ncds in africa:- burden of disease, control strategies and health...

NCDs IN AFRICA:-

Burden of Disease, Control Strategies and Health System Integration

Prof. Gerald Yonga MD, MBA (healthcare),FRCP (Edin) FESC, FACC

1. Visiting Professor, NCD Research, University of Nairobi, Kenya

2. President, East Africa NCD Alliance, Kampala, Uganda

3. BOD, Global NCD Alliance, Geneva, Switzerland

4. WHO-CSO Working Group on NCDs, Geneva, Switzerland

Declaration of conflicts of interest

•None

Outline

❖ NCD burden in Africa❖ Framework and strategies for Control❖ HIV- NCD care Integration

CancerDiabetes

CardiovascularDisease

Chronic RespiratoryDiseases

Mental Ilnesses

Renal Disease

Disability

Osteoarthritis

PsoriasisOral health

Neurological Disorders Blindness

Physicalinactivity

Alcohol

Tobacco

Unhealthy diet

NCDs and their risk factors

Osteoporosis

Airpollution

RISK FACTORS FOR CVD

Fast Food vs traditional foods

Behavioral&

Environmental

RF

Tobacco

Alcohol

Physical

Inactivity

Nutrition

Air Pollution

Physiological

RF

BMI

Blood press.

Blood Glucose

Cholesterol

Outcomes

CVD

Stroke

Diabetes

Cancer

CRDs

NCDs Causal Chain

Low-income countriesGroup III - Injuries

Group II – Other deaths from NCDs

Group II – Premature deaths from NCDs (below the age of 70), which are preventable

Group I – Communicable diseases, maternal, perinatal and nutritional conditions

0

10 million

15 million

20 million

25 million

High-income countries Upper middle-income Lower middle-income Low-income countries

1.9M

6.0M

6.1M

1.9M

So

urc

e:

Global situation of NCDs

17%

65%

17%

11%

7%

35%

Regional situation of NCDs

Low-income countriesGroup III - Injuries

Group II – Other deaths from NCDs

Group II – Premature deaths from NCDs (below the age of 70), which are preventable

Group I – Communicable diseases, maternal, perinatal and nutritional conditions

35% of deaths in Africa

from NCDs and injuries

Deaths attributable to NCDs in sub-Saharan Africa

• In 1990 NCDs caused 25% of total deaths in SSA (1.7 million deaths)

• In 2015 NCDs caused 34% of total deaths in SSA (2.7 million)

• The majority of NCD deaths are attributable to CVD (12% of total deaths), cancer (7%), and diabetes (5%)

Partnerships in CVD Prevention and care in Africa

Leading causes of health loss in SSA

• CVD is 6th leading cause of DALYs (years of healthy life lost to premature death and disability)

• Diabetes, mental and substance use disorders, and cancer take 9th, 10th, and 11th place

• Health loss attributable to CVD increased by 40% between 1990 and 2015

• Health loss attributable to diabetes increased by 46% between 1990 and 2015

Partnerships in CVD Prevention and care in Africa

Leading risk factors for NCDsin sub-Saharan Africa

• High blood pressure, poor

diets, and air pollution are

the top 3 risk factors for

health loss from NCDs in

SSA

• Nearly 6% of DALYs and 15%

of deaths in SSA are

attributable to high blood

pressure and unhealthy diets

• Other metabolic risk factors

such as high BMI and high

blood sugar are also leading

risks

• The importance of these risk

factors is related mainly to

their contribution to CVD and

diabetes

2005 2006-2015 (cumulative)

Geographical regions (WHO

classification)

Total deaths

(millions)

NCD deaths

(millions)

NCD deaths

(millions)

Trend: Death from

infectious diseaseTrend: Death from NCD

Africa10.8 2.5 28 +6% +27%

Americas6.2 4.8 53 -8% +17%

Eastern Mediterranean

4.3 2.2 25 -10% +25%

Europe9.8 8.5 88 +7% +4%

South-East Asia14.7 8.0 89 -16% +21%

Western Pacific12.4 9.7 105 +1 +20%

Total 58.2 35.7 388 -3% +17%

NON-COMMUNICABLE DISEASES - DEATH TRENDS (2006-2015)(W

HO

Ch

ron

ic D

ise

as

e R

ep

ort, 2

00

5)

NCDS RISING AS CDS DROP

MoH Kenya, 2011

NCD BURDEN

• Leading cause of mortality worldwide

• In Africa deaths from NCDs are rising faster than anywhere in the world.

- Slowing economic development

- undermining the attainment of SDGs

- amplifying social inequality

• Main NCDs are CVD, Cancer, Diabetes, Chronic Lung disease, Mental illnesses

• Main Risk factors: Tobacco, Unhealthy diet, harmful use of alcohol, physical inactivity and Air pollution.

Global CommitmentUN High-Level Summit on NCDs and adoption of UN

Political Declaration on NCDs

2011

Galvanised Political Commitments

Global CoordinationUN Task Force on NCDs

20132014

2015

1

2

3 5

Global Action & Accountability

“25 by 25” NCD targets and Global Action Plan 2013-

2020

2030 AgendaUN Sustainable

Development Goals

4

National CommitmentUN High-Level Review &

time-bound national commitments

2014

Agenda 2030 for Sustainable Development

HIV- NCD COMORBIDITY

•NCD patients who develop HIV ?

•HIV patients who develop NCD?

•People diagnosed with HIV and NCD?

•Does it matter?

#AIDS2018 | @AIDS_conference | www.aids2018.org

NCD MORBIDITY IN HIV

• AIDS defining illnesses still account for majority of admissions to hospital, critical care admission & mortality

(AKUHN closed chart audit 2015, Nduku Kiko et al)

• However, the proportions of HIV patients with non-AIDS defining Non-Communicable Diseases (NCDs) are rising especially in outpatient care settings with potential to being major causes of morbidity and mortality in HIV

(Jay S et al, Kaittany F et al, Njenga E et al, Murbi N et al, Mutwiri

et al, Awori et al - AKU MMed Theses )

• Cardiovascular diseases (CVD) contribute the highest proportions to non AIDS defining illnesses seen in both in-patient and out-patient settings

SILO HEALTHCARE SYSTEM IN AFRICA

NCD careMCH/HIV &

FP care

Same people, same behavior, same health

problems…Different doors

NIH ICs, OGAC, CDC, USAID, HRSA, DoD, Peace Corps

Technical Working Group

Chaired by FIC ABWafaa El-Sadr & Bill Tienery

Education, Awareness, and Dissemination (AED)

Steering CommitteeSecretariat

NIH, CDC, USAID

Technical Operating Groups (TOG)

PEPFAR NCD PROJECTResearch to Guide Practice: Enhancing HIV/AIDS Platforms to

Address Chronic, Non-Communicable Diseases in Low Resource Settings

Landscape Analysis/ Research Questions

1) Generate Data on the burden on NCDs in PLWH

3) Develop country-based toolbox for HIV/NCD integration

2) Refine /prioritize implementation science questions

4) Compare HIV/NCD models of integration

6) Develop a COP for the project participants

5) Edit and publish project materials

Technical Activity Groups (TAG)

Population-Level Disease/Condition Questions

Health Systems Integration

#AIDS2018 | @AIDS_conference | www.aids2018.org

Research to guide practice: enhancing HIV/AIDS platform to address non-communicable diseases in sub-Saharan Africa

Supplement Launch!

July 1, 2018 - Volume 32 - Supplement 1

#AIDS2018 | @AIDS_conference | www.aids2018.org

Common Challenges Faced Across

Health ThreatsHIV/AIDS Diabetes CVD Chronic Lung

DiseaseCancers Mental

Health

Demand-side barriers + + + + + +

Inequitable availability + + + + + +

Health worker shortages ++ ++ ++ ++ ++ ++

Lack of adherence support ++ ++ + + + +

Inadequate infrastructure and equipment

+ + ++ ++ ++ +

Inconstant supplies of drugs and diagnostics

+ + + + + +

Missing linkage and referral systems

+ + + + + +

Need for client and community engagement

+ + + + + +

Stigma and discrimination ++ + + ++

Adapted from Rabkin and El-Sadr, Global Public Health, 2011

#AIDS2018 | @AIDS_conference | www.aids2018.org

Leveraging the Lessons of HIV

Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics , standardized diagnostic protocols

Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support

Multidisciplinary family-focused care

A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient

Longitudinal monitoring Health information systems have standardized and easily retrievable data

Linkages and referrals Links within the health facility (to lab, pharmacy, others),between facilities, and between facility & community

Self management An informed, motivated patient is an effective manager of his/her own health

Community linkages and partnerships

Need functional partnerships between health facility-based providers and community-based groups that facilitate access to services across the care continuum

HIV-CVD PRIMARY CARE INTEGRATION

#AIDS2018 | @AIDS_conference | www.aids2018.org

Economics of integration

• Recommendations for minimum economic dataset

• Integrated HIV/NCD care has many potential benefits but the economic justification is unproven

• We need better evidence on the cost, cost-effectiveness, and fiscal sustainability of integrated programs to justify this approach in limited-resource countries

• Four major research needs:– Additional economic evaluations including CEAs

– Better longitudinal data on NCD risk and outcomes in PLHIV

– Studies are needed that assess the interactions of multiple NCDs

– Methods, data sources, and assumptions of the HIV and NCD economic modeling communities would benefit from harmonization and standardization

#AIDS2018 | @AIDS_conference | www.aids2018.org

BCC Integration • In SSA, BCC interventions extensively used in HIV epidemic; are increasingly used in NCD as

well

• Review highlighted BCC strategies utilized for NCD, some e.g mhealth showing feasibility and

early effectiveness

• Few studies integrated HIV and NCDs

• Integrated NCD/HIV BCC could improve effectiveness of preventive services, access, and

demand

• Public health impact of such approaches unknown, Implementation science tools e.g. REAIM

aspects poorly characterized

• Although data on integration of HIV/NCD health promotion efforts is low, there is a fair

amount of evidence to support the feasibility of integration,

• Strategies employed in HIV global response (including peer support and mHealth) provide the

initial experience, tools, and platforms useful in planning NCD health promotion programs.

• Need for research addressing best ways to scale NCD health promotion in high HIV burden

settings and characterize important implementation science dimensions

CHV AND CHEW & PEER COUNSELORS INTEGRATION IN BEHAVIORAL CHANGE FOR HIV AND CVD

#AIDS2018 | @AIDS_conference | www.aids2018.org

HIV Partners: Coverage (Role of Partnerships)

Area of Support Global Fund

to Fight AIDS,

TB, Malaria

Joint United

Nations

Programme on

HIV/AIDS

(UNAIDS)

President’s

Emergency

Plan for AIDS

Relief

(PEPFAR)

UNITAID Private Sector

Partnerships

(ex. PRPR,

PEPFAR-AZ and

PEPFAR-BD)*HIV/AIDS Service Delivery; Financial or Technical

Support Focus Focus Focus Minimal Contribute

Comprehensive Health Systems Capacity SupportContribute Contribute Contribute Contribute Contribute

Implementation Research to Improve Delivery Contribute Contribute Contribute Contribute Contribute

Introduction and Availability of New Health ProductsContribute Contribute Contribute Focus Focus

Political Advocacy for Accountability, Inclusion, and

Resource Contribute Focus Focus Contribute Minimal

Enhanced Approaches to Sustainability and TransitionContribute Contribute Contribute Contribute Minimal

* PRPR=Pink Ribbon/Red

Ribbon, AZ=Astrazeneca, BD=Becton-Dickinson

Green = Plays primary leadership role in utilizing this mode or supporting this activity when

addressing HIV/AIDS in LMICs

Yellow = Plays a supporting (but not primary) role in utilizing this mode or supporting this

activity when addressing HIV/AIDS in LMICs

Orange= Plays a very small role in utilizing this mode or supporting this activity when addressing HIV/AIDS in LMICs

#AIDS2018 | @AIDS_conference | www.aids2018.org

Investments in HIV Response Lay

Foundation for Quality HIV-NCD

Integrated Care

El-Sadr, Goosby, AIDS, 2018

Initial Chronic Care Model (The MacColl Institue ® ACP-ASIM Journals and books.)

#AIDS2018 | @AIDS_conference | www.aids2018.org

APPROACHES TO HEALTH SYSTEM INTEGRATIONS

• Horizontal blocks (e.g. HIV & TB, HIV &MCH/FP, HIV & CVD, HIV & Cancer….)

• Pan Horizontal (HIV and all NCDs, TB, MCH/FP….)

• Diagonal approaches (human resource development, financing, facility planning, drug supply and quality assurance)

• Total Integration (WHO model for ICC in countries in transition)

#AIDS2018 | @AIDS_conference | www.aids2018.org

TOTAL INTEGRATION:-

SDG & MAINSTREAMING OF HEALTH IN ALL GOALS

• Most upstream drivers of both NCDs and HIV lie

outside the health sector

• These drivers involve multiple sectors; across the

public and private sectors (health, agriculture,

education, trade& industry, physical & economic

planning…)

• Approach should to address the health of the

population as a human development agenda rather

than only “preventing and treating diseases”

• Mainstream health issues across all sectors and in

human development agenda at national and global

level

Agenda 2030 for Sustainable Development

JOURNEY TO UHC 2019 – LET US WALK TOGETHER

5 Concluding Remarks

• Strengthen action on SDG 3 (integrated approach to health agenda)

• Mainstream health as an integrated agenda in all SDGs (upstream drivers of health lie outside health sector)

• Position health not as cost but an investment in overall human development agenda

• Achievement of Universal Health Coverage through Strengthening PHC (integrated prevention & Primary Care of both CDs & NCDs)

• Increased evidence base, economic models, best-buys and best practices, surveillance and monitoring

Thank You!