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