Non-Communicable Diseases in Sub-Saharan Africa and on the African Continent at Large

Preface

In recent years, non-communicable diseases (“NCDs”) – now the unambiguous leading cause of death and disability worldwide – have begun to receive increased global health attention and calls to action by world health authorities.1 Starting in 2011, several high-level UN meetings have generated political declarations; assessments of global progress; and NCD-related Sustainable Development Goals  (“SDGs”), for reducing premature mortality one-third by 2030, agreed to by all nations of the world.FN2 In concert, WHO has presented best practice national policies deemed cost-effective for systematically and equitably reducing NCD mortality and morbidity, including the provision of relevant metrics, market- oriented interventions, and policies governing access to key medications and clinical care.FN3 Yet the message is clear from experts monitoring global responses to these NCD initiatives: progress globally is too slow and inadequate, with broad failures to meet SDG commitments.FN4

Large areas of the developing world, including in Africa (with limited exceptions), have made very poor progress in addressing the growing tide of NCDs.FN5 The reasons behind Africa’s poor response are manifold, some of which are understandable, although not acceptable. The continent, and particularly Sub- Saharan Africa (“SSA” or “the Region”), have heavily prioritized communicable, maternal, neonatal, and nutritional diseases (“CMNN diseases”) historically, in response to local needs as well as global priorities that pre-date SDGs. In more recent years, with the alarming rise of NCDs in Africa, NCD and CMNN diseases are now having to compete side-by-side for scarce healthcare services, insufficient and already strained healthcare budgets, and diminishing global aid.”FN6

There are numerous other factors also contributing to poor progress on the NCD front in Africa, as described in Chapters II-IX. One important contributing factor relates to the poor quantum and quality of data across the continent,FN7 including remarkably few efforts to synthesize the totality of data on priority NCDs. As an example, to our knowledge, major NCDs in SSA (as a collective grouping of diseases) have been summarized only once, and that was just this last Fall by Gouda, et al., in the Lancet.FN8 While an important and highly useful report, Gouda, et al. was limited largely to a discussion of Disability Adjusted Life Years (“DALY”) data from the most current Global Burdens of Disease (“GBDs”), along with macro trending observations about the Region.FN9 Very little narrative was provided on the diseases themselves. This absence of disease details makes the numbers more difficult to understand for many readers not schooled in epidemiology or intimately familiar with the state of health in the Region.

In response to this gap in literature, TEAMFund has sought to gather and summarize available population-based evidence on the full range of priority NCDs in Africa, especially in SSA which is the primary focus of this book. We believe our overview of priority NCDs in Africa and SSA is the most detailed summary of its type thus far, insofar as it seeks to provide a full range of GBD data (not just DALYs), and also provides detailed population-based evidence about each of the priority diseases.

It is our hope that this more fulsome review will be helpful to a wide array of stakeholders who are anxious to see more aggressive NCD agendas advanced in SSA and on the continent at large. To that end:

• Chapter I provides a very brief introductory overview of the rapidly transitioning demographic, urban, and epidemiological trends relating to NCDs in both SSA and on the continent at large.
• Chapters II-IX, the bulk of the report, focuses more specifically on priority NCD burdens within Africa, and in particular SSA. As noted above, in preparing this book, we took the view that numbers alone cannot tell the full story of NCDs’ growing burdens on the African continent. Population- specific discussions of prevalence, key challenges, and priority recommendations to tackle each disease, are also important for more complete understanding of NCD trends. So, for each priority NCD afflicting SSA and the continent at large, we include considerable discussion summarizing important data on each disease, along with GBDs.

The six categories of NCDs that are priority health concerns for SSA (and Africa generally) include cardiovascular diseases, cancers, diabetes, mental health/substance use disorders, kidney diseases, and respiratory diseases.FN10 We discuss those diseases in that order, by separate chapters (Chapters III- VIII). We then provide in Chapter IX, brief overviews of other notable NCDs, including vision, musculoskeletal, children’s, and digestive NCDs. Although our narratives for each disease attempt organizational consistency to facilitate comparative review between diseases, our discussions are necessarily tailored to the available data and unique aspects of each disease.

• In Chapter X, which is also our conclusion, we provide summary tables of GBDs for both Africa and SSA, showing the relativity of NCD burden numbers side-by-side. In these tables, we offer further details than what we previously have seen thus far in Africa-focused literature. Specifically, we provide for each disease, detailed numbers for: (1) percent change from 1990 to 2017 (both DALYs and deaths); (2) current GBDs (2017) by percent of all NCDs (DALYs and deaths); (3) current percent of all-cause DALYs and deaths; and (4) this same range of information by gender and for combined NCDs (which we call “all NCDs”).

These detailed breakdowns, particularly our inclusion of separate breakouts on mortality, provides more meaningful understanding than DALYs analyzed alone. Mortality is especially important for high-death/premature-death NCDs, where DALYs necessarily are lower.FN11 Also, because some of our readership may have more limited experience with data-dense epidemiology, we have streamlined GBD data presentation (e.g., by providing numbers without ranges and confidence intervals) and included user-friendly tables relevant in each Chapter, to facilitate review by a broader audience.

This book in toto continues to reinforce the themes we at TEAMFund have sought to advance with our stakeholders since our inception:

• that infectious and maternal diseases/conditions remain a critical concern for SSA and the continent at large, and we will continue to consider any potentially transformative technology in these areas;
• but that nonetheless, TEAMFund will remain focused strongly on NCDs. We do so for three principal reasons:

1. Highlighting NCDs and their Growing Importance in SSA: While communicable diseases are on the decline in SSA, NCD burdens continue to rise at alarming levels in the Region and across the continent in all priority non- communicable disease categories. These trends are highlighted by the graphics below.

As detailed in Chapters III-IX, each and all major categories of NCDs are poorly studied, and often even poorly acknowledged by authorities, healthcare providers, and the general population. These impediments disadvantage the prospects for more organized, evidence-based advocacy, so critically needed to stem the looming NCD health crisis of multiple, often cascading diseases on the continent.

Although affecting all of Africa, needs are especially grave in SSA, where healthcare systems are already struggling to deal with the heavy burdens of CMNN diseases, and where poverty and CMNN diseases conspire to further increase the burdens of NCDs.FN12 NCDs strike societies and individuals with impaired resistance and deficient health systems.FN13 Further voices, including ours at TEAMFund, are essential to raising awareness around these growing NCD concerns.

2. Helping Close Sharp Funding Inequities: Africa and other LMICs account for almost 70% of NCD deaths, yet only 1% of global health funding addresses these burdens.FN14 Each NCD category of disease competes for only a fraction of this 1% of global health funding. Moreover, as global assistance dollars decline in Africa and other LMICs,FN15 we cannot expect either donor organizations or local governments to close the gap on NCD spending in any meaningful way. The private sector must be part of the solution.

3. Showcasing the Enormous Value MedTech Can Contribute to Helping Better Manage NCD Trends: Finally, although select devices have provided enormous contributions to infectious and maternal diseases/conditions (e.g., diagnostics), the majority of MedTech innovation is focused on NCDs, and it is this category of disease where MedTech/digital/Artificial Intelligence (“AI”) innovations (and in turn TEAMFund) can make the most meaningful contributions to African and global health generally.

Footnotes

FN1: Global Burden of Disease (“GBD”) (2017). GBD Compare. https://vizhub.healthdata.org/gbd- compare/. GBDs are a data source and a research tool, that currently represent the best available estimates for global burdens of disease. They were last updated in 2017 and are managed by the Institute of Health Metrics and Evaluation (“IHME”), University of Washington, Seattle, Washington. Nugent, Rachel, Ph.D., et al. Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals. Lancet. Volume 391, Issue 10134, P2029-2035, May 19, 2018. DOI:https://doi.org/10.1016/S0140-6736(18)30667-6. Gouda, Hebe N., Ph.D., et al. Burden of non-communicable diseases in SSA, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet. Volume 7, Issue 10, PE1375-E1387, October 01, 2019. DOI: https://doi.org/10.1016/S2214-109X(19)30374-2.

FN2: United Nations Sustainable Development Goals, Goal 3.4 https://www.who.int/sdg/targets/en/. WHO, Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013- 2020. Geneva: World Health Organization, 2013. https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf;jsessionid=118 0B07D6C896CB5D2252AAE1858EF6C?sequence=1. NCD Countdown 2030 collaborators. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet 2018; 392: 1072-88. Kishore, Sandeep P., and Majumdar, Usnish B. Learning from progress: global NCD policy implementation at national level. Lancet Glob Health. Volume 8, Issue 1, PE4-E5, January 01, 2020. DOI:https://doi.org/10.1016/S2214-109X(19)30496-6.

FN3: Id. World Health Organization. National Multisectoral NCD Policies, Strategies and Plans. https://www.who.int/ncds/governance/policies/en/.

FN4: Horton, Richard and Sargent, Jennifer. 2018 must be the year for action against NCDs. Lancet 2018; Volume 391, Issue 10134, P1971-73. DOI:https://doi.org/10.1016/S0140-6736(18)30674-

FN5: Nugent, Rachel, Ph.D., et al. Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals. Lancet. Volume 391, Issue 10134, P2029-2035, May 19, 2018. DOI:https://doi.org/10.1016/S0140-6736(18)30667-6.

Niessen, LW, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; published online April 4. http://dx.doi.org/10.1016/S0140- 6736(18)30482-3. Jan, S, et al. Action to address the household economic burden of non-communicable diseases. Lancet 2018; published online April 4. http://dx.doi.org/10.1016/S0140-6736(18)30323-4. Sassi, F, et al. Equity impacts of price policies to promote healthy behaviours. Lancet 2018; published online April 4. http://dx.doi.org/10.1016/S0140-6736(18)30531-2. Bertram, MY, et al. Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services. Lancet 2018; published online April 4. http://dx.doi. org/10.1016/S0140- 6736(18)30665-2. Jamison, DT, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898-955.

FN5: Nugent, Rachel, Ph.D., et al. Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals. Lancet. Volume 391, Issue 10134, P2029-2035, May 19, 2018. DOI:https://doi.org/10.1016/S0140-6736(18)30667-6. United Nations Economic Commission for Africa. Healthcare and Economic Growth in Africa. https://www.uneca.org/sites/default/files/uploaded-documents/ABHF2019/healthreport_executive_summary.pdf. Horton, Richard and Sargent, Jennifer. 2018 must be the year for action against NCDs. Lancet 2018; Volume 391, Issue 10134, P1971-73. DOI:https://doi.org/10.1016/S0140-6736(18)30674-3. Kostova, D., et al. Synergies between Communicable and Noncommunicable Disease Programs to Enhance Global Health Security. Emerg Infect Dis. 2017 Dec;23(13). doi: 10.3201/eid2313.170581. Dieleman, JL, et al. Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Aff (Millwood) 2014;33:878-86. 10.1377/hlthaff.2013.1432.

FN6: Id. United Nations Economic Commission for Africa. Healthcare and Economic Growth in Africa. https://www.uneca.org/sites/default/files/uploaded-documents/ABHF2019/healthreport_executive_summary.pdf.

FN7: Gouda, Hebe N., Ph.D., et al. Burden of non-communicable diseases in SSA, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet. Volume 7, Issue 10, PE1375- E1387, October 01, 2019. DOI: https://doi.org/10.1016/S2214-109X(19)30374-2.

FN8: Id.

FN9: See endnote 1 for an explanation of GBDs. As noted above, DALYs are calculated by summing years of life lost (“YLLs”) due to premature mortality, and years of life lived with disability (“YLDs”), incorporating both fatal and non-fatal burdens.

FN10: Global Burden of Disease. (2017). GBD Compare. https://vizhub.healthdata.org/gbd- compare/. Gouda, Hebe N., Ph.D., et al. Burden of non-communicable diseases in SSA, 1990- 2017: results from the Global Burden of Disease Study 2017. Lancet. Volume 7, Issue 10, PE1375-E1387, October 01, 2019. DOI: https://doi.org/10.1016/S2214-109X(19)30374-2.

FN11: Global Burden of Disease (“GBD”) (2017). GBD Compare. https://vizhub.healthdata.org/gbd-compare/. WHO. 2019. Maternal Mortality. https://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality. As noted above, the recent 2019 Lancet summary review of NCDs in Sub-Saharan Africa by Gouda, et al. highlighted only DALYs. Gouda, Hebe N., Ph.D., et al. Burden of non-communicable diseases in SSA, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet. Volume 7, Issue 10, PE1375-E1387, October 01, 2019. DOI: https://doi.org/10.1016/S2214- 109X(19)30374-2.

FN12: Id. Gouda, Hebe N., Ph.D., et al. Burden of non-communicable diseases in SSA, 1990-2017: results from the Global Burden of Disease Study 2017. Lancet. Volume 7, Issue 10, PE1375- E1387, October 01, 2019. DOI: https://doi.org/10.1016/S2214-109X(19)30374-2. Niessen, LW, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. Lancet 2018; published online April 4. http://dx.doi.org/10.1016/S0140- 6736(18)30482-3. Hegelund, Maria H., et al. Prevention of opportunistic non-communicable diseases. Int Health. 2019 Mar 11. pii: ihz011. doi: 10.1093/inthealth/ihz011.

FN13: Hegelund, Maria H., et al. Prevention of opportunistic non-communicable diseases. Int. Health 2019 Mar 11. pii: ihz011. doi: 10.1093/inthealth/ihz011.

FN14: Nugent, Rachel, Ph.D., et al. Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals. Lancet. Volume 391, Issue 10134, P2029-2035, May 19, 2018. DOI:https://doi.org/10.1016/S0140-6736(18)30667-6. United Nations Economic Commission for Africa. Healthcare and Economic Growth in Africa. https://www.uneca.org/sites/default/files/uploaded-documents/ABHF2019/healthreport_executive_summary.pdf. Kostova, D., et al. Synergies between Communicable and Noncommunicable Disease Programs to Enhance Global Health Security. Emerg Infect Dis. 2017 Dec;23(13). doi: 10.3201/eid2313.170581. United Nations Economic Commission for Africa. Healthcare and Economic Growth in Africa. https://www.uneca.org/sites/default/files/uploaded- documents/ABHF2019/healthreport_executive_summary.pdf. Dieleman, JL, et al. Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Aff (Millwood) 2014;33:878-86. 10.1377/hlthaff.2013.1432.

FN15: United Nations Economic Commission for Africa. Healthcare and Economic Growth in Africa. https://www.uneca.org/sites/default/files/uploaded- documents/ABHF2019/healthreport_executive_summary.pdf.