyroidism Iodine deficiency Epilepsy Meningitis, malaria Neurological Stroke Rheumatic mitral stenosis, endocarditis, malaria, HIV Renal Chronic kidney disease Streptococcal disease Chronic osteomyelitis Bacterial infection, tuberculosis Musculoskeletal Musculoskeletal injury Trauma Source: Adapted from: [56] *Links between cancers and diseases of poverty such as infection shown in Table 3. 30 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa iii) Presence of one condition can increase the BOX 1: Collaborative Framework for the Care and likelihood of developing another condition: Control of TB and Diabetes for example, NCDs or their risk factors can Diabetes triples the risk of developing TB and is a also increase the risk of infection, for example common co-morbidity in people with TB. Lessons smoking and diabetes each increase the risk of learnt from approaches to reduce the dual burden TB [140-141]; of HIV and TB can be applied to screening, diag- iv) Treatment of one condition can increase the nosis, treatment, and prevention of diabetes and risk for developing another condition, for ex- TB [146]. A framework for joint management has ample anti-retroviral therapy (ART) for HIV been proposed as part of a move to better inte- can increase risk of developing metabolic syn- grate communicable and NCD prevention and drome [142]; care strategies, focusing on the patient rather than the disease [147-148]: v) Presence of one condition can worsen the outcome of another, for example co-morbid- 1) Establishing mechanisms for collaboration; ity of TB and diabetes can worsen outcomes for example through joint coordination, plan- for both diseases [143], and tobacco and alco- ning, surveillance, and agreement of a set of core indicators for monitoring and evaluation hol use can impact negatively on HIV disease progression and the ability to fight HIV-re- 2) Detecting and managing TB in patients with di- lated infection [144]; abetes; by for example screening people with diabetes for chronic cough, along with investi- vi) Presence of one condition may act as a barrier gation, referral, and treatment as needed and to prevention of another, for example, stigma raising awareness amongst health workers of associated with HIV may impede participa- the interactions between the two diseases to tion in physical activity and health promoting improve case-finding opportunities [145]. 3) Detecting and managing diabetes in patients These inter-linkages have consequences for the with TB; through for example screening management of care, as illustrated in Box 1 and ex- patients with TB for diabetes, along with further panded further in the sections that follow. investigation and treatment as required. Many maternal illnesses and lifestyle behaviors can affect the child, for example tobacco and alcohol rising levels of CVD in people of middle age in fu- use, anemia and over- and under-nutrition, and have ture [40]. potential long term consequences [149-150]. Gesta- tional diabetes is a strong predictor of future health, Putting effective interventions in place for both of the mother, who may develop diabetes and women – such as reducing malnutrition, preventing CVD later in life, and the child who also becomes anemia, and improving access to effective contracep- at risk. Poor maternal nutrition before and during tion – and improving nutrition in early life are likely pregnancy, as well as tobacco use during pregnancy, to be important preventive measures also for NCDs contribute to poor intrauterine growth, resulting in [40, 152-153]. Promotion of breastfeeding – which low birth weight (LBW), which in turn predisposes protects against diarrhea, respiratory infections, and the child to metabolic disorders and NCD risk in obesity – would also help prevent NCDs and protect later life [35, 83]. The problem can be compounded against infection, apart from its nutritional benefits by HIV and malaria: for example, LBW and malnu- [154]. Screening for gestational diabetes and screen- trition are more frequent in HIV-infected children ing for and prevention of malaria, HIV, and HBV [37], and malaria infection during pregnancy is a transmission from mother to child could be part of common cause of anemia and LBW [151]. Thus, the an integrated antenatal care program with multiple current poverty of much of SSA may contribute to benefits [155]. 4. THE RATIONALE FOR PUBLIC INTERVENTION This section describes the rationale for public in- • Imperfect information: People are not always fully tervention on NCDs and RTIs, under the following aware of the health (and other) consequences of headings: unhealthy lifestyle choices such as smoking, al- cohol abuse, physical inactivity, and poor diet. • Economic rationale They may also be misled by deliberately distorted • Human capital rationale information promoted by the food, alcohol, and tobacco industries. Government intervention in • Development rationale. the form of the provision (and production) of NC- D-related health information (such as the health 4.1. Economic Rationale consequences of smoking) provides a public good Experiences from different countries suggest that that generally is undersupplied compared to the NCDs and RTIs may impose a huge financial and social optimum. This also includes the role for a social burden on government and society [156-157]. government to engage in research about the health As detailed in Box 2, recent assessment conducted consequences of unhealthy behavior. in the Russian Federation and in China clearly illus- • Non-rational behavior: Children and adolescents trates the magnitude of this burden. (and even adults) tend not to take into account Interventions for the prevention and control of the future consequences of their current choices, irrespective of whether they are informed about NCDs have been identified which are highly cost-ef- them or not. Their current choices may well con- fective [160]. Investment in their implementation is flict with their long-term best interests. This pro- justified in economic terms in that the potential wel- vides, in principle, a justification for government fare gains and economic losses that could be averted to support interventions to prevent people from are considerably larger than the investments them- harming themselves in situations where they do selves [161]. Justification can also rely on a rights- not fully appreciate the consequences of behaviors based argument for NCD services: the raison d’etre that pose health risks. of a health system is to address health conditions prevalent in the community, and health systems and There are two distinct rationales for public policy governments need to be responsive to the needs of intervention to achieve a net improvement in social their citizens. welfare, one equity-based and one efficiency-based [163]. Regarding NCD prevention and treatment in While the largest share of costs of disease are borne low- and middle-income countries, these could be by the individual concerned, the economic case for framed as follows [160]: government action relates to ‘market failures’. These are areas where the market alone fails to achieve so- • For primary prevention, which is mainly through cially optimal outcomes [162]; namely: population-level and non-clinical interventions, a regulatory and fiscal framework is needed to limit • Externalities: There are substantial external costs externalities relating to tobacco (such as harm resulting from second-hand smoke and alco- and associated costs resulting from second-hand hol-induced RTIs and fatalities. NCDs also im- smoke) and alcohol (such as social harm and RTIs pose costs on health care and the social insurance and deaths). Information can be provided in cul- system and hence on “third parties�. turally appropriate formats about the various risk 31 32 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 2: The Economic and Social Impact of NCDs in the Russian Federation and in China In Russia, poor adult health, largely due to NCDs, negatively ling for other relevant factors. Chronic illness was also found affects economic well-being at the individual and house- to affect household incomes negatively, particularly during hold level. If effective action were taken in Russia, improved the period 1998-2002, when chronic illness contributed an health would play an important role in sustaining high eco- estimated annual loss of 5.6 percent of per capita income. nomic growth rates at the macro level. In China, in the absence of a scaled-up Government re- The cost of absenteeism due to ill health: On average, 10 sponse, heart attacks, stroke, and diabetes alone are ex- days per employee per year are lost due to illness in Russia, pected to result in a loss of US$550 billion between 2005 while in the EU-15 the average is 7.9 days. Absence due to and 2015. More specifically, a recent World Bank report calls sickness incurs a direct cost, namely the benefits paid to ab- attention to the following potential gains stemming from ef- sent employees, and the indirect cost of lost productivity. fective NCD policies: The overall cost varies between 0.55 and 1.37 percent of GDP (annual absenteeism rates can be converted into a monetary • At the microeconomic level: A change in adult health sta- value either by using the average wage rate, resulting in the tus can result in a 16 percent gain in hours worked and a lower value, or the GDP per capita, resulting in the higher 20 percent increase in individual income. Tackling NCDs, value). This is a significant impact, given that the indicator on top of being a valuable health investment, may thus fails to capture the many other ways that ill health impacts be seen as an investment into people’s productivity and the labor market. In particular, it does not capture the effects hence their earnings potential. of reduced productivity and mortality. • At the macroeconomic level: Reducing mortality from CVD The impact on the labor supply: Ill health also impacts labor by 1 percent per year over a 30-year period (2010–2040) supply because jobholders with chronic diseases or alcohol- could generate an economic value equivalent to 68 per- ism are more likely than healthy individuals either to retire cent of China’s real GDP in 2010, more than US$10.7 trillion early or lose their jobs and draw on state pensions. While a at purchasing power parity. hypothetical Russian male aged 55 with median income and • The society-wide ‘economic costs’ of NCDs are even larger if other average characteristics would be expected to retire at the value which people attribute to health is captured. Re- age 59, chronic illness would lower his expected retirement ducing CVD mortality by 1 percent per year produces – if age by two years. Similar results are obtained for females. the intrinsic value that is attributed to life is measured – an Also, an individual who suffers from chronic illness has a annual benefit of about 15 percent of China’s 2010 GDP significantly higher probability of retiring in the subsequent (US$2.34 trillion at purchasing power parity), while a 3 per- year than the same individual would be, free of the illness. cent reduction would amount to an annual benefit of 34 This all means that chronic illness is a highly significant percent (US$5.40 trillion at purchasing power parity). predictor of subsequent retirement in Russia. The lower the income of an individual in Russia, the more likely that chronic The combination of exceptionally fast population aging in illness will result in the decision to retire. This implies that China with a low fertility rate will strain China’s labor force less-affluent people carry a double burden of ill health: first, participation rate by 3–4 percentage points by 2030. The in- they are more likely to suffer from chronic illness in the first crease in NCDs, if not addressed effectively as a governmen- place, and second, once ill, they are more likely to suffer worse tal priority in the years to come, would not only exacerbate economic consequences – having less income than rich peo- the expected labor force shortages, but also compromise the ple tends to perpetuate socio-economic disadvantage. quality of available human capital, because more than 50 Job loss: Alcohol abuse, which is arguably an important percent of the NCD burden currently falls on the economi- factor in explaining the high adult mortality in Russia, sig- cally active population (aged 15–64). nificantly increases the probability of job loss (that is, it was To optimize labor productivity as the population ages, found that alcohol has a positive and statistically significant interventions to improve the quality and skill mix of the ex- effect on the probability of being fired). isting labor force and extend the retirement age could only The impact on the family: The death of a household mem- provide a short-term solution. The success of these interven- ber affects other household members’ welfare and behavior tions in the medium and longer terms would depend on the in various ways. Alcohol consumption was found to increase working-age population’s staying healthy. Indeed, if not ad- by about 10 grams per day as a consequence of the death of dressed, the rise of NCDs will dilute and hinder the positive an unemployed household member and by about 35 grams effects of such policy measures. Inertia in response to NCDs if the deceased had been employed; also, the probability of will result in an aggravation of health inequalities, and may suffering depression increased by 53 percent when control- contribute to a slowdown in economic growth. Source: [158-159] An Overview 33 factors (given that people are not always aware of 4.2. Human Capital Rationale the consequences of their lifestyle choices), partic- People need to be healthy, educated, and adequately ularly to reach poor populations. It should, how- ever, be noted that the effectiveness of information housed and fed to be more productive and better able campaigns alone in changing health behaviors is to contribute to society. In Africa, around a third limited, and they are not a substitute for effective (38 percent) of adults are illiterate; around a third regulatory and fiscal measures. Thus, on efficiency (37 percent) of children will not complete primary grounds, there is a strong rationale for: taxes on school; and only 5 percent of the relevant age group tobacco and alcohol that make them less afford- go to university [121]. This is likely to impact health able; advertising bans; information labels on pack- literacy and people’s ability to understand and en- aging; and a ban on smoking in public places – gage in health-promoting interventions and in man- and also, in the case of middle income countries, aging their own diseases. regulation to address the content of manufactured Better health outcomes depend in part on stronger foods. As delivery of these interventions in most health systems, but investment may be insufficient. settings is not transaction intensive and does not SSA has spent a relatively low share of income on require strong health systems, they are likely to be a first priority for low-income countries, and they health, estimated at 5.1 percent (equivalent to I$82 are the most effective and cost-effective. per capita) in 2001, and only rising to 6.5 percent (equivalent to I$159 per capita) by 2011 [164-165]. • For secondary prevention and treatment, mainly In addition, its relatively high external funding per at the level of the individual and clinical-based- capita amounts to little, compared to the amount services, the choice of interventions and budget mobilized by local governments and individuals’ allocation decisions would depend on cost-effec- tiveness, as well as on the health system’s capacity out-of-pocket payments. Furthermore, while stud- to deliver effective services. ies show that countries with the highest investments in social security tend to have low poverty rates, SSA – Equity concerns would motivate a public role also spends only 8.7 percent of GDP on social ser- for achieving a set of simpler, low-cost NCD vices, the lowest in the world [121]. interventions which could be included in a well-targeted basic package of services, deliv- Programs to build human capital can also bene- ered probably in non-hospital settings, which fit NCDs. Sexual and reproductive health programs have a high chance of reaching the poor, and aimed at reducing fertility rates and HIV transmis- which will not strain the government budget. sion, through increasing access to condoms and An example of such an intervention might be promoting safer sex, also contribute to primary pre- ‘see-and-treat’ cervical screening and treatment vention of cervical cancer [166]. Community-based in community clinics, using visual inspection nutrition programs to reduce the prevalence of by acetic acid (VIA) method to reach women stunting and underweight and maternal malnutri- aged 35-45 years at least once. tion will in turn reduce the development of chronic – Efficiency concerns relating to insurance markets diseases in the long term. Social protection and safe- or public financing would motivate for the public ty-net programs can reduce and mitigate the differ- role of intervening on high-cost NCD services, ent income risks that poor households may meet, so an example of which might be multidrug treat- that when faced with health care bills, a family will ment for secondary prevention of CVD. Again, be less likely to have to cut down on nutrition. these would need to be delivered in a way that is pro-poor, taking into account the country’s health Transport systems play a part – ensuring the system, context, and capacities, and at a pace that basic quality of local transport infrastructure and is affordable and sustainable. Other public inter- services enables an easier, cheaper, and safer move- ventions might be for the government to influ- ment for pupils and teachers to access school and ence the cost-effectiveness ratio, for example by improves attendance, as well as reducing the risk of negotiating lower drug or vaccine prices. injuries [167]. 34 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa 4.3. Development Rationale close associations among NCDs, infectious diseases, and maternal and child health, and to encourage The rising burden of NCDs threatens to reverse the some rethinking of the relative allocations of health gains already made on MDGs, especially those re- development assistance and delivery approaches lating to poverty, education, and child and maternal [161, 174]. Although funding to developing coun- health [129, 168-169]. There are many examples of tries for NCDs grew more than sixfold during the links between NCDs, child mortality, and infectious period 2001-2008, it still comprised less than 3 per- diseases and the general well-being of households: cent of overall, global development assistance for illness can reduce household earnings and ability health in 2007 – a similarly disproportionate, small to provide for and educate children; disability of amount, relative to the NCD contribution to DALYs an adult may mean a child (probably a girl) staying [175]. This imbalance is highlighted in Table 7. home from school to provide care; tobacco and alco- hol use-related illness, cost of health care, and death In order to re-position NCDs within health and of the main wage earner can propel a family into development agendas, a different approach and poverty [163, 170]. view may be needed. It may be helpful to reframe the debate at country level to emphasize the soci- There are co-benefits for health from actions to etal (rather than individual) determinants of dis- address climate change, and vice versa; for example, ease, and the inter-relationship with poverty and through increasing walking and cycling. An im- development [176]. Distribution of resources could proved understanding of the relationship between be made on the basis of avoidable mortality, health NCDs, RTI, and climate change could enable im- effects, or broad care needs rather than disease or proved policy formulation to the common benefit of category. For example, an analysis of Tanzanian these issues [171-172]. health data according to chronicity and mortality Developing policies for NCD prevention and con- found that for the majority of the population older trol requires a better understanding of the processes than five years, the burden of disease, irrespective of and political economies of policy making in Africa, etiology, would require a health system that could in particular the relationships between national pol- provide long-term care and management [177]. icy making and international economic and political Resources could be mobilized through an inclusive pressures as well as the extent to which the health approach that links closely with global health and MDGs and aid architecture supports (or not) an development agendas, allowing emerging strategic NCD agenda for Africa [129, 173]. and political opportunities to be seized and built There has been a call for including NCDs in new upon, with better coordination of efforts among international development goals, especially given the global actors [176-178]. Table 7: ODA Funding for Health and Disease Areas per 2008 DALY 2008 DALYs Health Development Funding per LMIC (million) Assistance 2007 DALY HIV, TB, Malaria 264 US$6,315 million US$23.9 NCDs 646 US$503 million US$0.78 All conditions 1,338 US$22,013 million US$16.4 Source: [175] 5. A COMPREHENSIVE, INTEGRATED APPROACH TO NCDs AND ROAD SAFETY In this section, the elements of a comprehensive ap- countries were reported as having national strategies proach to NCD and road safety control are consid- that set targets for reducing road deaths and injuries, ered. It draws on the available literature, and explores for example. the potential for adopting shared approaches with Given the range of risk factors and determinants other conditions. The section covers the following: of NCDs and RTIs, multiple stakeholders from dif- • Policy approaches ferent sectors within and outside government have a contribution to make in prevention and control – • Population-level prevention health, welfare, transport, environment, education, • Individual-level prevention agriculture, trade, urban planning, the private sec- • Therapies – treatment, care, and rehabilitation tor, Civil Society Organizations (CSOs)/Non-Gov- ernmental Organizations (NGOs), and victims of • Strengthening health systems disease and/or injury. With respect to road safety, • Addressing information and health gaps ministries of the interior, traffic police, transport, • The role of public and private employers and busi- education, health, emergency services as well as nesses. private sector enterprises such as alcohol, car, and health insurance industries need to work together. 5.1. Policy Approach A cross-governmental task force, steering group, or coordinating committee of multiple stakeholders Improving Commitment and Response can help achieve the broad perspective required, but needs sufficient convening and decision-making An important starting point for action is clear gov- power to promote participation, commit resources, ernment acknowledgement of the problem and and design a plan of action. commitment to address the issue [179]. There is ev- idence of a renewed effort across Africa and within Ministries of health and public health profession- countries to strengthen action on NCDs [54, 180- als have an important leadership role to play, but 182] since the initial commitments made during critical mass is low, with departments understaffed, the previous decade [53-54, 183-184]; this has not and there are few qualified public health profession- necessarily been translated into policy or action at als: over half (55 percent) of African countries, par- country level [64, 185-186], however, and some pol- ticularly in Lusophone and Francophone areas, do icies have had only mixed results or been weakened not have any postgraduate public health programme [187-188]. On road safety, several global reports [194]. Public health agencies or institutes can make a and the Decade of Action for Road Safety [59-60, critical contribution by providing technical evidence 117, 189] appear to have revitalized Africa-wide in- to health authorities for decision making, and in terest with the resulting Accra Declaration in 2007 monitoring and evaluating NCD-related programs, [190], a set of targets in 2009, and an African Road projects, and interventions, but these are not pres- Safety Plan of Action in 2011 [15, 191]. While some ent in all countries: the International Association progress has been made and positive examples have of National Public Health Institutes has members emerged from some countries [181, 192-193], there from only 15 SSA countries. Where public health appears to be much still to do: by 2013, only 12 SSA institutes do exist, they may have had a strong focus 35 36 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa on communicable disease rather than experience in ing their road safety strategies, and another global tackling NCDs and RTIs: for example, although epi- survey in 2010 found that only seven SSA countries demiological research in SSA has increased dramat- appeared to have an operational NCD policy with a ically since the 1990s, it has been largely driven by a dedicated budget [59, 64]. Given the number of re- few countries, and has focused mainly on commu- lated and potentially interlinking programs, a more nicable diseases especially AIDS, TB, and malaria, integrated approach could be taken to estimate re- with very little attention yet given to the growing source requirements, costs, and expected impact; in burden of NCDs and injuries [195]. this regard the joint United Nations One Health tool A global survey of country capacity to prevent may hold some promise [199]. and control NCDs revealed major gaps in health system capacity in many LMIC in Africa [196]. Op- Developing a Strategic Framework for Action portunities exist for better coordination of existing, A number of global and African strategic frameworks relevant policies and approaches at national and exist to frame a comprehensive approach for NCDs sub-national levels, and with governmental and [53, 200-201] and for RTIs [191, 202]. Within these, non-governmental actors including donors [197]. certain common principles are promoted (Table 8). Low-cost mechanisms include shared targets and There is some debate over the relative value of hav- indicators and intersectoral and intrasectoral com- ing multiple NCD issue-specific or disease-specific mittees and projects [198]. policies or programs, for example for CVD, diabetes, Commitment needs to be underpinned by re- and tobacco, versus a single, more comprehensive sources. One global survey in 2012 found that only policy for NCD prevention. While the latter is seen three SSA countries had full funding for implement- as having certain advantages (for example, providing TABLE 8: Principles to Guide Action on NCDs and RTIs Multisectoral response Mobilize a multisectoral response to build support and capacity Partnership & Ownership Establish effective partnerships and promote civil society engagement, broad participation, and ownership Evidence-based Select cost-effective and evidence-based approaches, and use and build an evidence base, with investment in research Stepwise & Prioritize Implement priority interventions according to potential for health gains, local considerations, and need Integration Take account of common risk factors, determinants, and care models across diseases, and promote integration where it adds value and/or saves costs Comprehensive Balance a combination of population-level primary prevention and individual prevention health care strategies Life course Promote prevention throughout life, beginning in early life and continuing with interventions for adults and the elderly Health system Reorient and strengthen health systems, in particular primary health care, striving for strengthening universal coverage and fairness in resource allocation Enabling & Empowering Enable and empower people with NCD and their families to manage their conditions better Equity Promote equity, taking account of social and environmental determinants Evaluation & Strengthen surveillance, monitoring, evaluation, and information-sharing to increase Accountability accountability and target effort and resources more effectively Development Integrate with national programs for sustainable development, and ensure consistency with national health policy and existing programs Source: Authors based on: [53-54, 64, 200-204] An Overview 37 clarity of vision and purpose, emphasizing common While donor-driven and global health initiatives elements, and facilitating efficient and effective use of have mobilized substantial new resources for health resources [200, 205]), the reality of individual coun- in many LMIC, there is a recognized challenge to tries may be that a mixture of policies, programs, combine disease-specific programs with broader and interventions are already in place, as was found approaches for health improvement so that posi- in the case in Ghana and Cameroon, [192, 206]. A tive synergies are capitalized upon and negative im- meeting of SSA health leaders in 2009 suggested the pacts minimized [218-219]. Any approach involving value of having a generic NCD plan which integrates greater integration or ‘diagonalization’ may meet palliative care, surveillance, and the reduction of risk with resistance if it appears to take control away factors, alongside disease-specific plans that take ac- from donors and proponents of vertical programs count of specific issues in individual diseases (such [215], or if it undermines existing programs and as diagnosis and treatment) [207]. The challenge is their broader benefits [220], or fails to take account to find a good model that fits a specific context and of lessons learnt [221]. Both potential negative im- the specificities of SSA [179], and focus on achieving pact (loss of funding and of political attention) and outcomes. First Implementing a priority set of inter- positive impact (a greater commitment to investing ventions, such as tobacco control and salt reduction in health care for chronic diseases) have been seen as measures, before adopting a more comprehensive potential outcomes. Nevertheless, there is increas- approach, has been proposed lest starting with a ing enthusiasm for leveraging HIV resources, expe- comprehensive plan is too ambitious, and risks di- rience, and models for the benefit of other chronic verting resources from moving ahead quickly with conditions, and to ‘jumpstart’ initiatives to provide the most productive actions [208]. prevention, care, and treatment services for them [5, 142, 222-225]. After all – on grounds equity and ef- There has also been debate over the place for ‘ver- ficiency – some argue that there is no basis for HIV/ tical’ (stand-alone) programs in health systems [209], AIDS care to be better resourced than care for other and concern that establishing new vertical programs chronic conditions, such as diabetes. for NCDs and RTIs in resource-constrained countries risks placing them in direct competition for scarce funding with existing programs such as those on com- 5.2. Population-Level Prevention municable diseases and maternal and child health, Population-level interventions are not reliant on which is likely to be unsustainable [210]. Both advan- health services for delivery: costs are relatively low tages and limitations of ‘vertical’, disease-specific pro- and they may even generate funds; they have rela- grams have been recognized, with calls for the lessons tively little “downside�; most people will be exposed learnt to be applied [211-212]. Further research has to them; and people who are at high risk or already been proposed to ascertain what ‘integration’ would suffering from NCDs will benefit [226]. Popula- really mean in different settings and for different tion-level prevention, particularly in resource-lim- services [144], and instead of a false dichotomy be- ited countries, benefit from a strong regulatory and tween so-called vertical and horizontal approaches, fiscal framework, particularly for tobacco control. analytical and conceptual frameworks have been pro- Most cost-effective measures to reduce risk factors posed to help shift the debate and reframe the issues are in the domain of agencies or ministries other [213-214]: for example ‘diagonal’ programs have been than health, such as ministries of trade, finance, agri- proposed whereby disease-specific interventions are culture, and transport, but may challenge vested in- designed to minimize the untoward impact on other terests and face strong lobbying by tobacco, alcohol, health programs, and/or support health systems and other industries. Therefore, while they include more. Similarly, rather than refer to specific disease some of the cheapest and most effective interven- categories, there have also been proposals to rethink tions (such as tobacco and alcohol taxation), they health systems to be better able to encompass all dis- may be politically difficult to achieve, requiring ro- eases, with a greater emphasis on primary health care bust, high-level leadership and/or effective impacts and community-based interventions [215-217]. to build partnerships and garner broad support. 38 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa TABLE 9: Population-Level Priority Interventions for NCDs Relevant to SSA (by Incremental Cost-Effectiveness) Area Interventions Status Cost-effectiveness Raise prices by raising taxes on tobacco BEST BUY Very cost-effective Inform on harm from use and benefits of quitting BEST BUY Very cost-effective Tobacco Enforce bans on tobacco advertising BEST BUY Very cost-effective Protect people from tobacco smoke BEST BUY Very cost-effective Offer counseling to smokers GOOD BUY Quite cost-effective Restrict access to retailed alcohol BEST BUY Very cost-effective Enforce bans on alcohol advertising BEST BUY Very cost-effective Alcohol Raise prices by raising taxes on alcohol BEST BUY Very cost-effective Enforce drink-driving laws (breath-testing) GOOD BUY Quite cost-effective Offer brief advice for hazardous drinking GOOD BUY Quite cost-effective Promote reduced salt intake BEST BUY Very cost-effective Promote replacing of trans-fat with polyunsaturated fat BEST BUY Very cost-effective BEST BUY in Promote public awareness about diet Very cost-effective combination Diet Restrict marketing to children of nutrient-poor food and bever- GOOD BUY Very cost-effective* ages, food high in salt, fats, and sugar Replace saturated fat with unsaturated fat GOOD BUY Very cost-effective* Manage food taxes/subsidies to discourage consumption of un- GOOD BUY Very cost-effective* healthy foods and encourage consumption of healthier options Physical BEST BUY in Promote physical activity (mass media) Very cost-effective Activity combination Legislation and enforce bicycle helmet use, 80% coverage BEST BUY Very cost-effective Injuries Speed cameras + breath testing + motorcycle helmets, 80% cover- BEST BUY in Very cost-effective (road age combination traffic) Seat belts + motorcycle helmets + bicycle helmets + speed cam- BEST BUY in Very cost-effective eras + breath testing, 80% coverage combination Source: Authors, based on [12, 64, 232-234] * Needs more studies, not yet assessed globally, therefore given only ‘good buy’ status. There have been a number of efforts in recent years the diversity or specificity of individual country con- to identify effective and cost-effective interventions texts, it does provide a broad indication of value for for NCD and RTI prevention [12, 226-229], and on money, and can form the basis of an evidence-based how much a combined approach would cost [230- policy package [12, 64]. 231]. Table 9 draws together a list of ‘best buys’ and In practice, ‘best buys’ or ‘good buys’ and other ‘good buys’7 for low- and middle-resourced coun- cost-effective interventions are not always pursued tries, countries with high adult and child mortality, [235]. This may be because of the reasons referred to and SSA. While this list does not take into account above such as difficulties related to political will, so- cial preferences, or vested interests. It may also be that 7 WHO defines ‘best buys’ as “highly cost effective, cheap, feasible, and cul- turally acceptable to implement�, and ‘good buys’ as “effective interventions most are based on cost-effectiveness studies derived that provide good value for money but which may cost more or generate less mainly from high-income countries or on their im- health gain�. An intervention is defined as very or highly cost-effective if the cost of generating an extra year of healthy life (equivalent to averting one plementation in ideal conditions rather than SSA re- DALY) is below the average annual income or gross domestic product (GDP) per capita (I$2 000); and ‘quite cost-effective’ if less than three times per alities. In the sections that follow, examples are given capita GDP per DALY. Interventions that are effective but which are three-fold more costly than per capita GDP per DALY are considered ‘less cost-effective’ where these interventions have been successfully im- or ‘not cost-effective’, depending on source, and are not included in this list. plemented in LMIC and particularly in Africa. Main data sources for globally applicable, cost-effectiveness estimates are the Disease Control Priorities project and WHO-CHOICE project. An Overview 39 Tobacco with the most successful tobacco control programs There is strong evidence, including from LMIC, to (South Africa, Mauritius, and Kenya) partnership show that tobacco excise taxes are an effective tool in between CSOs and government institutions is a key reducing tobacco use, particularly amongst the young feature, and NGOs in 15 African countries have pro- and the poor, as well as a reliable source of govern- duced ‘shadow reports’ monitoring compliance of ment revenues. Multiple-country examples and tech- their country with FCTC obligations [243]. nical guidance to assist implementation exist [236]. Increasing tobacco taxes by 10 percent will reduce BOX 3: Regional Response to Tobacco tobacco use by up to 8 percent in LMIC as well as an increase revenues by 7 percent [237]: in South Af- In 2011, the global tobacco epidemic killed almost six rica, for example, each 10 percent increase in price million people; nearly 80 percent of these deaths oc- reduces consumption by 6 percent. A focus on excise curred in LMIC. Cigarette consumption in Western Eu- taxes is recommended, relying more on specific than rope dropped by 26 percent between 1990 and 2009, ad valorem tax, especially where tax administration but increased in Africa and the Middle East by 57 per- is challenging. All tobacco products should be taxed cent during the same period. African countries are expe- as relative increases in the prices of cigarettes may riencing the highest increase in the rate of tobacco use lead to substitution by lower-price products – par- amongst developing countries: the number of smokers ticularly important given that smokeless tobacco in SSA is projected to increase 148 percent by 2030, to (snuff or chewing) is more common amongst youth 208 million smokers or one-fifth of the total population. and women. Arguments that higher taxes will have Africa is at a crossroads in its response to tobacco con- harmful economic effects, for example by encour- trol. On the one hand, countries in this region have be- aging smuggling or reducing employment, are false come an increasingly attractive market as tougher reg- or overstated [238]: in South Africa the tobacco in- ulations, high taxes, and greater consumer awareness dustry claims that illicit trade is 20 percent whereas in developed countries are ‘closing the door’ to tobacco research indicates it is only 10 percent, underlining imports and leading to reductions in use. On the other hand, cigarettes are becoming more affordable as in- the importance of scrutinizing data sources for mis- comes rise in many African countries. information or tobacco industry involvement [94]. Significantly, Africa is fighting back. In Africa, 42 percent Although the Framework Convention on Tobacco of countries have already signed the 2003 WHO FCTC, Control (FCTC) has entered into force in most SSA which binds them to a number of anti-tobacco measures. nations (40 by December 20128; see Box 3)[239], only Additionally, on June 3-5, 2012, the World Bank, in part- modest progress has been made in its implementa- nership with the Southern Africa Development Commu- tion. While many countries have legislation or poli- nity (SADC), the Ministry of Finance of Botswana, the cies on protection from exposure to tobacco smoke, Bloomberg and Bill and Melinda Gates Foundations, and only a handful meet required standards in imple- WHO, convened a high level forum on The Economics of mentation. Little progress has been made on pack- Tobacco Control: Taxation and Illicit Trade. With the par- aging and labeling of tobacco products and while ticipation of delegations from the Ministries of Finance, slightly better progress has been made in banning Trade, and Health of 14 SADC member countries, the aim tobacco advertising, promotion, and sponsorship, of the forum was to promote dialogue on best practices again this is not to required standards [240]. Lessons in effective design and administration of excise taxes from a review of African countries are that an ac- on tobacco as an instrument to promote public health, and to share knowledge on the dimensions, causes, and tive tobacco control civil society movement, politi- extent of illicit trade in tobacco products and strategies cal will, and active research support are significant to control it. The involvement of high-level officials from contributors to success [241-242]: in the countries different sectors in the forum underscored the potential for multisectoral collaboration and action to prevent 8 At the time of publication, in SSA, Mozambique and Ethiopia have signed but not ratified or entered it into force, and Eritrea, Malawi, and control tobacco addiction that contributes to ill Somalia, South Sudan, and Zimbabwe have not signed, ratified, or health, disability, and premature mortality in Africa. entered it into force. 40 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa Partners such as those in agriculture, trade, fi- mon practice for drunk driving and car crashes. In a nance, justice, public health, and NGOs all have a recent global survey of 44 SSA countries, only nine role to play, particularly in countries where tobacco countries had a national drink-driving law based on is an important cash crop, and the support of inter- Blood Alcohol Concentration, and only one country national agencies is relevant in developing alterna- (Botswana) rated their enforcement of drink-driv- tive livelihoods and crop diversification. Regional ing laws as good [59]. Although 25 countries had cooperation is also important in counteracting il- targets for reducing alcohol-impaired driving, most licit trade and in south-south capacity-building: the were unable to measure or monitor the prevalence Kenyan Revenue Authority, for example, has been of the problem. active in sharing its experience and supporting other countries in supply-chain control, tracking and trac- Food ing technology, and enforcement [94]. SSA already has a mixed picture of malnutrition and overweight/obesity, and both can contribute Alcohol to NCDs. Efforts to improve food security and al- A substantive evidence base also shows that mak- leviate under-nutrition include improvement of ing alcohol more expensive and less easily available, agricultural productivity, pro-poor primary care, banning alcohol advertising and its promotion, and and food programs [247]. The time from concep- enforcing drink-driving legislation or countermea- tion until two years of age is a critical period when sures are cost-effective in reducing alcohol-related length-for-age can be improved by high-quality harm [244]. nutrition. Yet, care must be taken, learning from Increasing alcohol prices, usually through raising some programs in Mexico, Chile, and Brazil where alcohol taxes, is particularly effective among prob- under-nutrition was traded for over-nutrition lem drinkers and youth. Restrictions on availability [248-249] – programs that miss the main opportu- include restrictions on sales and consumption by nity for height recovery, or that continue to supply people below a legal drinking age: in some coun- energy-dense foods to children who already meet tries the age for legally buying alcohol is as low as weight-for-age criteria, can unintentionally in- 15 years (Angola). Another means for restriction is crease overweight [250]. through government control of alcohol distribution For NCD prevention, traditional diets, which for and sales: in the Gambia, for example, there is a state example are high in added salt or sugar or low in monopoly on the production and sale of beer, and vegetables, could be improved from nutritional and alcohol advertising is banned on national television public health perspectives. Effective salt-reduction and radio. strategies for a country depend on whether salt con- Restriction of alcohol marketing is one of the most sumption is largely non-discretionary (that is, it is promising strategies for governments in developing added during food manufacture) or discretionary countries [245]. Sophisticated marketing strategies (that is, added during cooking or at the table) [251]. target African youth, with alcohol portrayed as a For most countries, it will mean a focus on the food symbol of heroism, courage, and virility, and infor- industry and reformulation of products [252-253]: mation on the risks are missing or on a small scale in South Africa, it has been estimated that reducing [246]. the salt content of bread, soup mix, seasoning, and Nevertheless, the infrastructure for enforcement margarine could achieve 7,400 fewer CVD deaths and the monitoring of restrictions and regulations and 4,300 fewer non-fatal strokes per year [254]. may be missing. In the Gambia, the mandatory health The potential for intervening in agricultural poli- warning message on alcohol advertising is rarely en- cies to encourage healthy eating appears limited, but forced [96]. Violation of laws and regulations can there are important links among agricultural poli- extend to the practice of ‘shaking hands’ (requesting cies, food industry choices, and consumer diets, and and providing bribes to the police), an all-too-com- so the food supply chain as a whole needs to be taken An Overview 41 into account [255]. Brazil has used a combination of Physical Activity and the Imperative fiscal and other legislation to protect and improve of Road Safety its traditional food system: supporting cooperatives Increased communications about healthy eating and and small-scale farmers to produce green vegeta- physical activity as part of programs of information bles and other fresh foods, and helping to protect and education at the sub-national and national levels and stabilize prices of healthy staple foods and in- could be used to reinforce legislation and other in- gredients so that they become more affordable and terventions. An important factor is the design of ur- available [256]. Brazilian children are entitled to one ban environments and road and transport systems, meal per day at school and legislation also requires which can be influenced to promote or maintain that at least 30 percent of the national budget for physical activity. school lunches be spent on fresh foods from local/ family farms [87]. Keeping people physically active as part of daily living is important for counteracting obesity [264]. The market for snacks, soft drinks, and processed A health-supporting and safe environment that foods is growing fastest in LMIC, and its correla- facilitates walking and cycling can be part of a tion with higher tobacco and alcohol sales suggests common industry tactics [257], enabled by rising pro-growth, pro-health, and pro-poor transport incomes and weak regulation. Use of fiscal pric- strategy, helping increase urban productivity, re- ing (tax or subsidy) policy instruments have also duce poverty, and improve health [265]. Only two been proposed to influence food consumption SSA countries have national policies that encour- patterns to favor the intake of healthier, less en- age walking and/or cycling as an alternative to car ergy-rich foods and drinks [258]. For prevention travel, and only 10 SSA countries have national of overweight and obesity, evidence suggests that policies to separate road users as a way of protect- non-trivial pricing interventions could impact on ing vulnerable road users [61]. weight, particularly among children, adolescents, As discussed in Box 4, consistent with the goals of low socio-economic populations, and those most the 2011-2020 UN Decade of Action on Road Safety, at risk, but that small taxes or subsidies have little a safe and efficient road and transportation environ- effect [259-260]. Restricting the promotion of en- ment is needed in Africa which gives high priority ergy-rich, high fat, and high sugar foods to young to large-scale traffic calming measures, pedestrian children through advertising on television or in infrastructure, and the provision of safe transport schools can be achieved through government-sup- space for pedestrians and cyclists alongside major ported forms of self-regulation and statutory mea- arterial roads [105, 266]. sures [261-262]. Good and safe roads are increasingly seen as a International efforts could be made to prohibit critical investment for enhancing competitiveness the hydrogenation process that generates industrial and resilience in Africa. International experience saturated fats and trans-fats. Governments also need shows that the most effective and sustainable way to mitigate the impact of large transnational food to make roads safer is to adopt a “safe system ap- corporations, some of which have headquarters proach�. The good news is that multilateral devel- within African nations: for example, many of the opment banks, including the World Bank, have South African “Big Food� companies, particularly the supermarket chains, have invested in other Afri- committed to supporting countries in developing can nations [263]. For the ultra-processed food and sustainable “safe systems� to prevent road traffic drink industries, as with tobacco and alcohol, there casualties, including mobilizing more and new re- is clear evidence that public regulation and market sources for road safety [267]. intervention can help prevent the potential harm The key challenge in most countries in SSA is caused by ‘unhealthy commodities’, and that these to build and strengthen institutions and capacity industries should not have a role in national policy to plan, manage, and implement road safety ini- formulation [86]. tiatives at national scale that go well beyond just 42 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 4: The Imperative of the 2011-2020 UN Decade of Action on Road Safety in Africa Unnecessary loss of life can be prevented by the adoption of measures that are clearly outlined in the five pillars of the ongoing 2011-2020 UN Decade of Action for Road Safety, which is supported by 103 countries worldwide. These are geared to: • Strengthening institutional capacity to further national road safety efforts, including activities such as establishing a lead agency for road safety in the country involving partners from a range of sectors and developing a national road safety strategy; • Influencing safe road design and network management to make roads safer for users, particularly the vulnerable (pe- destrians, cyclists, children, the elderly, bus passengers) and reducing the severity of crashes; • Making vehicles safer by adopting motor vehicle safety standards; implementing new car safety assessment programs; and ensuring that all new cars are equipped with seat belts that meet regulatory requirements and pass applicable crash test standards; • Influencing road user behavior through sustained enforcement of road traffic laws and standards and rules combined with public awareness/education activities; and • Improving post-crash care for the injured, including transporting them in ambulances or rescue helicopters to hospitals and clinics according to a pre-hospital screening process which determines the appropriate health facility to which to transport patients, rather than sending them to the nearest facility which might not have the capacity to offer needed care, to prevent further loss of life. adopting isolated interventions. The road safety States – have adopted a safe systems approach which system (Figure 15) is one scheme for drawing all is anchored in the long-term vision of eliminating these aspects together. road deaths. Under this approach, improved road Countries that have successfully reduced RTIs safety results depend on three inter-related ele- and fatalities – such as, Australia, Great Britain, the ments: institutional management functions, inter- Netherlands, New Zealand, Sweden, and the United ventions, and results [269]. Some African countries such as Ghana, Kenya, Namibia, Nigeria, and South Africa have in place FIGURE 15: The Safe System Model for Road Safety most of the elements of the safe systems approach but additional efforts are required to strengthen in- Safer travel stitutions and governance capacity for road safety, Admittance to system including that of the lead agency capacity to better Understanding (condition for entry/exit of vehicles and the road user) crashes and risk coordinate and manage an effective multisectoral response. Alert and compliant road users Sustained support from the highest levels of gov- Safer speeds ernment is needed to: (lower more forgiving of human error) • Strengthen the results focus of the lead agency and Human tolerance to physical force coordinate arrangements among sectoral institu- tions and different levels of government; Safer roads and roadsides • Promote active engagement by business, profes- Safer Vehicles (more forgiving of human error) sional, and non-government entities; • Implement policy reviews and institutional re- Education and forms to improve legislation and enforcement Safer travel spaces for Enforcement of information supporting road users pedestrians and cyclists road rules practices, accountability, and the capacity of orga- nizations, and the testing and licensing of drivers Source: [268] with an addition by the authors and the imposition of vehicle safety standards; An Overview 43 • Secure sustainable and adequate funding for the juries. Setting and enforcing speed limits reduces lead agency and key stakeholders, and strengthen RTIs by up to 34 percent, particularly among pe- their management and operational capacity to destrians, cyclists, and motorcyclists. The intro- achieve safety targets; and duction of speed cameras has led to a 14 percent • Enhance nationwide RTI-surveillance systems reduction in fatal crashes and a 6 percent reduc- to collect data, better understand the nature and tion in nonfatal crashes in developed countries. characteristics of the problem, and evaluate the re- • Comprehensive programs can improve road-user sults of interventions. behavior, but laws and standards need to be en- forced, monitored, and combined with public Sustained support is also needed to implement awareness and education campaigns to increase effective Interventions with a results focus. This re- seatbelt and helmet wearing and to reduce speed quires the following: and drink-driving and distractions such as texting • Road safety should be integrated in all phases of on mobile phones while driving. Only 11 coun- planning, design, and operation of road infra- tries in Africa have national speed limits on urban structure. Improved project design is helped by roads less than or equal to 50km/hour and allow analyses of the safety performance of road net- local authorities to reduce these, and only three works, conducted at the planning stage of new countries rate their enforcement of speed laws as road construction, and complemented by road good. Whereas 35 African countries have national safety audits and safety impact assessments. Also, seat belt laws, these only cover all occupants in 18 reviews of road sections with high concentrations countries, and only six of these rate enforcement of crashes help target investments towards places as good. Almost two-thirds of countries have na- with the highest crash-reduction potential. tional laws regulating the use of mobile phones while driving, but very few collect data to monitor • Intersection controls, crash barriers, signs, mark- use [59]. ings, traffic calming measures around schools, and road maintenance are effective interventions. • RTIs are also reduced by setting and enforcing le- gal blood alcohol limits and minimum drinking • Vehicle design and safety equipment: The use dur- age laws, using checkpoints to stop drivers ran- ing the daytime of cars and motorcycle lights, and domly to detect alcohol, and running mass media other safety technologies such as electronic stabil- campaigns to reduce drinking and driving. Other ity-control systems, seat belts, and airbags, con- measures, such as license revocation and suspen- tribute towards reducing road traffic crashes and sion, markedly reduce fatalities from alcohol-re- fatalities. Fiscal and transport policies, customer lated crashes. Measures to outlaw the use of cell information, and incentives can be used to ensure phones and texting devices by young drivers are motor vehicles reach internationally-agreed stan- starting to show positive results in countries such dards, provide high levels of road user protection, as the United States. and discourage the import and export of new or used cars with reduced safety standards [268]. • Effective post-crash medical care and treatment • Legal measures to improve road-user behavior can prevent deaths and limit the severity of inju- include: issuing graduated driving permits for ries. France’s Service d’Aide Médicale d’Urgence teenagers that require six months of driving with (Emergency Medical Assistance Service, SAMU), learners’ permits, curfews prohibiting driving be- and the effective service arrangement established, tween midnight and 5:00 a.m., and passenger re- for example, in Kenya, Nigeria, and Namibia, are strictions on the first year of driving after getting a good practices in this area. license. Mandatory seat belt use helps reduce road A strategy that simultaneously implements multiple traffic deaths and serious injuries once a crash has road safety interventions produces the most health occurred. Requirements on the use of motorcycle gains for a given investment [60]. The adoption by and bicycle helmets protect against fatal head in- governments and international agencies of “shared 44 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa value� principles [270], which combine economic and events or transition points in people’s lives, for ex- social concerns, could help redress road infrastruc- ample, entering school, starting work, becoming a ture deficits and implement the road safety agenda in parent, and retirement [273-275]. Behavioral strat- Africa. This approach is needed to generate collective egies in SSA need to take account of the socio-cul- action and help win political and community support tural context and consider whether and which inter- to implement the African Road Safety Action Plan ventions at individual, family, or community level 2011-2020, forge public and private partnerships to are likely to be effective[114, 129]. share the cost of enhanced infrastructure and inter- So-called settings approaches to health promo- ventions, and build institutional and management ca- tion are organized to reach defined populations in pacity to deal effectively with road safety challenges. a holistic way in their everyday life, in places “where they learn, work, play, and love�. These approaches Protection against Environmental in settings such as schools, workplaces, and prisons and Occupational Risk Factors seek to develop health-supporting environments, in- Particular hazards include those within the home, corporating the values of participation, equity, and for example indoor air pollution from use of stoves partnership. There have been healthy cities initia- burning solid fuels, exposure within the workplace tives in SSA (and other regions) for over a decade (for example in particular industries such as min- [276], and Africa has seen a significant development ing and agriculture), and exposure in the outdoor in health promotion in recent decades [277-278]. environment to solar radiation, urban air pollution, Almost all the countries in SSA have structures in and hazardous industrial and household waste [43]. place for health education or promotion, some in- Relatively low-cost, population-level prevention volving a diverse set of players, as in South Africa, measures lie with environmental and occupational Mauritius, and Uganda. There is a recognized need legislation and regulation, although environmental to build greater capacity of practitioners across gov- protection and occupational health standards need ernment and community sectors, and to establish to be monitored and enforced. Examples include a sustainable financing mechanism [279-282]. So- worker protection through health and safety mea- called ‘sin taxes’ (on tobacco and alcohol) have been sures; safe use of dangerous substances; as well as reg- proposed as a means of funding health promotion ulations to reduce contamination of drinking water foundations [283-284]. and soil to protect the public and environment and HIV prevention and control is probably one of bans on the use of asbestos. Better food storage could the best examples of good health promotion in Af- reduce aflatoxin-related liver cancers, and improved rica and some of these skills and resources may be water and sanitation could reduce the spread of in- transferrable. There is also potential for community fectious agents such as helicobacter pylori which are health workers and other community cadres (for linked to cancers. Enabling families to switch from example agricultural extension workers and com- traditional fires to fuel-efficient ventilated stoves that munity nutrition workers) to be mobilized to sup- fit their lifestyles would dramatically reduce harm- port more integrated approaches at the community ful indoor air pollution, carbon emissions, and use level. Most community health workers already have of wood fuel [271]. Policies that combine promo- a strong health promotion element to their work, tion and facilitation of active urban travel through have been selected on the basis of being respected walking and cycling alongside those promoting low- community members, and have the potential to act er-emission motor vehicles are a potential win: win as change agents at community level [285]. for both public health and climate change [272]. Strengthening integrated health promotion sys- tems and interventions that cover NCDs, commu- Promoting the Health of Individuals, nicable diseases, and maternal and child conditions Families, and Communities is a key policy issue. For some countries, there has Opportunities for health promotion occur through- been a gradual weakening of health promotion units out the life-course but particularly at significant of ministries of health, which is linked to limited An Overview 45 financing and external financing that is allocated A Focus on Determinants to specific interventions rather than to systems Programs need to take into account social determi- strengthening [286]. nants – the causes underlying causes – which influ- ence risk factors and behaviors; for example, gender Community-Based Interventions norms have implications for health prevention and The community, whether defined socially or spatially, care strategies in Africa [130, 295]. The discussion can be a good hub for health promotion in Africa, as on burden of disease in Section 2 highlighted clear elsewhere [277]. Community-based demonstration variations in the risk factors between women and projects for CVD prevention have been shown to be men; thus policies, interventions, and monitoring of effective in achieving reduced rates of CVD and risk impact need to be gender sensitive. Both the health factors, and given the common risk-factor approach and non-health sectors have roles to play in improv- these have been expanded to focus to NCD prevention ing day-to-day living conditions and addressing [287-288]. The approach is based on low-cost lifestyle the inequitable distribution of power, money, and modifications and community participation and is resources so that people have greater health oppor- generalizable, with the general principles the same re- tunities [296]. Investing in early child development gardless of the degree of development of the country and compulsory education at primary and second- [289-290]. Table 10 summarizes the main components ary levels can have strong returns, and comprehen- of a community-based intervention program. sive and universal social protection strategies would Any demonstration project to pilot and evalu- support a level of income for healthy living [128]. ate the approach in a country context should work Helping people change their behaviors can be dif- closely with national policy makers throughout, with ficult, and needs to take account of the challenges a view to scaling-up and country-wide dissemina- that face people and understanding what motivates tion. Shifting from project to program and ensuring and influences their behaviors and choices [297]. sustainability can be challenging, requiring invest- Successful NCD preventive interventions do make ment in the skills and capacity of community-based it feasible for people, including those in poverty, organizations and public health systems during a to adopt healthier lifestyles. Making the healthier phased transition [291]. choice the easier choice can be achieved through the TABLE 10: Components of a Community-Based Program for NCD Prevention A good understanding of the community’s needs, practices, beliefs and priorities, developed in Diagnosis close collaboration with the community itself Carefully planned activities that take account of the community context, including primary health care services, voluntary organizations, food shops, restaurants, work sites and schools, that link Planning with any existing strategies for identifying and targeting people at high risk, and which build upon the existing skills and resources within the community Messages and interactions to provide information and reinforce behavior change, using the most Communication effective channels (media, peer-to-peer, opinion leaders, and so forth) Equipping practitioners with the necessary skills and competencies to carry out cost-effective Interventions interventions, ensuring the community is exposed to an effective dose of the intervention Working with community organizations and sectors such as education, transport, environment, Health-Supporting and spatial planning to help change social and physical environments to make them more health- Environments supporting and conducive to health and healthy life-styles Monitoring the change process and evaluating the interventions and program objectively and in Evaluation terms of the community’s perceptions, and including an economic component in the evaluation where possible; disseminating results so that other communities can benefit Source: Authors, adapted from [275, 292-294] 46 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa creation of health-supporting and enabling environ- 5.3. Clinical Services for Individual- ments (for example, through urban design, such as level Prevention the nature and location of buildings and transpor- tation routes), the presence of encouraging mecha- There are some relatively low-cost measures for pre- nisms (for example disincentives and incentives such vention and care which could be delivered to relieve as regulatory and fiscal measures, and food pricing), present suffering from NCDs and prevent future in the way that choices are presented (for example, burden (Table 11). opt-out rather than opt-in), and engagement (for example getting people involved in designing initia- Cardiovascular Risk Management tives) [298-299]. A combination of population-level and individual Conditional cash transfer programs have proved strategies is needed for cardio-vascular risk reduc- effective in increasing the use of preventive services tion [305]. For primary prevention of coronary heart and improving health status, leading for example to disease and stroke, it is more effective and less ex- better nutritional outcomes in children [300-302]. pensive to manage according to assessment of the Nevertheless, given their dependence on effective risk of having a cardiovascular event within 10 years primary health care and mechanisms for disburse- (total cardiovascular risk score) rather than to use ment of payments, careful introduction with rigor- arbitrary thresholds such as levels of single risk fac- ous evaluation is needed for low-income countries tors such as hypertension; this is so, also in Africa with limited health system capacity in SSA, so as to [305-306]. For people at very high risk – that is, at replicate the benefits seen elsewhere [303-304] and least a one in four chance of a cardiovascular event minimize potential negative associations [248]. within 10 years (10-year cardiovascular risk ≥ 25 TABLE 11: Priority Interventions for NCDs Relevant to SSA Involving Clinical Services at Population- or Individual-Level (by Incremental Cost-Effectiveness) Area Interventions Status Cost-effectiveness Very cost-effective Hepatitis B vaccination to prevent liver cancer BEST BUY Quite low cost Feasible (primary care) Very cost-effective Cancer VIA at age 40 (50% coverage) with treatment of pre- Very low cost BEST BUY cancerous lesions to prevent cervical cancer Feasible (primary care) (treatment may require referral) Cost-effective (depending on HPV vaccination at age 12 (US$0.60 per dose) GOOD BUY price of vaccine) Counseling and multidrug therapy (including glycemic control for diabetes) for people 30 years or over with 10 year risk of fatal or non-fatal Very cost-effective cardiovascular events of 30% or more (includes BEST BUY Quite low cost prevention of recurrent vascular events in people Feasible (primary care) CVD and with established coronary heart disease and Diabetes cerebrovascular disease) Very cost-effective Aspirin therapy for acute myocardial infarction BEST BUY Quite low cost Feasible (primary care) Quite cost-effective Respiratory Treatment of persistent asthma with inhaled GOOD BUY Very low cost Disease corticosteroids and beta-2 agonists Feasible (primary care) Source: Authors, based on [12, 64] An Overview 47 percent) – or those who have suffered a previous car- [311]. Male circumcision is associated with a weak diovascular event, a regimen of aspirin, statin, and reduction in the prevalence and incidence of high- blood pressure-lowering drugs may significantly re- risk HPV and increased clearance of infection [312- duce their risk of death from CVD, and can lower 313]. Given that licensed HPV vaccines are highly the risk of recurrent cardiovascular events with mul- effective against only a limited number of HPV tidrug therapy for secondary prevention (that is, for types, these interventions are likely to be synergistic those who have had a heart attack or stroke already). in countries without well-established programs for This regimen is considered highly cost-effective for cervical screening [314]. SSA [227]. There are a number of strategies available for cer- There are three particular challenges in SSA vical cancer prevention and the balance of vaccina- for implementing total cardiovascular, risk-based tion, screening, and treatment needs to be according guidelines [307]. First, current physicians would to country context. For Sub-Saharan African coun- need educating to change practice from targeting tries characterized by low income, high mortality and treating individual risk factors such as hyper- and low treatment levels, increased coverage of treat- tension to using total cardiovascular risk. Second, ment with or without screening would be cost-effec- simplified ways of measuring risk would be needed tive, as would one-off PAP or VIA screening at 40 where laboratory facilities for biochemical measure- years of age or vaccinations (at $0.60 per dose) [229, ment are limited, using for example non-laboratory 315]. The VIA method does not require laboratory tools for risk assessment which assess risk quickly facilities and can enable treatment of pre-cancerous and cheaply, avoiding the need for cholesterol values lesions [229, 315-316]. Where resources are limited, [308]. Third, better access to cheap, effective medica- cost-effectiveness could be improved with targeted tion is needed, given the lower use of secondary pre- screening and by directing vaccinations towards vention medication in rural areas and in countries people infected with HIV, since HIV infection is as- with lower income levels [309]. sociated with increased risk of cervical cancer. Box 5 describes examples of approaches taken by various Vaccination, Circumcision and Screening countries. Given the present high cost of HPV vaccines, Several highly cost-effective interventions to prevent countries need to decide the best strategies for their NCDs in SSA are available, often borrowing from in- context, based on the evidence, in order to allocate terventions more commonly used for communica- resources efficiently and equitably. While the GAVI ble diseases. Alliance has recently decided to support the intro- As the epidemiology suggests, for many LMIC, duction of HPV vaccines [320], and public-pri- most African CVD is not currently ischemic. Pre- vate partnerships exist to make breast and cervical vention can include rubella vaccination of women screening as well as HPV vaccination more available to prevent some forms of congenital heart disease and affordable in SSA (see for example [321]), coun- in their offspring, and controlling rheumatic heart tries still need to consider the longer-term budge- disease through treatment of suspected streptococ- tary implications for sustainable programs, and en- cal sore throat with penicillin (primary prevention), sure that effective treatment is available for detected and register-based prophylaxis with penicillin for lesions [322]. patients with a history of rheumatic fever, heart Early detection and screening programs could failure, and/or rheumatic heart disease (secondary achieve down-staging of the targeted cancers within prevention) [310]. Vaccination is also possible for five years, and could reduce mortality within ten viruses associated with liver cancer (HBV) and cer- years. For both programs, methods need to be ac- vical cancer (HPV) [26]. cessible, benefits need to outweigh potential harmful For prevention of cervical cancer, as for HIV, there effects (such as over-diagnosis and unnecessary in- is promotion of safe sex, use of condoms, avoid- tervention), and diagnosis, treatment, and follow up ing harmful use of alcohol, and male circumcision procedures need to be in place with quality assurance. 48 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 5: Cervical Cancer Screening The 2012 World Development Report “Gender Equality and Development� found that, while many disadvantages faced by women and girls have shrunk thanks to development, major gaps remain [317]. A significant gap is the excess female mortality, especially in childhood and during reproductive years. Cervical cancer — a preventable condition that usually results from a viral infection by HPV that is generally sexually transmitted — is one of the leading causes of premature death and ill health among women in SSA. Eastern, Western, and Southern African regions have the highest incidence rates of cervical cancer in the world. Rates exceed 50 per 100,000 of populations, and age-standardized mortality exceeds 40 per 100,000. This situation is due to minimal screening services for cervical cancer, resulting in a significant number of patients diagnosed with advanced-stage disease. In Eastern and Southern Africa, it is compounded by the high preva- lence of HIV (HIV-positive women are 4-5 times more likely to develop cervical cancer). A key problem in most cases is the limited health-system capacity to conduct widespread cytology screening – through microscopic examination of cellular specimens, accurate diagnosis of pre-cancerous lesions, and appropriate referral and treatment. This care pathway, which is common in developed countries, is work-intensive and expensive as it usually requires multiple visits, screening at reg- ular intervals, modern laboratory infrastructure, and specialized personnel. Also, among 20 countries reporting cervical cancer screening activities in 2009 in Africa as a whole, only 11 had ongoing country programs; and of 49 projects initi- ated, only six were funded by the domestic government [318]. Taking into account the health system limitations in Africa, reducing excess female mortality due to cervical cancer, partic- ularly among HIV-infected women, is likely to be feasible through lower-cost but equally effective “see and treat� screen- ing procedures, adopted and integrated into existing service-delivery platforms – such as maternal and child health pro- grams or HIV/AIDS prevention and control programs. Botswana and Zambia are already starting to use this cost-effective alternative to confront cervical cancer. A demonstration program in Botswana illustrates the point for cervical cancer prevention among HIV-positive women at a community-based clinic in Gaborone. As documented in a recent study [316], faced with resource limitations that hin- dered the expansion of cytology-based screening, the “see and treat� approach was introduced using the VIA procedure and enhanced digital imaging (EDI), as well as cryotherapy to destroy abnormal tissue in the cervix by freezing it. Between 2009-2011, slightly over 11 percent of the women screened were found to have low-grade lesions; 61 percent had a nor- mal examination result; and 27.3 percent were referred for further evaluation and treatment. In Zambia, the implementa- tion of the ‘see-and-treat’ approach linked to HIV care has also shown that it enhances the impact of the HIV/AIDS program by preventing cervical cancer in women living longer on ART who had never been screened [319]. These results indicate that the low-cost, “see and treat� approach for the prevention cervical cancer is a feasible and ef- ficient alternative, especially for reaching women living in distant and/or underserved regions of countries with limited access to cytology-based screening services. The results also show that this alternative has a significant impact on the early identification and treatment of precancerous and invasive cancerous lesions in HIV-infected women. 5.4. Therapies – Treatment, Care, and For countries with facilities able to make a rapid Rehabilitation diagnosis of acute myocardial infarction, relatively cheap and effective interventions exist that can re- Treatment of Conditions duce the relative risk of dying, such as drug treatment There are a number of effective interventions avail- with aspirin and atenolol and, in urban centers or able for treating NCDs. Lists differ by source but day hospitals with well-trained staff, the use of strep- some of those more commonly considered cost-ef- tokinase [307]. Acute treatment of stroke with aspi- fective are given here as a guide for decision mak- rin or by provision of a stroke unit is considered less ers. These are not exclusive or prescriptive, given cost-effective for SSA (cost per DALY of more than that local considerations need to be taken into ac- three times the average per capita income) [323]. For count within individual country contexts, notably patients with congestive heart failure, mortality risk epidemiology, health infrastructure, financing, and can reduced by the use of diuretics, exercise training, government support. and drug treatment for hypertension. An Overview 49 Several interventions for diabetes management are dardized protocols is important, prioritizing which effective and can help reduce complications such as cancers to include in an early detection or screening blindness, neuropathy, and diabetic foot and ampu- program [331]. There is limited availability of basic tation. Where resources are limited, blood pressure cancer therapies in SSA (Figure 16) public health control is one of the most feasible and cost-effec- systems: even where stated to be available, this may tive interventions for people with diabetes. Tight only mean a few facilities in the whole country [64]. glycemic control for people with hemoglobin-A1c (HbA1c)-values greater than 9 percent can reduce FIGURE 16: General Availability of Cancer microvascular disease, and foot care for those at Therapies in the Public Health System in SSA high risk of ulcers can reduce serious foot disease [324]. Annual eye examinations and treatment of 40% retinopathy can reduce serious loss of vision [323]. 35% Proportion of SSA countries stating availability of COPD is irreversible and progressive, and cur- 30% therapy in public health system (n-47) rent treatment options produce relatively little gain 25% relative to the cost [325]. Patients with asthma can be managed in general health services with inhaled 20% drugs such as salbutamol, and additional corticos- 15% teroids if persistent, avoiding costly hospitalization 10% [326]. Avoidance of environmental triggers such as secondhand smoke and smoke from combustion of 5% solid cooking fuels can also reduce acute exacerba- 0% Oral Morphine Radiotherapy Chemotherapy tions. Treatments too frequently rely on expensive imported drugs, with wide variability in cost across Source of data: Global Health Observatory Data Repository: http://apps.who.int/ghodata/ countries [327], but initiatives are underway to en- able countries to procure quality-assured inhaled drugs at lower prices to improve access [328]. A Public-Health Approach to Palliative Care In a population where the majority of cancers In a region where most cancer is diagnosed late, im- amenable to early detection are diagnosed at late provement in quality of life and relief from moderate stages, establishing an ‘early diagnosis’ program may to severe pain could be achieved relatively inexpen- be the most feasible strategy to reduce the propor- sively by improving access to pain management and tion of patients presenting with late stage cancer, and supportive care, particularly at home and at the pri- improve survival rates [329]. Such a program would mary-care level [332]. involve raising awareness amongst public and health Access to pain relief and symptom control is poor professionals of the common signs and symptoms of in many developing countries [333-335]. In SSA, an cancers such as breast, cervical, colorectal, and skin, estimated 88 percent patients with cancer pain are that may be amenable to effective treatment with without relief [336]. Although some palliative care limited resources. programs exist in Africa for cancer and other dis- Some cancers may not be amenable to early di- eases such as AIDS [337][Box 6], the general lack of agnosis but nevertheless have a high potential for awareness, policy, and provider skills add barriers to being cured, such as childhood leukemia, or have accessing pain medication [338]. a high chance for significant prolongation of sur- vival, such as breast cancer and advanced lymphoma Emergency Care and Rehabilitation [64]. Treatment options need careful selection based For victims of road traffic crashes as well as stroke, on evidence and the resources available [330]. In there is a need to improve responsiveness and the low-income countries, improvement in the quality ability of health and other emergency systems to and coverage of cancer treatment following stan- provide appropriate emergency treatment and lon- 50 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 6: Palliative and End-of-Life Care for AIDS, victims receiving minimal or no treatment in the Cancer and Other Conditions field, and with hospitals and their staff not equipped to provide trauma care [345]. Even if admitted to a Uganda was the first country in Africa to include palli- more sophisticated unit, disabilities are often inad- ative care for chronically and terminally ill people as a equately assessed and rehabilitation services not in priority within its National Health Policy in 1999 [337]. place for the vast majority of cases [346]. This situa- It later participated in a joint project with four other countries – Botswana, Ethiopia, United Republic of Tan- tion results in a great loss of human potential. Ghana zania, and Zimbabwe – and WHO to improve the qual- is probably not the only country in which 95 percent ity of life of AIDS and cancer patients by developing of disabled people have had no access to rehabili- comprehensive palliative care programs with a com- tative services [347]. A study in Nigeria found that munity-health approach [339]. ART has not removed RTIs resulted in disability for 29.1 percent of sub- the need for palliative care. Around one-quarter to jects, of whom 67.6 percent were unable to perform one-third of patients on ART can experience virological failure [340], and despite treatment, HIV-related can- activities of daily living; 16.7 percent consequently cers still develop, pain persists, and psychological and lost their jobs, and 88.6 percent had a reduction in spiritual need continues [341]. earnings [348]. Palliative or end-of-life care for people, irrespective of cause or condition, is scarce across the continent 5.5. Strengthening Health Systems [342]. One study mapping such initiatives during 2003- 05 found services in only 26 countries, and only in Countries’ ability to address chronic disease is Uganda, South Africa, Kenya, and Zimbabwe were they limited by challenges in many aspects of health sys- integrated into the existing health system [343]. The tems; notably, governance, financing, medicines and nature of palliative-care needs and services in SSA re- technologies, service delivery, workforce, and in- flects their development in the context of poverty and formation [349]. The challenges are not related just AIDS, and include pain and symptom control, psycho- logical support, and financial support for food, shelter, to the income or development level of the country. and funeral costs. Such a holistic approach is likely to The shortcomings are hampering progress to com- be relevant for any life-threatening condition. The Afri- municable disease control and MDG targets, and can Palliative Care Association advocates for palliative responding to NCD and RTI needs is likely to be care to be an integral part of health systems (with ser- even more challenging. Box 7 illustrates the man- vice delivery models that span diseases), and promotes ner in which countries as diverse as South Africa, south-south collaboration [344]. Mauritius, Ghana, and Kenya are working to assess the health systems challenge posed by NCDs and to ger-term rehabilitation. Prompt emergency care can address them comprehensively. save lives, reduce the incidence of short-term dis- ability and dramatically improve the long-term con- Governance sequences for victims and their families [63]. A well-governed health system should have clear Setting up a single, nationwide telephone number goals, participation of relevant stakeholders, trans- for emergencies could help simplify matters [202], parent policies, oversight, and accountability [356]. but one-third of SSA countries have no emergency Weak governance impedes the work to improve number, and in another third there are multiple health-system effectiveness and health outcomes, numbers which leads to inefficiency in dispatch and, to some extent, may reflect the wider gover- [61]. Five countries have no ambulance services, and nance-environment in a country [357]. As already described in Section 6.1, in SSA relevant policies in only nine countries do a reasonable proportion frequently do not exist or are poorly implemented, (50 percent or above) of injured patients reach hos- and regulatory frameworks are not in place or are pital by ambulance. weakly or not enforced. Performance management There is a lack of resources for emergency response in African health systems is hindered by the ab- and care, especially in rural areas, and there is evi- sence of robust indicators of quality of services as dence of inconsistent pre-hospital care with most experienced by citizens. Inadequate monitoring and An Overview 51 BOX 7: Country Responses to NCD Challenges In Namibia, a September 2012 report from the Ministry of Health and Social Services emphasized the manner in which health systems need simultaneously to address the challenge of undernutrion and overnutrition [350]. An estimated 29 percent of Namibian children (under five years of age) are classified as stunted, with 17 percent classified as underweight, and 8 percent classified as wasted. However, slightly more than 4 percent of Namibian children (under five) are classi- fied as overweight or obese – with this figure reaching 7 percent of children (under five years of age) in urban settings. Among women 16-49 years of age, 6 percent were moderately or severely thin, in contrast to the 28 percent of women considered either overweight or obese. Data based on health facilities indicates hypertension and diabetes as the first and second causes of disability among adults, respectively. The proportion of NCD-related deaths was estimated at 8 percent in 2007. The Namibian Ministry of Health and Social Services is focusing on addressing these challenges within the context of its broader efforts at developing the country’s health systems. In Mauritius, recent data indicates that NCDs represent an estimated 80 percent of the total disease burden and account for 85 percent of total deaths each year. Surveys on the prevalence of NCDs and risk factors indicate that among adults 30 years and older, there is a 19.3 percent prevalence of diabetes, 30 percent prevalence of hypertension, and 38 percent of the population is either overweight or obese. In addition, 39.3 percent of the population smokes tobacco, and 19.1 percent have been classified as heavy drinkers. In response to such data, Mauritius is implementing a national strategy to address NCDs, which involves the use of mobile clinics/medical teams to address primary prevention at community level (including schools and workplaces), a community-based network of health centers and community health centers to address prevention needs at the secondary level, and a structured prevention program at the tertiary level (involving specialized units in all regional hospitals) [351]. In South Africa, the 2000 Burden of Disease Study indicates that NCDs accounted for 37 percent of deaths and 16 per- cent of DALYs, while the leading causes of death were HIV/AIDS (30 percent), intentional injuries (7 percent), and uninten- tional injuries (5.4 percent). It should be noted that the high coverage of the ART program has transformed HIV/AIDS into a chronic disease as the needs of ART patient now resemble those of patients with NCDs. Additionally, the urban poor bear the heaviest burden of NCDs, in addition to other diseases. Alcohol use, tobacco smoking, and excessive weight are responsible for 13.9 percent of total DALYs and nutrition is a major challenge to South Africa’s NCD epidemic, with the average diet high in sodium and fat consumption. Nationally, 60 percent of women and 31 percent of men are either obese or overweight [352]. The South African heath system has responded to this challenge at the facility level through the integration of care for NCD and communicable chronic conditions, expanded outreach by primary health care teams at the community level, and with a greater focus on human resource management and health information programs to support these initiatives [353]. In Kenya, NCDs are estimated to contribute 33 percent of total mortality and over half of the top 20 causes of morbidity and mortality. About 53 percent of all hospital admissions in Nairobi are due to NCDs, with diabetes contributing 27.3 percent of this figure. Smoking prevalence is 26 percent among adult males and alcohol use prevalence estimated to be 20 percent. HPV prevalence in women is estimated to be 38 percent. The national strategic response to NCDs involves strengthening health services for the integrated prevention and management of chronic diseases, as reflected in the annual operating plans for the health sector and the integration of NCDs into the primary health care system. Achieve- ments, to date, include improved human resource capacity, provision of medical equipment and other supplies to ad- dress NCDs, infrastructure improvement for expanded service delivery, and routine screening for NCD risk factors during routine health facility visits [354]. In Ghana, stroke and hypertension have been among the leading causes of hospital deaths for over 20 years. The esti- mated adult prevalence of diabetes in Accra increased from 0.4 percent in 1956 to nearly 7 percent between 1998 and 2002. By 2003, an estimated 35 percent of women in Accra were classified as obese, with 40 percent hypertensive and 23 percent hypercholesterolemic. Although the public health response to NCDs has been described as limited to date, the government is now processing nine health-related bills (including a tobacco bill) into law [355]. There has also been a fivefold expansion in the uptake of clients screened for cervical cancer using VIA in an Accra hospital, following an intensive health educational campaign. The recently introduced District Health Information Management System is an- ticipated to serve as an integral tool in capturing preventive and clinical service outputs, thereby enabling the collection of more accurate and timely NCD-related data at decentralized levels in the future. 52 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa assurance of the quality of services within govern- to respond to the challenge of NCDs [8]. This may re- ment limits return on investment for management quire institutional adaptation and new ways of work- of NCDs [358]. Reviews of health governance in ing [364] and examples are emerging (Box 8). Kenya, Nigeria, and Rwanda found that citizens and civil society commonly had minimal roles in policy- Health Financing making processes, and where there were also struc- In 2010, total expenditure on health (THE), as a per- tural and institutional weaknesses and capacity gaps, centage of GDP, was 6.5 percent for the WHO Afri- the responsiveness of services and accountability of can Region, slightly up from 5.8 percent in 1995, and government was further limited [359-361]; lower than the global average of 10.4 percent. Simi- Nevertheless, all is not gloomy. Africa has made larly, health, as a share of total government expendi- recent progress in improving governance, including ture, registered a modest increase, from 9.8 percent better economic governance and public financial in 2004 to 10.8 percent in 2010. The average per ca- management, respect for human rights, and the rule pita total health expenditure for SSA countries has of law [362]. CSOs are emerging and growing and, more than doubled, increasing from US$32 in 1995 together with other non-state actors (professional to US$84 in 2010 [366]. This may seem relatively groups and private sector), are starting to play im- good compared with regions of similar GDP per ca- portant roles in providing checks and balances to pita [367]. Yet, much of the increase is from external government, and demanding accountability and sources. There is also a wide variation across coun- transparency. tries in the magnitude and level of increases. And There is emerging consensus that population health in 2009 there were still 21 African countries fall- is not an outcome of a single ministry but involves ing short of the minimum THE per capita (US$44) a wide range of actors and a synergetic set of poli- needed to ensure universal access to even just a cies [363]. The UN Political Declaration called for a limited set of essential health services focusing on whole-of-government and a whole-of-society effort HIV, TB, malaria, maternal and child health, and BOX 8: Integration of the Health Sector in Botswana Botswana is one of the countries hardest hit by HIV/AIDS. In response, the Government of Botswana, along with signifi- cant support from international development partners, invested heavily in the health sector to provide a comprehensive response to the epidemic. Although the creation of a completely separate department of HIV/AIDS within the Ministry of Health (MOH) has enabled Botswana to be a leader of the AIDS response in the region, the epidemic has overstretched the capacity of the health workforce and created fragmentation in the overall planning of the health sector. The MOH has embarked on an ambitious agenda to harmonize and align health-sector planning, financing, and moni- toring and evaluation. These include: revising the national health policy to reprioritize health issues; a more appropriate focus on key diseases and conditions beyond HIV/AIDS; improving organization and management of the sector with the inclusion the private and NGO sectors as well as traditional medicine; and redressing health service weaknesses to attain the MDGs. The MOH has also begun designing an Integrated Health Sector Plan, which will be a ten-year strategic plan to guide the country in tackling current priority problems, and preparing for future health needs. They have also com- mitted to restructuring the MOH to merge the Departments of HIV/AIDS and of Public Health, thereby creating a more streamlined approach to planning, care, and evaluation. A recent strategy agreed upon by the Government with the World Bank and technical partners such as the George W. Bush Institute’s Pink Ribbon Red Ribbon initiative, that mobilizes the coordinated participation of a diverse groups of in- stitutions such as US CDC, US PEPFAR, USAID, UNAIDS, Susan G. Komen Foundation, Bill and Melinda Gates Foundation, CARIS Foundation, pharmaceutical companies such as Merck, GlaxoSmithKline, and Bristol-Myers Squibb, and Becton, Dickinson and Company, IBM, and QIAGEN, is rolling out a Cervical Cancer Control Program. This will include cervical screening and HPV vaccination, and will use the HIV diagnostic and treatment platforms established across Botswana over the last decade, with key elements financed by the Botswana National HIV/AIDS Prevention Support Project. Source: Authors, adapted from[365] An Overview 53 some NCD prevention [79]. Many African LMIC vention, treatment, and rehabilitation) when needed are heavily reliant on external financing. External and without incurring financial hardship for the resources for health as a percentage of THE in 2010 whole population. To achieve this, countries need a ranged from 2 percent in Mauritius and Equatorial health-financing system that raises sufficient funds, Guinea to 63.8 percent in Malawi. External financ- protects people from financial impoverishment as- ing is volatile and uncertain, and a big issue for SSA sociated with health care costs, and uses resources is the fungibility of government spending and donor efficiently [371, 373]. This requires balancing trade- spending. There is evidence of a strong substitution offs among the populations, services, and costs that effect, with donor funding for health substituting for can realistically be covered. health financing by recipient governments, the effect Moving towards universal health coverage, as for being largest in low-income countries [368]. Donor example in Ghana, South Africa, and Tanzania, re- funding for NCDs is negligible, comprising only quires less-fragmented financing arrangements, less about 2-3 percent of overall development assistance reliance on out-of-pocket payments at the point of for health in 2007. service, increased financial protection for people in Some LMIC – notably Rwanda and Ghana – have the informal sector, and more equitable allocation of made significant progress in developing financing public resources [374]. systems towards universal coverage, although frag- Ways of raising additional resources for health in- mentation and sustainability can be a continuing clude better revenue collection, increasing the share problem. Many people have little financial protec- of government budgets for health, and more innova- tion against the high costs of health care. More than tive means such as increasing excise taxes on tobacco half (51 percent) of THE in the WHO African Re- and alcohol. As African countries with rich endow- gion is private health expenditure (global average ments of natural resources largely do not have good 37.1 percent) of which more than half (55.6 per- human development outcomes, including in health, cent) is out-of-pocket, ranging from 8.1 percent in natural resource wealth-management should con- the Seychelles to 90 percent in Guinea-Bissau [367]. sider both the long-term requirements for economic WHO estimates that if the proportion of THE that is growth when these revenues dwindle, as well as the out-of-pocket is below 15-20 percent, the incidence immediate need to increase public investment in of financial catastrophe caused by such expenses is health, education, and social protection to cut pov- negligible: in 2010, only 7 SSA countries were be- erty, reduce inequality, and build human capital as low the threshold of 15 percent [369-370]. Only 5-10 a key contributing factor to diversified growth over percent of people in SSA are covered by social pro- the medium and longer terms [375]. International tection in the event of lost wages during illness or aid may need to be restructured to better align in- pregnancy [371]. centives and goals. Performance- or results-based fi- Available resources must be used efficiently and nancing (RBF) which links funding to performance equitably to realize potential gains in health out- has been promoted as a means of achieving this. It comes. A study of Tanzania, Ghana and South Africa has been used for example by the Global Fund in found that although overall health care financing was HIV, TB, and Malaria programs [376] and the World progressive in all three countries, the distribution of Bank as a way of incentivizing health workers and service benefits favored richer people, despite illness health providers towards the achievement of health burden being greater amongst lower-income groups, goals. Overall, the evidence for the effectiveness of and access to necessary services was the main chal- these strategies in improving health care and health lenge to universal coverage [372]. in LMIC is mixed, and results depend on the design of the intervention; for example, who receives pay- Responses ments, the size of the incentives, the targets and how Many countries have embraced the goal of “uni- they are measured, additional funding and support, versal health coverage�, aiming to ensure equitable and contextual factors [377]. Rigorous evaluation of access to effective health services (promotion, pre- a randomized study in Rwanda demonstrated large 54 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa improvements in quality and quantity of care for of the affordability of medicines in LMIC, purchas- maternal and child health, and impact evaluations ing some common medicines for the treatment of are underway in many other countries. RBF is in- NCDs would impoverish a large proportion (up creasingly being adopted in SSA; currently there are to 86 percent) of the populations of many African three countries with nationwide programs and 14 countries [383]. countries with ongoing pilots [378]. Existing health resources could be used much Access is inadequate even for many items on the more efficiently. The WHO estimates that 20-40 list of essential medicines in most LMIC [382, 384- percent of resources spent on health are wasted, for 385]. Prices vary widely and are comparatively high example through medical errors, waste, and corrup- in developing countries, with affordability deterio- tion. Reducing unnecessary expenditure on, and in- rated as a result of the global economic crisis [386]. appropriate use of, medicines could save countries Availability may be worse for medicines for chronic up to 5 percent of their health expenditure [371]. diseases than for acute disease [387]. Figure 17 Replacing fee-for-service payments by capitation presents results for WHO African Region countries payments at the primary-care level can reduce in- to a WHO survey on the availability of NCD drugs centives for over-servicing. A significant step could in the public health system, although whether these be to link allocative efficiency and spending deci- are always physically available or require co-pay- sions with the practice of care. Evidence-informed ment is not clear [64]. clinical guidelines, together with quality standards and measurable indicators derived from them, can FIGURE 17: Availability of NCD Medicines in the be powerful tools to underpin pay-for-performance Public Health System in SSA schemes, hold providers accountable, and drive more efficient and equitable use of technologies. 100% Proportion of SSA countries stating availability of NCD 90% Also, as the Public Private Partnership (PPP) of medicines in public health system (n-47) 80% the Queen ‘Mamohato Memorial Hospital and Clin- 70% ics in Lesotho has shown, health PPPs are becoming 60% 50% more popular and could be structured to address 40% NCDs effectively along the medical care continuum 30% and, in a relatively short period of time, transform 20% the quality of care being provided to its population 10% [379-380]. There are four key factors driving govern- 0% in Sa mg) Tam tins di e CC lers E in s Me itors n cor ben ers Th inje de Pre diur s iso tics (10 s s ipr Oral xifen e ol AC ocker ide on irin tab um roi id ium in Be nsuli rm tam ne mi dro Gli lock Ste brom op rph e iaz cti a Sta ments to use the PPP model: (1) desire to improve 0 rg hib tfo nh Asp lone o tiso cla lbu I bl atr mo b so ta he dn atc ep operation of public health services and facilities and n oti Nic Hy to expand access to higher quality of services; (2) opportunity to leverage private investment for the Source: Authors from [496] benefit of public services; (3) desire to formalize ar- rangements with non-profit partners who deliver Under-funding, poor planning, and inefficient an important share of public services; and (4) more procurement, supply, storage, and distribution potential partners for governments as private health systems within the public sector may exacerbate care sector matures [381]. the problem, leading patients to the private sector where prices for generic medicines can be two- to Medicines, Vaccines, and Technologies three-fold higher than in the public sector, and ex- Drug costs make up a substantial part of the direct pensive branded products may predominate [349, costs of programs for chronic diseases [349]. Up to 371]. Weak systems may be exacerbated in countries 90 percent of the population in LMIC buy medicines where the involvement of multiple donor agencies through out-of-pocket payments [382]. In one study operating without any coordination can contribute An Overview 55 to fragmentation and/or duplication in distribution National Essential Medicines Lists need to include functions [388]. drugs for NCDs chosen by national experts based on Medicines may be of poor quality and the num- considerations of cost-effectiveness, budget impact, ber of cases of counterfeit medicines is increasing. affordability, and so forth. Challenges also exist around the promotion of ra- Lessons might be learnt from the scale-up of ART tional use of medicines: given the long-term market where transparency in price information, generic potential of drugs for ‘chronic diseases’, the phar- competition, and price negotiation helped achieve maceutical industry can be actively engaged in the dramatic decreases in price; some steps have already development of clinical guidelines which can lead to been applied in Brazil to reduce the cost of certain potential conflicts of interest [389]. cancer medicines [392]. A GAVI-like capacity at re- gional or global level could be useful to negotiate, Responses bulk purchase, and distribute vaccines and drugs. Equitable access to essential medicines, vaccines, Mechanisms such as Advance Market Commit- and technologies, their assured quality and safety, ments, as used for vaccines [393], could be consid- and their effective use by prescribers and consum- ered to offer an improved market for drugs now in ers are important goals [373]. For some NCDs, as development, ensuring that drugs are bought only if for AIDS, prevention may be aided by treatment: it they meet pre-determined standards of efficacy and is estimated that appropriate use of medicines alone safety and helping to assure a sustained and afford- could reduce the burden of NCDs by up to 80 per- able supply in the long term. cent [388]. Many patients will require long-term, if There are emerging concerns regarding intel- not life-long, access to medicines as well as other lectual property rights in relation to NCD drugs, equipment; living with Type 1 diabetes mellitus for particularly for cancer and diabetes, and how these example requires not just insulin but also syringes, might interfere with innovation models and ac- needles, and diagnostic and monitoring tools [390]. cess to treatments [394]. Since the WTO TRIPS Both price- and non-price barriers to access need (trade-related aspects of intellectual property rights) to be overcome. Improving purchasing efficiency, agreement, health officials need a good understand- eliminating taxes, and regulating mark-ups could ing of patent status in order to procure lower-cost reduce medicine prices; and more efficient procure- generic products, use health budgets efficiently, and ment and distribution of medicines would increase determine the ‘freedom to operate’ in research and access [385]. Guidelines for good pharmaceutical development of new medicines; this may require na- procurement have been published and capacity tional and regional capacity to be built. building and information exchange could improve An additional area requiring joint commitment essential procurement and regulatory capacities in and resources to strengthen the overall response to many countries [391]. NCDs, involves the need for improving governance Countries could save an estimated 60 percent of and regulation in the pharmaceutical sector, build- their pharmaceutical expenditures if they shifted ing upon ongoing efforts as noted in Box 9. from originator medicines to generic products, but only a few wealthy and middle-income countries do Health-Care Delivery so [371]. Most first-line drugs for the treatment of Health service delivery systems in LMIC are typi- NCDs are off-patent and inexpensive: even for can- cally more suited to providing episodic care for cer, many medicines are off-patent generics, costing acute conditions. Models for the delivery of care for less than US$100 per treatment course [214]. Ge- chronic conditions, such as integration of care across neric products could be promoted through patient levels, may be unfamiliar to policymakers and prac- and professional education, alongside technology titioners, and their establishment hindered by lim- assessment and evidence-based guidelines which itations of space, staff, systems, and infrastructure are enforced and adapted to the local situation. [211, 396]. To some extent, HIV/AIDS may have 56 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 9: East African Community Medicines Regulatory Harmonization Project Strengthening governance, regulations, and accountability in the pharmaceutical sector is an important challenge of health systems. Improved regulatory policies and harmonization of efforts can lead to more competitive markets, eco- nomic growth, improved access to new medicines, better quality of pharmaceuticals in circulation, and ultimately to bet- ter health outcomes. In 2009, a coalition of partners including the Pan African Parliament, NEPAD Coordinating and Planning Agency, WHO, the Bill and Melinda Gates Foundation, UK Department for International Development, and the Clinton Health Access Initia- tive came together to establish the African Medicines Regulatory Harmonization (AMRH) program. Working with African regional economic communities, the program’s goal is to increase access to good quality, safe, and effective medicines through harmonizing medicines regulations, and expediting the registration of essential medicines. With support from the Bill and Melinda Gates Foundation, the Global Medicines Regulatory Harmonization Multi-Donor Trust Fund (GMRH) was set up by the World Bank in 2011 to implement and scale-up AMRH activities. In 2012, the East African Community (EAC) became the first regional economic community in Africa to receive GMRH funding. The East African Community Medicines Regulatory Harmonization Project (US$5.5 million grant) is a five-year project that will be implemented in two phases. GMRH provides support for Phase I which covers the first three years (2012-2015) of the project. The project’s aims are: to harmonize medicine registration systems, to improve efficiency, and to enhance transparency in medicines registration among EAC Partner States (Burundi, Kenya, Rwanda, Tanzania, and Uganda). The results of this innovative partnership are expected to include: (1) EAC Partner States participating in harmonized medicine registration; (2) National Medicine Regulatory Authorities (NMRAs) using common integrated Information Management System; (2) NMRAs have a functioning quality management system in place; (4) regulatory capacity building in the region institutionalized; and (5) government, industry, and civil society partnerships improved. As the project moves ahead, con- tinuous dialogue and collaboration with local industry and civil society groups will be emphasized to improve the quality of technical standards being developed. Source: [395] made the situation worse, where vertical approaches The use of traditional medicine is widespread, to planning and managing health systems crowded often in parallel to modern medicine: in some SSA out pre-existing, more-integrated approaches and countries, 80 percent of the population rely on tra- attention to NCDs. ditional medicine for primary health care [399]. Health-care infrastructure is insufficient across all Payment is always out-of-pocket and can be sub- tiers of service delivery, not just in the case of facil- stantial: a national survey in South Africa in 2008 ities but also laboratory and diagnostic systems and found that there was widespread use and that almost capabilities. The WHO African Region as a whole three-quarters of the poorest quintile had spent had the lowest ratio of hospital beds per 10,000 of more than 10 percent of their household expendi- population of any region, which ranged from one ture in the previous month on traditional healers in Mali to 63 in Gabon (global average 30) [397]. [400-401]. Chronic NCDs may be over-represented in hospi- Primary health care in much of SSA is dismal, tals, with patients lingering for weeks or months, and prevention and promotion aspects are limited. partly because of a lack of reliable outpatient facil- A study in Senegal and Tanzania found that on av- ities for follow up; one study in Rwanda found that erage only 19 percent of primary health facilities in these conditions accounted for 30-40 percent of Tanzania and 39 percent in Senegal had access to adult hospitalization time [56]. basic infrastructure (electricity, water, sanitation) There is a growing sector of private health care [358]. Around half (47 percent) of clinics in Senegal providers in some parts of Africa which already and one-fifth (22 percent) in Tanzania did not have treats a significant proportion of those covered by access to the most basic equipment (thermometer, private health care insurance and the well-to-do stethoscope, weighing scale) and around one-fifth [398]. of clinics (22 percent Senegal; 24 percent Tanzania) An Overview 57 experienced shortfalls in stocks of essential drugs. curement and supply of medicines and equipment, One-fifth of health workers (20 percent Senegal; 21 and task shifting. percent Tanzania) were absent on a given day. Most indices were worse in rural settings. Primary Health Care An overhaul of the health care delivery system so Primary care is the main entry point into health that it is also responsive to chronic conditions and services for most people. Ideally, although perhaps NCDs, could focus on a number of areas: not often achieved, care is person-centered, compre- hensive, and integrated, with continuity and partic- • Re-engineering of primary health care within a ipation of patients, families, and communities [403] well-functioning district system, with a greater (Figure 18). Apart from the management of disease, role for prevention and promotion [402] primary care opens up opportunities for disease pre- • Design of a delivery system suited to the coordi- vention and health promotion as well as early detec- nated continuity of care needed for chronic con- tion of disease. ditions • A greater role for patients in self-management Primary care helps prevent illness and death, is better value for money than its alternatives, and, in • Decision support tools and clinical information contrast to specialty care, is associated with a more systems. equitable distribution of health in populations [403- This would need to be underpinned by broader 404]. Health systems with a strong primary care ori- health system strengthening such as sustainable fi- entation, emphasizing comprehensive care and the nancing, performance management, improved pro- overall health of the patient, are likely to find it eas- FIGURE 18: WHO Model of Primary Care and its Place within a Larger Network Specialized Care Hospital Emergency TB Community Mental Department Control Centre Health Unit Maternity Consultant Tra c Diabetic Clinic Support Accident Placenta Referral for Surgery Multi-Drug Resistance Praevia Referral for Hernia Complications Primary-care Team, Self-help Continuous, group Comprehensive Diagnostic Services Person-Centred Care Training Training Centre Social Support CT Scan Diagnostic Services Support Liaison community Other health worker Pap Smears Other Cytology Lab COMMUNIT Y Waste Disposal Alcoholism Inspection Mammography Gender Environmental Violence Health Lab Cancer Screening Alcoholics Centre Anonymous Women’s Shelter Specialized Prevention NGOs Source: [403] Services 58 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa ier to introduce practices that benefit patients with BOX 10: Integrated Care for Communicable chronic conditions [405]. Diseases and NCDs in Primary Care In many African countries primary care for NCDs In South Africa, cough is the commonest complaint in is very poorly developed and expectations of what primary care and eight of the top 10 diagnoses are re- can be delivered need to take account of the reali- spiratory conditions of both an infectious and chronic ties and challenges faced. Practical policy propos- nature, including upper respiratory tract infection, acute bronchitis, asthma, TB, and HIV-associated pneumonias als for improving primary and NCD care include: [399]. improving data on disease burden; implementing Programs such as PALSA PLUS (Practical Approach to a structured approach to care delivery, with the Lung Health in South Africa) have been training health part played by primary care in the broader system workers in state-funded primary care clinics to take a of care better defined; and highlighting quality of more people-centered rather than disease-centered ap- care, aligned with broader health system strength- proach, using a syndromic, integrated guideline for di- ening [406]. A number of existing programs in agnosis and care of patients with respiratory symptoms low-resource countries such as TB control and ma- [408]. An educational outreach program has enabled the guideline to be used successfully by nurse practitioners ternal and child health include strengthening pri- with favorable outcomes, including increased TB-detec- mary care as one aim. This creates an opportunity tion rates, proportion of patients with asthma appropri- for improvements for NCD care to ‘piggy-back’ ately managed, and cost-effectiveness [409]. onto existing efforts [406]. The PALSA PLUS program has been extended to include Innovations to cope with staff shortages in primary the most frequently occurring NCDs in the primary care setting. This program is called ‘PRIMARY CARE 101’ [410]. care include developing a cadre of clinical associates to perform a limited clinical role, and on-site train- ing of nurses and mid-level health workers for inte- sign of the health care delivery system for it to be grated care of chronic diseases, whether infectious more accessible and desirable to people, especially or NCD in origin [399]. The role of appropriate- in rural areas. ly-trained community health workers for NCD care should also be explored for SSA settings. Chronic-Care Models Frameworks and simple, standardized protocols Primary health care should not be seen in isola- for case finding, diagnosis, and treatment of several tion – it is but one cog in a wheel of care that also risk factors and diseases can effectively be used by involves secondary and tertiary care as well as the nurses and mid-level health workers [399]. These may be adaptations of protocols for individual dis- community and patient, in both public and private eases, such as TB [407], and designed for the man- health systems. And while for SSA the challenge agement of symptoms and signs of chronic disease, of strengthening primary health care remains, and irrespective of cause (see Box 10) [408], potentially there is limited integration of NCD prevention and increasing cost-effectiveness by improving the care promotion in primary health care, hospitals are also of several conditions [409]. not ready in most countries to address even the ex- isting burden of NCDs and RTIs. Widespread use of traditional medicine provid- ers for primary care may reflect cultural and/or A further challenge is ensuring that various aspects health beliefs, taboos, or inaccessibility of other of care are linked and coordinated across care levels forms of health care and drug costs, but one reason and boundaries. Care of chronic conditions requires for its popularity may be a desire for continuity of a complex response over an extended time period, care [401]. There have been moves to acknowledge involving coordinated inputs from a wide range of its role within primary health care and national health professionals, continuous access to essential health systems, as well as to ensure its safety and medicines, health information and monitoring sys- quality [411]. Better understanding of why people tems, and a system that promotes patient empow- go to traditional healers could help inform the de- erment [412]. Several organizational models exist An Overview 59 for managing chronic conditions, with the Chronic and the use of health care resources, it is less clear if Care Model (CCM) [413] and WHO’s related In- the whole model is needed, or whether only some novative Care for Chronic Conditions (ICCC) components would be sufficient [420-421]. framework [414](Figure 19) amongst the most well- Chronic care models are already being applied in known [415]. There have also been attempts to ex- the care of chronic conditions of infectious origin pand the model to better integrate health promotion such as HIV/AIDS and adapted for use in Africa and prevention aspects [416]. [422-423](Box 11). The otherwise limited applica- The main models have been applied in a number tion in LMIC, however, may reflect the need for a of countries, the CCM most frequently in high in- level of capacity and resourcing that is out of reach come countries [417-418] while the ICCC frame- for many countries at present [215]. Models of care work has been applied in a more diverse range of developed in one setting may not easily translate to settings [419]. While there is evidence that single another although they may be more easily imple- or multiple components of the Chronic Care Model mented in health systems with a strong primary care (such as self-management support, delivery system orientation [420]. design, decision support, and clinical information A health care delivery system can be designed, systems) improve quality of care, clinical outcomes, even for very low-income populations that decen- FIGURE 19: Innovative Care for Chronic Conditions Framework POSITIVE POLICY ENVIRONMENT Integrate policies Promote Strengthen partnerships consistent nancing Provide leadership & advocacy Support legislative Develop & allocate frameworks human resources LINKS HEALTH CARE COMMUNITY ORGANIZATION Raise awareness & S TER Promote continuity & coordination HE reduce stigma OR ALT Encourage quality through PP HC Encourage better outcomes Prepared leadership & incentives SU through leadership & support AR IT Y Informed Organize & equip ET UN health-care teams EA Mobilize & coordinate resources MM Motivated M Use information systems CO Provide complementary services Support self-management PATIENTS AND FAMILIES & prevention BETTER OUTCOMES FOR CHRONIC CONDITIONS Source: [414] 60 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 11: Quality Improvement Lessons for HIV Improve Care for Other Chronic Conditions in Uganda In the Buikwe District, Uganda, the USAID Health Care Improvement project has been working with patients, providers, managers, and the central Ministry of Health to improve the health care system for people with HIV using the Chronic Care Model. These efforts are being carried out at 15 hospitals and health centers and emphasize: (1) improving support for pa- tient self-management to strengthen patients’ knowledge, skills, and confidence to care for themselves; (2) reorganizing the design of the delivery system to decrease waiting time and increase the amount of time providers are able to spend providing patient care; and (3) improving longitudinal documentation systems to facilitate patient care and continuous quality improvement. As a result, patient enrolment has increased and health outcomes have improved. Providers working in the same facilities are now using lessons from HIV-focused work to improve care for patients with diabetes and hypertension. They have established: (1) routine screening of all adults for hypertension; (2) dedicated clinic days for hypertension and diabetes; (3) improved support for patient self-management; and (4) longitudinal documenta- tion to facilitate ongoing follow up. These interventions have led to more than a tenfold increase in the number of patients receiving care for hypertension and an eightfold increase in patients receiving care for diabetes. Between February and November 2011, the percentage of patients meeting blood pressure goals (110/60-140/90mmHg) and fasting blood glu- cose targets (4-7.5mmmol/L) increased by 49 percent and 54 percent respectively. Source: [433] tralize and integrate chronic care to span the spec- levels (community, health center, district hospital). trum of diseases (neuropsychiatric, infectious, non As illustration, an example of such a system devel- -communicable, physical disability) as well as across oped in Rwanda is shown in Figure 20 [56]. FIGURE 20: Units of Care for Endemic NCDs in Rural Rwanda HEALTH FACILITIES NCD SERVICES Referral centers Cardiac Surgery Medical Specialties Pathology (1 per 2.5 million people) Cancer Center Surgical Specialties Radiology 2nd - level acute inpatient care Advanced NCD outpatient care District hospitals (1 per 250,000 people) Integrated chronic care Advanced neuropsychiatric care Integrated gynecology services (benign and malignant) Health centers Integrated outpatient chronic care (1 per 20,000 people) (HIV, TB, NCDs, and neuropsychiatric) Chronic care community health services Community health workers (1 per 400 people) Acute care community health services Source: [56] An Overview 61 In this example, a strengthened district hospital cross-boundary relationship – an example is shown provides clinical leadership and training, reduces in Figure 21 [424]. Human resources could be de- transfers to tertiary centers, and creates a path- veloped to provide the skills and clinical capacity for way for decentralizing uncomplicated chronic care effective management of other chronic illnesses. so that conditions are managed closer to patients’ Large-scale service delivery models for chronic homes and scarce specialist time is judiciously used. Both outpatient management of chronic conditions conditions in developing countries appear to be and inpatient care of their acute exacerbations take relatively absent [192]. Chronic diseases initiatives place at the district level. At the community or pri- can potentially learn lessons from the approach to mary care level, simplified protocols based on local HIV scale-up whereby a model for health main- epidemiology enable the health worker to assess pa- tenance as well as disease management, with pro- tients, and broadly categorize them to the appropri- motion of treatment adherence and long-term be- ate clinical pathway, making referrals and managing havior change, was put in place in a relatively short treatment accordingly. period of time [211]. Table 12 gives examples of For HIV/AIDS, guidance already exists that lays some of the program innovations which could be out the principles of good chronic care and the transferrable. FIGURE 21: Approach to Chronic Care at Primary Care and District-Level Facilities for HIV/AIDS, Relevant for Managing Other Diseases and Conditions CLINICAL TEAM First-level facility health Clinicians at district workers or health workers/lay clinic/hospital staff at district level Assess, refer patient Consult/refer for certain patients Diagnose with suspected chronic illness Initiate treatment without referral in certain de ned circumstances Develop Treatment Plan ent Plan Treatm Treat according to Treatment Plan Refer back for scheduled follow up Follow up Do regular follow-up as for exacerbations/poor control Modify diagnoses or described in Treatment Plan of Treatment Plan Treatment Plan as needed Manage severe Treat acute exacerbations Good communication exacerbations Hospitalize when indicated Source: Adapted from: [424] 62 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa TABLE 12: Illustrative HIV/AIDS Program Innovations Stewardship Transparent target-setting; ‘Three Ones’ principles*; support for decentralization Financing and payments Performance-based financing, elimination of user fees, and innovative insurance schemes Human resources Training, mentoring, task-shifting, task-sharing, and engaging PLWH in care and support Infrastructure Renovations and repairs of clinical, counseling, laboratory, and pharmacy space Commodities Development and strengthening of procurement systems /supply chain Information /data On-site medical records, electronic medical records, and ‘Three Ones’ approach Clinical services Family-focused care, adherence support, and comprehensive primary care for PLWH Behaviors of providers Multi-disciplinary teams, prominent use of counselors and peer educators, increased focus and patients on adherence and psychosocial support, and enhanced demand/uptake of services Source: [211] * In 2004, donors, developing countries, and UN agencies agreed to three core principles – known as the “Three Ones� – to better coordinate the scale-up of national AIDS responses; namely, one agreed HIV/AIDS action framework that provides the basis for co¬ordinating the work of all partners; one national AIDS coordinating authority, with a broad based multi-sector mandate; and one agreed country-level monitoring and evaluation system [425, 426]. An integrated approach to the management of services [177]; and the establishment of multidis- chronic diseases in LMIC, irrespective of cause, is ciplinary chronic disease clinics with standardized being called for increasingly [427]. Suggestions in- approaches could improve continuity of care [429], clude integrating the management of chronic NCDs adherence to therapy [430], and in turn efficiency such as diabetes and hypertension with those of gains. It may also help to decrease the stigma often chronic communicable diseases such as AIDS [428]. associated with some communicable diseases. Ex- A focus on broad care needs rather than disease amples of ‘cross-fertilization’ of care between com- categories could be more beneficial in planning municable and NCDs are given in Box 12. BOX 12: Cross-Fertilization of Care for Chronic Conditions Care models from HIV/AIDS, TB, and other communicable diseases are being extended or adapted to address other chronic conditions and co-morbidities. The DOTS framework (directly observed therapy, short-course) has been a cornerstone of TB control for over a decade. The model has also been developed to deliver ART successfully in Malawi, with simplified management protocols, unin- terrupted drug supplies, and monitoring of standardized treatment outcomes and key contributory factors [431]. It was proposed that a similar paradigm could be adapted for NCDs [407] and aspects of the DOTS model have since been ap- plied to the management of people with diabetes mellitus in Malawi [432]. Care for people with HIV/AIDS was resourced and expanding in Cambodia, but care for diabetes, hypertension and other chronic diseases was limited. During a three-year project, multi-disciplinary chronic disease clinics were established to of- fer integrated care for patients with HIV/AIDS, diabetes, and hypertension within the same clinic [428]. Services were well accepted by patients and continuity of care and adherence to treatment were achieved with good outcomes. Providing care for sero-positive patients and those with other conditions within the same facility also reduced HIV-related stigma. Chronic care models, more frequently used for the care of chronic NCDs, are also being applied to cover chronic diseases whatever their cause. Projects using such models to improve quality of care for chronic conditions such as HIV, hyperten- sion, and diabetes are underway in Uganda, Tanzania, and South Africa [5, 422-423, 433]. There have also been moves to apply self-management programs from chronic NCDs to HIV care [434]. An Overview 63 Guidelines and Quality of Care multiple co-morbidities [437], and runs contrary to Support for decision making by health care profes- patient-centered care. sionals in the form of evidence-based guidelines and other educational materials, educational meet- Self-Management and Patient-Centered Care ings, audit, and feedback, improve their adherence For developing countries, team-work and patient to disease management guidelines and standardized partnership may be as important as adequate fund- case management, and improve patient outcomes ing [438]. Apart from the organization and quality of [421]. High-quality drugs need to be procured and care, it can be a significant challenge in some settings supplied at low prices and equipment upgraded and to enable patients to understand the choices they available. Successful implementation of guidelines have, and to make informed decisions, as well as to requires wide distribution, training, and supervision support patient compliance and active participation of health workers, and evaluation in practice with in treatment. appropriate quality or care and outcome measures Supporting patient self-management is worth- [118]; this is not straightforward, given the short- while, central to good outcomes of NCD treatment, ages of health workers and funding and the orga- and has the potential to alleviate pressure on health nization needed. Nevertheless, the use of clinical and social services [439], especially given that peo- guidelines as tools for linking allocative efficiency ple with long-term conditions manage these most with the practice of care has already been discussed of the time by themselves or with family members. in Section 5.5 on ‘Health Financing’. Self-management support, particularly patient edu- Using models familiar from communicable dis- cation about their condition and care and motiva- ease care has been proposed for strengthening per- tional counseling, improves patient adherence to formance management [435]; and lessons learnt treatments and outcomes, service use and satisfac- from efforts to improve quality of HIV/AIDS care tion, and knowledge of their disease [421]. Patient- may be applicable to promoting quality of care of centered, self-management support is already pro- those with NCDs. Elements include the number and vided to PLWH in Africa although its quality may mix of health staff, clinician performance, a safe and vary [422]. An example of how patient self-manage- well-equipped health care environment, diagnostic ment for HIV has been implemented and extended support, and reliable drug supply [436]. to cover other risk factors is given in Box 13. Diagnosis and management of disease can be frus- Supporting self-management is likely to work best trated by the paucity or quality of equipment. Mea- as part of a wider initiative to improve care which surement of lung function or hypertension using also includes education of practitioners, effective use simple and inexpensive methods can be a major is- of evidence and technology , decision aids, and com- sue for diagnosis and management of disease, given munity partnerships [439]. Information provision the limited access to spirometry and sphygmoma- alone is unlikely to be enough, and different clinical nometers [51] for example. Adaptation of guidelines conditions may need varying approaches according for use in low-resource settings to avoid dependence to the self-care activities required. There is emerging on laboratory measurement has been referred to al- evidence that strategies co-created by professionals ready in relation to CVD risk assessment [308]. and service users have positive outcomes [440]. Efforts to scale up interventions for chronic dis- Given the limited health service resources in eases still tend to focus on individual diseases [349] low-income countries, ‘full self-management’, with or use a single disease guideline as a starting point the patient as the hub of disease management, sup- [147]. This approach is likely to be unaffordable and ported by smart phone technology, peer support, unsustainable as populations age [215]. It risks con- and other resources such as primary care providers fronting front-line health workers and patients with and informal care givers, has been proposed as an multiple disease management frameworks, which alternative to models of chronic care that are more may be unworkable in practice for patients with provider-centered [441]. 64 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 13: Supporting PLWH Self-Management Leads to Expanded Services in Tanzania In the Morogoro Region of Tanzania, the USAID Health Care Improvement project has been working with providers, health officials, and community-based organization to support a facility-based, peer mentoring program for people with HIV. PLWH with a record of successful self-management are recruited and trained as expert patients, known as “peer men- tors�. They volunteer at health facilities to support new HIV patients and patients having difficulties in providing good self-care through group education sessions and individual motivational counseling. Improved self-management support has resulted in significant increases in adherence, appointment-keeping, and the percentage of patients expressing the confidence to self-manage themselves. These peer mentors have also assumed many routine clinic tasks, such as: pa- tient registration, filing, packaging of cotrimoxazole tablets, and assessment of patients’ nutritional status. Consequent reductions in provider work load have allowed facilities to begin introducing expanded services for HIV patients such as hypertension screening and treatment. Source: [422] Human Resources for Health will waste investments. Potential solutions need to Africa has long struggled with acute health work- identify and address country-specific labor market force shortages: SAA has 24 percent of the global leakages and inefficiencies, including through: (1) burden of disease but only 3 percent of all health monetary and non-monetary incentives; (2) inno- workers, and migration of health workers, both to vative education models (including rural pipeline positions that do not include patient care and to models); (3) increasing opportunities for funding clinical positions in higher income countries, is a for human resources for health, particularly in rural significant problem [442]. Furthermore, some see areas; and (4) strengthening management and ac- the growing private health care sector in some coun- countability systems in frontline facilities [444]. tries as having the potential to siphon off both hu- man and financial resources [398]. The average phy- Task Shifting sician-to-population ratio in SSA is 2.2 per 10,000 Innovative strategies to expand health-system ca- of the population (ranging from 0.1 in Liberia to 5.7 pacity to address HIV and other health challenges in Cape Verde). The nursing and midwifery person- include ‘task-shifting’ in clinical settings so that tasks nel-to-population ratio is nine per 10,000 population performed by physicians (or any higher cadre) are (ranging from 0.4 in Guinea to 28.4 in Botswana) delegated where appropriate to lower cadre health [397]. There are relatively few specialist training in- workers who have a defined set of skills or been spe- stitutions in Africa, with some countries completely cifically trained to perform a limited task [445]. Ap- reliant on foreign education for specialists. propriately trained nurses have been demonstrated The severe shortage and imbalanced distribution to provide effective care for patients similar to that of trained health workers (and health promoters) provided by doctors, and to achieve positive health is not just an obstacle to tackling NCDs but also to outcomes in chronic disease management, illness the delivery of good quality clinical services in gen- prevention, and health promotion [446-447]. This eral, jeopardizing achievement of the MDGs and approach has been applied in a range of NCDs, such improvement of the overall health of the poor, sug- as asthma, hypertension, and diabetes mellitus, and gesting the need to align health sector, civil service, with minimal additional resources can also improve and macroeconomic policies in finding workforce patient retention and satisfaction for chronic disease solutions [443]. management [448-453]. Simply scaling up the production of health workers While the rationale behind transferring the tasks is is not a good enough fix, as urban unemployment, that the alternative would be no service at all to those rural shortages, health sector attrition, including mi- in need, the approach is not without risk. Unless gration abroad, as well as absenteeism and low pro- planned and managed appropriately, there is potential ductivity (labor market leakages and inefficiencies) for fragmentation and decreased quality of care, and An Overview 65 a balance needs to be achieved in physicians’ roles in and performance of existing health workers [373]. direct patient care and as supervisors or trainers to Some roles may be perceived to have low status, others [454]. Task shifting should be implemented especially for nurses, midwives, and auxiliary staff. within systems that contain checks and balances to To retain highly-trained staff, and redistribute the protect both workers and patients [455]. Task-shift- health workforce, African countries need to offer ing should also not be seen as a substitute for tackling internally competitive wages and benefit packages. some of the more fundamental issues relating to staff Non-monetary incentives, such as training, profes- shortages, as well-trained physicians (generalist and sional development, improved work environments, specialist) and nurses are needed; it should be com- and appropriate equipment, are also important plemented, for example, with other approaches such to improve motivation, quality and productivity as incentives for retention of health professionals and [443]. Partnerships are likely to be important to improved working conditions. support comprehensive human resources for health strategies. WHO’s ‘Treat, train, and retain’ plan to Task shifting efforts can go beyond the health strengthen health workforces in countries greatly workforce to include people with chronic diseases affected by HIV recognizes the impact of HIV on themselves, their peers, and family members, as health workers and the need to overcome persistent seen in the ‘expert patients’ successfully used in a stigma and discrimination to be able to treat and number of countries in Africa for HIV/AIDS [434, retain staff [461]. Given that many health workers 456-458]. Trained patients have been shown to be may also have NCDs such as diabetes there may be as effective in imparting knowledge to their peers as further transferrable learning. specialist health professionals if given appropriate training. Also, peer support interventions for adults Telemedicine and Information with diabetes in low-resource settings can improve Communication Technology (ICT) symptom management and blood sugar and hy- pertension control amongst participants [458-460]. The application of ICT in health (eHealth), through, Forming support groups for those living with dis- for example, telemedicine and electronic medical ease can contribute to success. records, has the potential to facilitate better health care delivery including in situations where health Equipping Health Workers services and human resources for health are scarce [398, 462]. Telemedicine can, for example, offer re- NCD care clearly needs a well-trained physician mote physician access, care, and diagnosis where (generalist and specialist) and nurse workforce. specialist opinions would be otherwise unavailable, Chronic disease management, disease prevention, reduce the need for patient transfers and travel, fa- and health promotion need to be well introduced cilitate knowledge-sharing and collaboration across into the education of health workers. Specializations boundaries, and provide professional support and such as family medicine, palliative care, and trauma opportunities for continuing professional develop- care may need to be introduced in some countries. ment to rural practitioners. A WHO survey in 2009 There are opportunities to equip and expand found the African Region to have one of the lowest health workers from all fields to be agents for NCD proportions of countries with established telemedi- prevention and care; for example, training midwives cine services, with less than 10 percent of respond- to identify and manage hypertensive disorders and ing countries having the four telemedicine fields gestational diabetes in pregnant women can reduce surveyed (teleradiology, telepathology, telederma- maternal mortality and have an impact on lon- tology, telepsychiatry) [463]. ger-term conditions [396, 438]. While mobile phone use in Africa is growing, with subscribers doubling to 500 million during 2008-11 Retain, Motivate, Raise Status [464], there are infrastructure challenges to e-health For a well-performing health workforce, entry and such as technical expertise, interrupted power sup- exits need to be managed, as do the distribution plies, insufficient communication networks, and 66 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa unreliable or limited internet connectivity. A posi- 75 percent of total MOH hospital beds, their labs, and tive sign is that although few African countries have satellite clinics and have plans to expand to at least national policies or governance relating to e-health 30 hospitals across Botswana. In Namibia, the Min- or telemedicine, a growing number have institu- istry of Health and Social Services is in the process tions involved in telemedicine development. There of integrating 61 disease-oriented, donor-supported, is already, for example, a well-established collabo- standalone applications into a single Web-based, ration between high- and low-income countries in Web-enabled platform. The Integrated Health Care the RAFT Project (Réseau en Afrique Francophone Information Management System is a patient-cen- pour la Télémédicine) coordinated by the Geneva tered record management system, that is HL79 com- University Hospital, Switzerland, and university pliant, which covers all aspects of hospital clinical hospitals in 18 largely francophone countries in Af- case management and ancillary services in day to rica, which focuses on telemedicine and distance day operations. The system is being pilot tested in the education of health care professionals working in Windhoek Central Hospital and it is expected to be remote sites [465]. operational in the other three largest hospitals in the country by the end of 2013, including the Katutura 5.6. Addressing Information and Hospital, which operates as the national trauma refer- Research Gaps ral center. It is expected that once full connectivity is in place, the system will allow the sharing of complete Information patient records across Namibian health institutions. Health information is needed for assessing health In the implementation of electronic health records needs, developing evidence-based policy-making, (EHR) and ICT platforms, important challenges performance management, and monitoring and need to be addressed in order to overcome, in ad- evaluating interventions [39]. Countries with the dition to existing technological barriers (such as greatest health challenges also tend to have weak in- lack of uninterrupted power supply, connectivity, formation systems [466]. On top of this, monitoring and bandwidth): (a) the transitioning of hybrid ap- and reporting requirements related to grants, global proaches where traditional paper-based processes declarations, and health and disease programs can are maintained in parallel in direct competition add considerable burdens – a potential risk that with the EHR and supporting ICT platform; (b) NCD efforts need to avoid. the adoption of common health and information Several countries (for example, Botswana, Na- exchange standards (for example, ICD-10; HL7); mibia) are making significant efforts in integrating (c) change-management strategies aiming to im- their multiple, disparate, disease-focused, standalone plement organizational change processes deemed health information systems. In Botswana, the MOH critical in the delivery of health services, incorpo- completed the Health Information Management Sys- rating the clinical workflows and decision-making tem Strategic Plan in April 2012, that provides an ICT processes supported by the new technology; and (d) road map in line with the MOH-adopted e-health the required, qualified IT operational and mainte- strategy, to integrate the current standalone systems nance support and financial backing needed for the into the existing Integrated Patient Management Sys- sustainability of the systems. tem (IPMS). IPMS is a centralized, electronic medical Limited civil registration and unreliable vital record system focused on patient care and treatment statistics relating to fertility, mortality and causes in clinic, and hospital settings. It stores data on var- of death in Africa are recognized problems: for ex- ious health services, including ART, prevention of ample, only four African countries report cause of mother-to child transmission, laboratory, and phar- macy, and in the near future will support the clinical 9 HL7 standards provide a framework for the integration, sharing, case-management of Safe Male Circumcision and the and retrieval of electronic health information. These standards define how information is packaged and communicated from one National Cervical Cancer Prevention Programs. It is party to another, setting the language, structure, and data types being implemented in 11 hospitals covering close to required for seamless integration between systems. An Overview 67 death statistics to WHO, of which only one is of high pressure; demographic surveillance sites could ex- quality [79]. There are a few recent signs of progress pand NCD surveillance; donors could fund more nationally and internationally: for example, South STEPS surveys; and partners could strengthen local Africa increased coverage of birth and death regis- capacity for NCD surveillance and epidemiology trations to nearly 90 percent by 2008, and the Statis- [470-471]. A good example is the ongoing effort tical Commission of Africa has prioritized strength- in South Africa to develop a strategic surveillance ening of civil registration and vital statistics for the system for NCDs involving vital statistics, popula- period 2012-17 [467]. All the main health and dis- tion-based health statistics, health facility data, and ease programs draw from the same data sources and health facility audits. Taking into account recent share common problems. Rather than develop sepa- WHO recommendations, indicators are being re- rate solutions, there is opportunity for shared action vised, alongside the strengthening of the analysis and benefit. For example, improved global report- and reporting capacity to ensure that information ing, oversight, and accountability for women’s and can be used for monitoring and planning, and the children’s health could lead to the strengthening of development of a strategy to strengthen research in civil registration systems [468]. the field of NCDs [472]. NCD mortality and morbidity surveillance is There have been moves to overcome health in- largely hospital-based and only 59 percent of coun- formation limitations: estimates of mortality and tries report having a cancer registry. However, there disease burden have been calculated and compos- is growing use of NCD risk-factor surveys to mea- ite NCD and road safety country profiles developed sure health determinants [6]; for example, by 2012 to assist countries’ needs assessments [473-476]. more than 20 African countries had carried out There are rapid assessments for health systems for STEPS surveys, some more than once, and most in- a number of diseases [477], and manuals exist to as- cluded physical and biochemical measurements en- sist countries systematically work through the steps abling assessment of the prevalence of hypertension involved, for example in assessing road safety man- and diabetes [469]. And, while health information agement capacity [269]. Community members can capacity in general and for NCDs may be low, there be engaged in diagnosis of problems and solutions. may be the possibility of adapting and exploiting Under-reporting of RTIs is also a problem, with some of the existing systems set up for communi- data quality affected by political influences, com- cable diseases [435]. Possibly three important and peting priorities, and the availability of resources; transferrable lessons for NCDs from the history the number of crashes involving vulnerable road of AIDS are: the need to pull evidence together to users and non-motorized vehicles are thought to be convince politicians to take action; the need for re- greatly under-reported [117]. A population-based liable ways to measure success accurately; and that survey in Dar es Salaam, Tanzania, found that po- vertical initiatives need system investment for sus- lice reports for RTIs were only filed 50 percent of tainability [466]. the time [478]. An assessment of RTIs in Zambia Better epidemiological data is called for and a vig- by the Road Traffic Safety Agency, Police, Ministry orous effort needed to gather more evidence that of Health, and World Bank, showed that current decision makers, including politicians, can absorb; registries of RTIs lack adequate use of standard including data about prevalence, demography, inci- codification (such as ICD-10), making it impos- dence trends, and costs to governments and donors. sible to determine the number of pre-hospital Better knowledge is needed about NCDs in Africa deaths and deaths after arrival at an emergency to underpin the design of contextualized NCD strat- room [479]. The hospital registries also lack the egies. A tremendous contribution could be made underlying causes of injury or death classified un- by the international donor and scientific communi- der the WHO International Classification of Dis- ties, for example: DHS surveys could be expanded eases (ICD-10 – Chapter 20) which are needed for to include NCD prevalence and risk factors such as effective public health interventions and related measurement of adult obesity, glycaemia, and blood preventive measures. 68 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa Improving information systems and links between Research Gaps police, transport, and health service data improve Research gaps exist for NCD prevention and con- data quality; for example, capturing figures for those trol in Africa. Priority areas for research include who die after admission to hospital and triangula- epidemiological surveillance, primary and second- tion of sources helps to confirm trends and identify ary prevention, and adaptation of health system re- data problems. Figure 22 illustrates a data manage- sponses [481]. National and international efforts are ment system for road safety. The health sector also needs to be better at collecting data on non-fatal needed to develop resource-appropriate strategies injuries in a standardized way as this can guide re- and create “frugal innovations�, such as low-cost ra- source allocation [480]. Collecting data on motor- diation therapy. Given the need for a health care sys- cycle helmet-wearing and seatbelt-wearing can in- tem that can cope not just with acute care but with dicate success of measures, and estimates of costs to chronic care needs effectively, it may be useful to ex- the health system and economy can help advocacy plore the further development of appropriate tools and decisions about enforcement efforts. to help model NCD/communicable disease combi- FIGURE 22: Systemic Use of Data for Road Safety Planning, Monitoring, and Evaluation Costs: Social Costs Medical costs, material and intervention Data costs, productivity losses, traffic jams (direct and indirect) (lost time) loss of life/quality of life Outcome Indicators: Crashes, Injuries and deaths Data Crashes, injuries, deaths, LT S (combined with exposure data) (�nal outcomes) SU RE Safety performance Indicators: Operational conditions of the road traffic system Data Speed, alcohol, restraints, (intermediate outcomes) helmets, road infrastructure, vehicle safety, trauma management Outputs Process/Implementation indicators: Data Road safety policies, plans, programmes, (interventions implemented) implementation of interventions. Interventions Road safety management functions Funding, R&D and Monitoring Coordination Legislation resource Promotion knowledge and Evaluation allocation transfer Source: [480] An Overview 69 nations of interventions and costs of new types of opment [486]. There is a growing recognition that community based services. current incentive systems fail to generate enough Without research in clinical- and cost-effective- research and development to address the health care ness of NCD prevention interventions in SSA to needs of developing countries and that global fi- guide and evaluate improvements, treatment and nancing and coordination needs to be strengthened prevention may be overly subject to the influence of [487]. A promising model for ‘growing research’ local and global commercial interests [482]. It can in developing countries is to use funding to link a also be very useful to monitor and make public the developed country supervisor with a developing activities in Africa of these global commercial inter- country supervisor for PhD students working in the ests, notably of the transnational manufacturers of developing country on local projects; this model is unhealthy commodities [483]. further strengthened if students from both settings work together in the developing country [488]. The For road safety, indispensable research would in- impact of all these efforts, however, would need to clude assessment of knowledge, attitudes, and be- be rigorously measured. haviors, and an evaluation of the effectiveness of interventions [484]. Much knowledge and informa- tion is potentially transferable from existing studies 5.7 Role of Public and Private elsewhere, given the similarity in contributory fac- Employers and Businesses tors and that many motorized countries have un- Public and private employers and businesses have an dergone a similar developmental stage, taking into important role to play in addressing the socio-eco- account cultural, economic, and social conditions in nomic determinants of health. Indeed, their involve- adapting successful experiences [63]. ment could be particularly important in addressing Research in Africa needs to address broader so- the complex burden of disease in Africa. The poor cial and cultural factors, as well as interventions. health of employees quickly affects a company’s bot- This means that research policy leaders must engage tom line and has a longer-term impact on earnings national governments and international agencies, and profits. Firms have a vested interest in support- service providers, and research communities [485]. ing activities to improve employee health, and can Multi-disciplinary, multi-institutional, and mul- have a strong influence on their employees’ behavior ti-country collaborations could conduct research and make them aware of health risks in ways un- and properly inform the design of interventions, available to the government. working with health care providers, policymakers, The involvement of major African companies, NGOs, and communities to bridge the gap between multinational corporations, and other stakeholders research, practice, and policy [129, 179]. Investment with experience in employee- and community-di- in postgraduate training in chronic disease research rected health programs will be critical in reducing is also needed to produce the next generation of NCDs and injuries. As discussed in Box 14, the con- multidisciplinary researchers. Under country own- cept of employers playing a larger role in improving ership, public-private research and training partner- employee fitness and health is not new, and there is ships can result in country-wide workforce devel- robust international evidence on its positive impact. 70 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa BOX 14: Healthier Workplaces = Healthy Profits The current debate in many countries on how to change a health system that is geared to treat illnesses to one that fo- cuses on preventing people from getting sick is highly relevant for the question in Africa on how companies can improve employee health. After all, employees spend most of their waking hours at the workplace. There is a robust body of evidence showing that investment in workplace wellness programs is not only good for em- ployees but also for the bottom line of companies. These programs, which are organized and sponsored by the employer, help employees, and in some cases, their families, adopt and sustain behaviors that reduce health risks associated with chronic diseases and injuries. Both employees and employers value these programs because they help reduce health risks, absenteeism, and employee turnover. The entry point for participation in these programs is employee health risk assessments, coupled with clinical screening for risk factors (such as, blood pressure, cholesterol, and body mass index) that provide the baseline for subsequent inter- ventions. Other methods include self-help education materials, individual counseling with health care professionals, and on-site group activities led by trained personnel. Besides obesity and smoking cessation, programs commonly focus on stress management, nutrition, alcohol abuse, and blood pressure, and on preventive care such as the administration of the flu vaccine. Companies have begun giving incentives to motivate healthy behavior, such as bonuses for completing health risk assessments, reimbursements for the cost of fitness-center memberships, or lower health insurance premiums if employees adopt healthier behaviors (for example, quit smoking). As new strides in global health continue to be made, the workplace should be seen as another promising “entry point� to tackle not only unhealthy behavior among individuals but also to reduce community health risks (for example, through the adoption of programs to better train truck drivers and conduct regular vehicle inspections to prevent road traffic deaths). The essential pillars of these programs are: • Engaged leadership: Johnson & Johnson helps employees living with HIV/AIDS access ART. Additionally, all of its facil- ities are smoke-free. • Strategic alignment with the company’s identity and aspirations: To promote a culture of health in a company where 60-70 percent of jobs are safety-sensitive, Chevron has made fitness-for-duty a central concern on oil platforms and rigs, in refineries, and during the transport of fuel. Its wellness program includes a comprehensive cardiovascular health component, walking activities, fitness centers, stress-injury prevention, and work/life services. • Design that is broad in scope and high in relevance and quality: To be relevant to the needs of their employees, companies have adopted programs that are not just about physical fitness but also focus on mental health issues such as depression and stress, which are major sources of lost productivity. • Broad accessibility: SAS, a software firm, makes low- or no-cost services a priority. This is complemented by convenient arrangements that ensure high employee participation; for example, recreation facilities that are open before and after work and on weekends. • Internal and external partnerships: Companies offer services, such as biometric health screenings, at the worksite. These, in turn, are used to devise “individualized� programs with a local sport club and medical practice for at-risk em- ployees. • Effective communications: To help overcome employee apathy or sensitivity about personal health issues, some com- panies are sharing information about wellness in regular corporate e-mails, health-related messages on intranet portals, and wellness “clues� in the workplace, such as the availability of bicycle racks in parking garages with showers nearby to make cycling to work appealing. What are the returns on this investment? In the case of Johnson & Johnson, since 1995 the percentage of employees who smoked dropped by more than two-thirds, and the number who had high blood pressure or were physically inactive de- clined by more than half. The companies reaped financial rewards as well: thanks to wellness programs in the workplace, medical costs for U.S. firms fell by about US$3.27 and illness-related absenteeism costs dropped by about US$2.73 for every dollar spent on such programs. Governments can play an important role in helping implement and expand employer wellness programs, not only to improve the health of the population, but also to control health care spending. The 2009 Affordable Care Act, adopted by the U.S. Government to expand health insurance coverage, is a good example, as it expands employers’ ability to reward employees who meet health status goals by participating in wellness programs and to require employees who don’t meet these goals to pay more for their employer-sponsored health coverage. Source: [489-492] “As we start the journey of the next fifty years, we are clear about the task before us: to educate our populace, and ensure healthy bodies and minds; to modernize and expand Africa’s infrastructure and connect our peoples and countries; to grow our agriculture and agro-businesses so that we can feed ourselves and the world; to use our natural resources to industrialize and grow our shared prosperity; to invest in science, technology, research and innovation as enablers of rapid progress; and finally to empower women and youth as the drivers of Africa’s renaissance�. Dr. Nkosazana Diamini Zuma Chairperson of the African Union Commission Commemoration of the 50th anniversary of the Organization of African Unity (OAU) now the African Union (AU) Addis Ababa, 25 May 2013 6. CONCLUSION Africa is seen as having the potential to become a There are both equity- and efficiency-based ratio- pillar of global growth [2], but its social and human nales for public policy intervention. Highly cost-ef- development indicators are lagging, and threaten fective interventions for the prevention and control to reverse gains made in sustainable development of NCDs and RTIs have been identified which are [116]. appropriate for low- and middle-income settings, and their implementation would appear to be eco- This report set out to address four questions: nomically justified by likely welfare gains and the (1) How is the growing burden of NCDs and avoidance of economic losses. RTIs changing the epidemiology of SSA? An appropriate response needs to balance popula- (2) What determines and drives this burden, and tion-based and individual-level strategies, prioritiz- what are the commonalities with communi- ing a set of effective and cost-effective interventions cable diseases? that are feasible, scalable, and affordable. Develop- ing a comprehensive approach requires adjustments (3) What is the rationale for public intervention? throughout the health system, some of which per- (4) How could resource-constrained govern- tain beyond NCDs and RTIs; such as, improvements ments approach NCD prevention and treat- in health governance, universal coverage, access to ment and road safety in a comprehensive, essential medicines, quality of care, and support effective, and efficient way? for self-management of chronic diseases. It also re- The evidence is that while communicable diseases, quires attention to broader determinants of health maternal, perinatal, and nutritional conditions re- and wellbeing such as social, economic, and envi- main leading causes of the disease burden, NCDs and ronmental conditions. RTIs are already a significant problem for SSA as a The report hypothesized that a broader under- whole, and a leading cause of death for some coun- standing of NCDs and RTIs, one which explores tries, populations, or age groups. Trends in risk fac- shared challenges, drivers, and potential solutions tors, drivers, and determinants predict rising levels with other diseases and conditions, could be con- of NCDs and RTIs. These, added to existing disease structive in SSA’s health and development context. burdens, put further pressure on already fragile health Reviewing the literature through this perspective, systems, and their impact on health outcomes may the report found many links between communi- have consequences for sustainable development. cable diseases, maternal, perinatal, and nutritional 71 72 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa conditions, and NCDs; for example, evidence for It should also be possible to continue ongoing ef- common causes; shared underlying social condi- forts to strengthen health systems in ways that enable tions; interacting co-morbidities; as well as com- the benefits to be shared – this report has included mon solutions such as vaccination, standardized examples of how improvements for NCD care can syndromic protocols, and care models. Many of ‘piggy-back’ onto other existing efforts at little ad- the measures needed for strengthening health sys- ditional cost, such as extending chronic care deliv- tems cut across disease categories, and there are ery to span a spectrum of diseases with similar care opportunities for NCDs and RTIs to benefit from needs, or for palliative care to reach beyond AIDS, the lessons and initiatives of interventions for HIV/ or for demographic and other health surveys to be AIDS, TB, and maternal health, for example, and expanded to incorporate measurement of NCDs and vice versa. Thus, the report concludes that there their risk factors. Finally, there are a number of NCD is likely to be added value in capitalizing on the interventions that are not only cost-effective but also shared challenges, drivers, and potential solutions potentially resource-generating and beneficial for across the different disease categories, with broader dealing with other diseases, such as putting in place health-systems strengthening measures, and that and enforcing a strong regulatory and fiscal frame- there is already evidence of this taking place and work for tobacco and alcohol including the raising being effective. of prices. In making this happen, and facilitating it, there are roles not just for politicians and policy- Globalization, rapid urbanization, population makers within countries but also at the regional and growth, and ageing are contributing to the burden international level. There is also work for researchers of disease in SSA, as NCDs and RTIs emerge from in furthering the evidence base on the integration of the shadows. The response to NCDs and RTIs in SSA health programs, the integration of health concerns needs to avoid establishing yet another set of vertical into other development interventions, and in differ- programs in competition for scarce resources. ent country contexts. As the evidence shows, divisions between disease In conclusion, it should be clear that controlling categories, or between so-called vertical and hor- NCDs and RTIs are key public health issues in Africa. izontal programs, are to some extent artificial, and Ensuring an effective response, however, is a partic- may not be optimal for Africa at this stage of its ularly difficult challenge in countries facing a double health development. Opportunities for integration or triple burden of disease with a low national in- can arise out of synergies between targeted interven- come level and weak health care systems. As argued tions, necessity, or desirability [493]. Consideration here, and fully consistent with the health improve- of NCDs and/or RTIs within broader development ment and poverty alleviation objectives of World initiatives could, for example, mean mitigating the Bank work in the health sector [494-495], efforts to impact of road infrastructure, buildings, and urban address this challenge effectively in Africa should be design on safe and active travel, by building in from part of broader multisectoral effort, including health the start ways of keeping pedestrians and cyclists system strengthening programs and activities, that safe and for managing speed. Or it could mean de- need to be supported by national governments, pub- signing programs to maximize benefit and minimize lic and private employers and businesses, civil soci- harm in terms of NCD and RTI outcomes, such as ety, and the international community over the short ensuring that infant feeding programs and condi- and medium terms. 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Plos Medicine, 2007. 4(6): p. 967-971. http://apps.who.int/glodata/ MAP IBRD 39854: SUB-SAHARAN AFRICA REGION 91 The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa: An Overview draws on a comprehensive review of the literature and on input from policy makers, researchers and practitioners to address four questions: (1) How is the growing burden of non-communicable diseases (NCDs) and road traffic injuries (RTIs) changing the epidemiology of Sub-Saharan Africa? (2) What determines and drives this burden, and what are the commonalities with communicable diseases? (3) What is the rationale for public intervention? And (4) How could resource-constrained governments approach NCD prevention and treatment and road safety in a comprehensive, effective and efficient way? The data show that action against NCDs and RTIs in Sub-Saharan Africa is needed, together with continued efforts to address communicable diseases and maternal and child health and reach the Millennium Development Goals (MDGs). The report suggests that NCDs/RTIs should not be tackled separately as a vertical program, nor should they displace communicable diseases as priorities. Instead, given resource constraints, and some shared determinants, characteristics, and interventions, there is scope for an integrated approach focusing on functions (prevention, treatment and care) rather than on disease categories. A healthier and more productive population is a critical factor for ensuring sustainable economic growth and social development over the medium and longer terms in Sub-Saharan Africa. “Countries will take different paths towards universal health “As we start the journey of the next fifty years, we are clear coverage. There is no single formula. However, today, an about the task before us: to educate our populace, and emerging field of global health delivery science is generating ensure healthy bodies and minds; to modernize and expand evidence and tools that offer promising options for countries…. Africa’s infrastructure and connect our peoples and countries; For decades, energy has been spent in disputes opposing to grow our agriculture and agro-businesses so that we can disease-specific ‘vertical’ service delivery models to integrated feed ourselves and the world; to use our natural resources ‘horizontal’ models. Delivery science is consolidating evidence to industrialize and grow our shared prosperity; to invest in on how some countries have solved this dilemma by creating science, technology, research and innovation as enablers of a ‘diagonal’ approach: deliberately crafting priority disease- rapid progress; and finally to empower women and youth as specific programs to drive improvement in the wider health the drivers of Africa’s renaissance�. system…. Whether a country’s immediate priority is diabetes; malaria control; maternal health and child survival; or driving Dr. Nkosazana Diamini Zuma the ‘endgame’ on HIV/AIDS, a universal coverage framework Chairperson of the African Union Commission can harness disease-specific programs diagonally to strengthen Commemoration of the 50th anniversary of the the system.� Organization of African Unity (OAU) now the African Union (AU) Dr. Jim Kim, President of the World Bank, Addis Ababa, 25 May 2013 World Health Assembly Geneva, 21 May 2013