Sub-Saharan Africa:
The Challenge of Non-Communicable
Diseases and Road Traffic Injuries
THE WORLD BANK
Patricio V. Marquez
Human Development Sector Leader
World Bank Country Office in Ghana
10 th Anniversary Conference of GHIS
Accra, November 4, 2013

 The changing context and health profile
 How can the disease silo trap be avoided?
 How can NCDs be effectively addressed in resource-constrained countries?
 Take-away messages

 While progress has been achieved in reducing premature mortality from communicable, maternal, neonatal, and nutritional causes, these conditions still account for 3 out of 4 premature deaths.
 At the same time, deaths from NCDs and road traffic injuries have emerged as leading causes of years of life lost.
 NCDs are expected to become the leading cause of ill health and death by 2030, influenced by rapid urbanization, change in diet, change in risk factors from poverty to behavior, and improvements in the control of CDs that increase life expectancy.

NCDs and RTIs already account for almost a third of deaths in the region
Proportion of deaths by cause in SSA, 2010
Source: Global Burden of Disease study, IHME 2013

Africa already has highest death rate from NCDs
Age-standardized Mortality Rates by Cause, WHO Regions, 2008
Source: World Health Statistics 2013, World Health Organization

Ghana compared with WHO African Region
Age-standardized Mortality Rates by Cause, 2008
900
800
700
600
500
400
300
200
100
0
Communicable, maternal, perinatal, nutritional causes
Noncommunicable Injuries
Africa
Ghana
Source: World Health Statistics 2013, World Health Organization

NCDs: Biggest killers among adults > 45 years
Proportion of Deaths by Age Group (Years) in SSA, 2010
Source: Global Burden of Disease study, IHME 2013

Further shift expected in relative disease burden
Burden of Disease (% total DALYs) by Groups of Disorders and Conditions,
SSA, 2008 and 2030
Source: Global Burden of Disease study: 2004 update (2008) (estimates; pending new projections from GBD/IHME 2013)

Shifts in the leading causes of disease burden
(DALYs) for males in Ghana, 1990-2010
Source: Global Burden of Disease study, IHME 2013

Shifts in the leading causes of disease burden
(DALYs) for females in Ghana , 1990-2010
Source: Global Burden of Disease study, IHME 2013

The contribution of different risk factors to disease burden is shifting towards those for NCDs
Top 10 global risk factors ranked by Attributable Burden of Disease for Sub-Saharan African Regions, 2010
Source: Global Burden of Disease study, IHME 2013

How to effectively address NCDs in SSA?

Align health strategy with SSA’s future to make a stronger case for investing in health
 To improve competitiveness and employment: a healthy and skilled workforce is critical.
 To reduce vulnerability and increase resilience among the population and in society: universal health coverage, both financial protection and access to quality services, needed to deal with cumulative effects of health shocks.
 Domestic social spending needs to be increased, particularly in mineral-rich countries, in tandem with building institutions and systems and drawing on the contributions of multiple sectors, to generate good health outcomes.

Potential risks of setting up yet another vertical program in resource-constrained countries need to be acknowledged and overcome, with integration and resource-sharing where feasible
 There are four ways that this might be achieved:
 Capitalize on links between conditions
 Focus on common functions (prevention, treatment, care) rather than disease categories
 Implement proven, cost-effective interventions
 Capitalize on existing resources and capabilities

Capitalize on the inter-linkages between conditions and on their common determinants
 Not much attention has been paid to the extent to which CDs contribute to the NCD burden and to the potential common intervention strategies in SSA.
 Shared underlying social conditions: poverty, poor nutrition
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Co-morbidities with both CDs and NCDs co-existing in the same individual
Presence of one condition increases risk or impact of the other e.g. smoking increases risk TB and impacts on HIV progression
Treatment of one condition increases risk of another e.g. ART for HIV increases metabolic syndrome
Presence of one condition can be barrier e.g. stigma of HIV may impede participation in health promotion opportunities

A third of cancers in Africa are related to infection, and other risk factors are shared with NCDs
Cancer sites Infectious agents Other risk factors of high public health relevance
Breast
Cervix
Liver
HPV
HBV, HCV
Hormonal/ reproductive factors, obesity, physical inactivity, alcohol
Tobacco
Aflatoxins (produced by Aspergillus moulds), alcohol
Prostate
Lymphomas (non-
Hodgkin and Burkitt)
Colon and rectum
Kaposi sarcoma
Oesophagus
Lung
EBV, malaria, HIV
(indirect), HCV
HIV (indirect), HHV8
Diet, obesity, physical inactivity, alcohol, tobacco
Tobacco, alcohol
Tobacco
Stomach
Bladder
Helicobacter pylori
(bacterium)
Schistosoma haematobium (fluke)
Source: Adapted from: Parkin 2006; Sylla & Wild 2012
Diets low in fruit and vegetables and high in salt, tobacco
Tobacco, occupational exposure
Abbreviations: HPV Human papilloma virus; EBV Epstein-Barr virus; HBV hepatitis B virus; HCV hepatitis C virus; HHV8 human herpes virus 8

Shared determinants between NCDs and risk factors related to poverty
NCDs
Cardiovascular
Respiratory
Endocrine
Neurological
Renal
Musculoskeletal
Condition
Hypertension
Pericardial disease
Rheumatic valvular disease
Cardiomyopathies
Congenital heart disease
Chronic pulmonary disease
Diabetes mellitus
Hyperthyroidism and hypothyroidism
Epilepsy
Stroke
Chronic kidney disease
Chronic osteomyelitis
Musculoskeletal injury
Risk factors related to poverty
Idiopathic, treatment gap
Tuberculosis
Streptococcal diseases
HIV, other viruses, pregnancy
Maternal rubella, micronutrient deficiency, idiopathic, treatment gap
Indoor air pollution, tuberculosis, schistosomiasis, treatment gap
Undernutrition
Iodine deficiency
Meningitis, malaria
Rheumatic mitral stenosis, endocarditis, malaria, HIV
Streptococcal disease
Bacterial infection, tuberculosis
Trauma
Source: Adapted from: Bukhman & Kidder, Partners in Health 2011

Maternal and child health has potential longterm consequences for NCDs
 Poor maternal nutrition before and during pregnancy together with smoking during pregnancy contributes to poor intrauterine growth, resulting in low birth weight, which in turn predisposes infant to metabolic disorders and NCD risk in later life.
 Gestational obesity is a strong predictor of future health, both of the mother, who may develop diabetes and CVD later in life, and the child, who also becomes at risk.
 Problem is compounded by poverty and HIV/AIDS and TB: e.g., low birth weight and malnutrition are more frequent in
HIV-infected children.

Focus on common functions (prevention, treatment, care) rather than disease categories
 Growing cross-fertilization of care approaches between CDs and NCDs:
 Care models from HIV/AIDS and TB are being extended/adapted for other chronic conditions and co-morbidities; e.g., DOTS for TB for management of diabetes in Malawi.
 Models already exist for collaboration with TB control programs for syndromic guidelines in primary care to also benefit patients with noninfectious respiratory diseases such as asthma.
 Chronic care models more frequently used for NCDs are also being applied to cover infectious chronic diseases: e.g., to integrate and improve quality of care for HIV, hypertension and diabetes are underway in Uganda, Tanzania, and South Africa.

Capitalize on existing resources and capabilities
 Leveraging the resources, experience, and models of existing programs, such as HIV/AIDS, could benefit management of other chronic conditions as part of integrated delivery systems
 Redesigning the delivery of services around multidisciplinary teams to facilitate task-shifting among personnel and bringing care closer to the patient
 Common procurement and supply lines for essential drugs, scaling up the use of new technologies, such as mobile phones and integrated health information systems
 Linking health spending decisions to adoption of clinical guidelines for service provision to encourage coordination of care and improve the quality of services

Approach for care of HIV/AIDS at primary care & district levels relevant for other chronic conditions
Source: Adapted from: WHO (2004) General principles of good chronic care

Chronic care model for NCDs adapted for HIV/AIDS
Example: USAID project in Uganda to improve care of people with HIV/AIDS
Source: Adapted from: WHO (2002) Innovative care for chronic conditions: building blocks got action: global report

Integrating HIV/AIDS and cervical cancer control: a promising high-impact entry point
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High incidence and mortality from cervical cancer
Minimal cervical cancer screening services contribute to patients being diagnosed at advanced stages of diseases
 HIV-positive women are 4-5 times more likely to develop cervical cancer
 Some common underlying determinants e.g., sexually transmitted infections; gender violence; links with alcohol
 Potential for integrated solutions e.g., sexual health promotion; cervical screening integrated into existing service delivery platforms

Incidence of cervical cancer is highest in Eastern, Western and Southern African regions – and a high proportion die
Age-Standardized Incidence and Mortality Rates per 100,000 Population, Females, World Regions
Source: GLOBOCAN, International Agency for Research on Cancer

Scaling up cervical cancer control
 Partnership between Ministry of Health, Pink Ribbon/Red
Ribbon Initiative, CDC and World Bank
 Co-financed by ongoing HIV/AIDS Prevention Project
 Use of existing HIV/AIDS community-based clinics
 Low-cost cervical screening (“see and treat” approach)
 Scaling up from demonstration project to 5 regions across the country
 HPV vaccination to be introduced, beginning with a pilot in Gaborone, targeting school age girls
 Robust M&E in place to measure results and impact

Implement proven cost-effective interventions
Effective tobacco control requires multisectoral policies and actions
 On June 3-5, 2012, the World Bank, with Ministry of Finance of
Botswana, Bloomberg/Gates Foundations, WHO and SADC, convened in Gaborone high-level forum “The Economics of Tobacco Control:
Taxation and Illicit Trade.”
 Delegations from Ministries of Finance, Trade, and Health of 14
SADC member countries and global and regional experts initiated dialogue on effective design and administration of excise taxes on tobacco to promote public health and share knowledge on causes and extent of illicit trade of tobacco and strategies to control it.
 A Community of Practice in 14 SADC member countries is now evolving under World Bank coordination with other development partners and funding from Bloomberg/Gates Foundations.

The 2011-2020 UN Decade of Action on
Road Safety: an entry point to deal with injuries
 Five categories or "pillars" of activities:
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 building road safety management capacity improving the safety of road infrastructure and broader transport networks
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 further developing the safety of vehicles enhancing the behavior of road users
 improving post-crash care
 The World Bank, working together with WHO and other development partners, plays a key role in supporting global effort

Countries that have successfully reduced RTIs have adopted a safe systems approach
Elements are already in place in some African countries but strengthening of institution and governance capacity is needed for better coordination of sectors
Source: Adapted from OECD/ITF (2008) Towards zero: ambitious road safety targets and the Safe System approach

A new role for Global Health Diplomacy
Collaboration and sharing of knowledge and experiences among countries
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A move away from “foreign health” /“domestic health” dichotomy towards “global health "concept
Interdependence of health of populations (e.g., linkage of health problems with production, trade, and travel)
Global transfer of health risks (e.g., tobacco trade, poor and unhealthy diets and “globesity”, environmental risks)
Global transfer of opportunities (e.g., translation of knowledge into new technologies, social action, evidence for policy)
Developing partnerships between countries (e.g., South-to-South exchanges) to share knowledge, experience, and good practices
Adapting international good practices, strategic support, and institutional capacity building to turn evidence into action
Source: Frenk, J. (2009)

Take-away Messages
 Improved health and social development are critical investments for social transformation and sustained growth in
SSA as they pave the road to accelerated poverty reduction and shared prosperity
 Rather than concentrating on a few diseases, governments and international agencies should prioritize building health systems that offer universal financial protection, along with improved access to and the use of quality services
 An effective response also needs multisectoral policies and actions for dealing with disease-related risk factors and their social, economic, and environmental determinants

The importance of health in a society
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“
When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied”.
Herophilus, 325 B.C.
Physician to Alexander the Great

pmarquez@worldbank.org