September 10, 2014 - Sub-Saharan Africa is facing a healthcare tipping point. Policy and resources are mainly dedicated to fighting infectious diseases today. HIV, malaria and tuberculosis are the big targets. But over the next 15 years chronic diseases like cancer, heart disease, and kidney failure will become the major killers. By 2030 they will account for 42% of all deaths in the region, up from 25% today, says the World Health Organization.
Their rise may be inevitable, but their impact could be better managed. Education, policy and health investment can all make a difference. Across the region, new ideas have worked – from grassroots measures to population-wide campaigns. They could be repeated elsewhere. And they need not cost a fortune.
Some of the best are highlighted in a new report from the Economist Intelligence Unit (EIU), commissioned by Novartis. The EIU carried out in-depth interviews with 16 healthcare experts and surveyed some 490 patients – or, in a small number of cases, their primary carers - with non-communicable diseases in ten South Saharan African countries, to understand how aware they were of the causes of and cures for their diseases and how well they are served by the healthcare providers in their countries.
“Progress is being made, but a whole lot more needs to be done,” says its author, Dr. Paul Kielstra.
The rise of chronic disease
There are four broad reasons chronic diseases are on the rise across the region, the report says. The first is rapid economic growth, and the urbanization it brings.
Both can raise living standards, but bring with them health negatives. Pollution increases. People can start to eat a worse diet, binge on alcohol and exercise less. In Nigeria and South Africa, for example, people typically consume a level of salt that is 60% above the daily recommended maximum.
Second, people often have little or no understanding of the risks that come with a chronic condition like heart disease. Some do not even know such dangers exist; 28% of people surveyed for the report did not think smoking was a health risk. Half the total did not know being overweight could damage their health. This lack of basic health knowledge makes prevention and treatment hard.
It isn’t just a question of people not appreciating the risks; culture is a factor too.
“Some African cultures look at a fat person as a healthy person,” says Dr Mary Amuyunzu-Nyamongo, coordinator of the Consortium for Non-Communicable Diseases Prevention and Control in the region.
Some 15% of those in the survey said family or community ignorance about their disease stopped them getting better care. They are often stigmatized, sometimes to an extreme degree, with people blaming their symptoms on witchcraft or curses. Cases of ostracism, divorce, and even physical beatings are not uncommon.
Lack of healthcare
The third factor behind the rise of chronic diseases is that healthcare is not widely available, and where it is, the quality is often poor. The research found that 30 health systems in the region spend less than $100 per person each year.
There are few specialists and often none in rural areas. Equipment is in short supply or non-existent. Almost half, 49%, of the people surveyed said the biggest barrier to better care was a lack of access to clinicians with the right equipment, specialists, or general practitioners.
The final issue is the cost of treatment, and of accessing treatment. People surveyed said on average their care cost 29% of their annual income. Most had to pay this themselves and borrowed money to do so. On top of medication, common expenses included travel, medical fees and lost income. “The majority cannot afford their treatment,” says Dr. Kingsley Akinroye, a Nigerian cardiovascular health expert and vice-president of the World Heart Federation.
The rise of chronic diseases is a significant challenge in sub-Saharan Africa, as it is in the developed world. But the report identifies several successful projects that could be rolled out more widely. Many of them involve education.
The Nigerian government has made radio programs with community and religious leaders to educate people in poor, remote communities. It worked with the Nollywood cinema industry to make Sugar Boy, a movie about a young footballer who discovers he is suffering from diabetes. Efforts to prevent chronic disease are sparse, but this kind of fresh thinking can pay dividends.
Education campaigns that encourage people to talk about their illness can remove stigma and encourage them to seek treatment sooner. The Ugandan Women’s Cancer Support Organisation, set up by a group of breast cancer survivors, helps newly diagnosed women to discuss their condition with someone who has survived the disease. It organizes bike rides, screening sessions and other media-friendly events to raise awareness and encourage other women to have a check-up.
Elsewhere, steps to encourage healthy behavior across a population have also proved effective. The proportion of adult smokers in South Africa fell from 33% to 24% when the country hiked tobacco taxes dramatically. Legal cigarette consumption dropped by 40% and deaths from smoking-related diseases fell. The creation of public no-smoking areas had a substantial impact at little or no cost. Now South Africa is looking at population-wide measures to reduce salt consumption.
Better health systems
Greater investment in health systems, and better use of existing resources, are essential. Much of what works in African healthcare today is narrowly focused on single diseases, such as malaria. Expanding these programs to include other conditions can improve care across a population.
In Zambia, a cooperative program involving the government, a non-governmental organization (NGO), the Center for Infectious Disease Research in Zambia and several international bodies, decided to house the country’s cervical cancer testing units inside HIV clinics. It now has the biggest cervical cancer screening program in Africa, with over 100,000 people tested. Next it’s looking at ways to use the same clinics for mental health tests.
Training existing medics to recognize and understand basic chronic disease care can have a rapid and substantial impact. Tanzania’s national referral hospital only had around 20 children diagnosed with Type-1 diabetes a decade ago. Now there are some 1,300 in clinics all over the country. Free insulin and simple diagnostic tests that general nurses can use made all the difference. The disease can be fatal within months, so accurate and early diagnosis saves lives.
“A lot of lives are being saved. The people we have reached understand cancer a bit better and people go to hospitals rather than traditional healers.”
Gertrude Nakigudde, advocacy officer of the Ugandan Women’s Cancer Support Organisation who represents the organization on the Board of Ugandan Women’s Health.
Another example is in Rwanda, where healthcare has improved dramatically over the last decade. Deaths from malaria are down 85% and from tuberculosis by 77%. This progress is not the result of greater spending, but better policy. Healthcare is universally available, with 98% ofpeople having some form of insurance. And the system is organized around primary care, with one of 45,000 trained community health workers ready to offer basic treatment, before referral to a doctor. The government is also busy developing a range of large-scale vaccination, education, regulation, prevention and screening programs across a number of fronts to tackle chronic diseases. A systematic approach works, says Rwanda’s Minister of Health, Dr. Agnes Binagwaho. “For what we can do [easily], there is no restriction; for what is hard, we start with the biggest problem.”
Could the lessons from Rwanda and elsewhere be applied region-wide? The study concludes that they can. Numerous specific examples of progress across the region show, creativity, cooperation and strategic thinking can save lives. And better allocation of existing resources and rigorous prioritising can lead to to improvements without the need for substantial increases in funding. The tools to enable progress are in place, the study concludes.