South Africa’s Quadruple Burden of Disease

This week, Pooja Yerramilli returns to explore Non Communicable Diseases (NCDs) and the quadruple burden as barriers to economic and social development with Sandhya Singh – Director of Disease, Disability, and Geriatrics within South Africa’s Department of Health.

Pooja Yerramilli Three years ago, I found myself on a bus in South Africa, with fifteen of my college classmates. We were on our way to Kruger National Park, after a week of volunteering and researching in Cape Town. As I stared out the window, appreciating rural South Africa’s beauty, a large billboard, seemingly in the middle of nowhere, caught my attention. “Relay for Life: A Fundraiser for the American Cancer Society.” This poster piqued my curiosity. I had always associated South Africa with HIV/AIDS and tuberculosis. In fact, I had documented a handful of posters in Cape Town that aimed to combat HIV/AIDS by reducing stigma and encouraging testing. Why, then, when the country was clearly facing an HIV/AIDS epidemic, would locals bother to fundraise for cancer research? Surely, they had more pressing public health challenges to deal with.

This mentality and these assumptions are widespread. But the statistics tell a different story. The burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, chronic respiratory conditions, and cancer, is rising globally and in South Africa. In 2008, NCDs accounted for 29% of all deaths in the country. Much of this disease burden is preventable and can be attributed to increasing exposure to risk factors, such as tobacco consumption, physical inactivity, unhealthy diets, and excessive alcohol consumption. Indeed, the 2008 South Africa Youth Risk Behavior Survey found that more than 1/3 of boys and over 40% of girls qualified as “sedentary,” increasing their risk of obesity and resultant complications.

Thus, South Africa, in essence, is facing a quadruple burden of disease: the HIV/AIDS epidemic alongside a high burden of TB; high maternal and child mortality; high levels of violence and injuries; and a growing burden of NCDs. Yet the country does not currently have the infrastructure to cope with chronic diseases.

Why is this important? Because, according to Sandhya Singh (Director of Disease, Disability, and Geriatrics within South Africa’s Department of Health), as South Africa aims to grow its economy, NCDs will pose yet another barrier to development.

Several months ago (July, 2014), I was able to speak with Singh about South Africa’s strategies for NCD care and control. In response to the rapidly escalating burden of NCDs, the Government of South Africa has defined three primary approaches required to control these diseases. As delineated in the country’s Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17, the first is to focus on health promotion and primary prevention at the individual and community levels; the second is to improve NCD control through health systems strengthening; and the last is to expand surveillance of NCDs and associated risk factors and conduct research on these subjects.

Given South Africa’s limited resources and its quadruple burden of disease, the overarching goal which underlies each strategy is cost-effective health systems strengthening. As treatment and control of HIV/AIDS improved, South Africa has seen a shift in the categorization of this disease from acute to chronic. Therefore, according to Singh, “we [the Department of Health] are really serious about learning lessons about the HIV journey and integrating care. If we continue to work in siloes,” she added, “there’s no way we’re going to be able to provide the optimal care we require.”

Accordingly, the Department of Health has identified several means through which NCD services may be integrated with programs and infrastructure already established for HIV/AIDS. The Integrated Chronic Disease Management Model (ICDM), which utilizes community health workers, aims to promote equity and access through community participation, intersectoral strategies, and an emphasis on health promotion. Moreover, the development of the National Health Insurance scheme aims to revitalize and revise primary health care infrastructure, human resources training, and health services integrated with school-based interventions, in a manner which improves NCD control.

The Department of Health aims to identify “best buys” for chronic disease control; for example, integrating NCD screening with the pre-existing HIV counseling and testing campaigns. A priority area currently under development, according to Singh, is drug distribution – specifically, how to deliver prepackaged medications for more than one month at a time, close to patients’ homes. For these projects, Singh suggested that the government can learn from the HIV/AIDS experience and piggyback off of these services. Moreover, Singh emphasized that strengthening primary health care is not sufficient – referral chains between facilities must also be developed and fortified.

Singh attributes much of the recent progress in NCD strategy development and control to political commitment. “I think we would be failing if we did not recognize that South Africa has moved a little further than our neighbors because of political and strategic support. We may not have the resources we need, but we have been able to make important changes, such as salt regulation – something unique to us – because of the political system.” Singh identified the 2009 Lancet article as a turning point and call to arms, because it suggested that “if we don’t do anything about [NCDs], we’ll be faced with the same situation as with the HIV journey.”

Indeed, South Africa’s resulting political commitment is evidenced by its support of the Brazzaville Declaration on NCD Prevention and Control in the WHO African Region (2011) and the UN Political Declaration on NCDs (2011). The government’s words are backed by legislative action, including anti-tobacco regulations, which resulted in a 22% reduction in smoking behaviors between 1995-2009; legislation to reduce trans fatty acids and salt in processed food; and bans on junk food advertisements to children and regulation of foods sold during school hours.

The government of South Africa has also aimed to pursue multisectoral approaches to NCD control. For example, the Department of Health is developing a National Health Commission housed in the presidency, which will bring together the distinct ministries to improve buy in and support for “health in all” policies. Singh suggested that the establishment of an NCD unit within the Department of Health was a crucial step toward catalyzing multisectoral plans, as it may serve as a focal point to advocate for inclusion of aspects of NCD control in all policies – a step that many countries have not yet taken.

Although South Africa has certainly made strides in prioritizing NCDs in its national health agenda, Singh affirmed that there remains inequity in funding across diseases. “Our government has an obligation to look at HIV/AIDS, maternal/child mortality, and MDG-related goals,” she stated. Nevertheless, she continued, “we are cognizant of the rising burden of NCDs and are looking at a range of means to increase internal revenue for NCD control.” The treasury provided funding for the HPV vaccine, out of recognition that “unless something is done now, we cannot afford the cost of cervical cancer,” Singh stated.

Yet Singh expressed concern that international funders continue to solely focus on HIV/AIDS and TB, when the mortality rates associated with NCDs are rising. She further emphasized that “we so often focus on mortality and we ignore the economic impact of morbidity.” The disabilities developed through NCDs often prohibit patients from contributing to the economy.

While political commitment appears key in South Africa’s ability to address NCDs, it is clear that limited resources continue to hamper progress – not only in improving NCD control, but also improving health outcomes for comorbid conditions and ultimately furthering economic progress. Thus, Singh urges international donors to take note of South Africa’s commitment to the cause and devote funds to NCD control.–

Pooja is currently a medical student at the Perelman School of Medicine, University of Pennsylvania and Project Coordinator for the Young Professionals Chronic Disease Network. She graduated from Yale University with a B.A. in Political Science, and holds an MSc. in Health Policy, Planning, and Financing, a joint degree awarded by the London School of Hygiene and Tropical Medicine and the London School of Economics. She has research experience in South Africa and India, where she studied the challenges associated with aging populations and cancer care and control. Pooja previously worked at and is currently collaborating with the Harvard Global Equity Initiative.