Stark choices: Africa’s double burden of disease


Roughly 50% of deaths from all types of communicable, or infectious, diseases worldwide, occur in Africa. In 2015, a person living in Africa was more than three times as likely to die from HIV/AIDS than a person living in any other developing region in the world. That same person in Africa was more than 10 times more likely to die from malaria.

Africa also experiences a high number of premature deaths from non-communicable diseases, like diabetes and heart disease. More than half of non-communicable diseases deaths in Africa occurred in people under the age of 70 and people in Africa are more likely to die from a non-communicable disease, across all age groups, than people living in the rest of the world.

Taken together, these facts underscore the magnitude of the double burden of disease in Africa.

Last year, world leaders adopted the Sustainable Development Goals (SDGs) – a comprehensive set of 17 development priorities with 169 targets. The third goal focuses on health outcomes and includes targets on communicable and non-communicable diseases.

Policies aimed at preventing mortality from communicable diseases are inherently desirable. But programmes that eradicate individual diseases can have far-reaching effects on health outcomes and demographic structures that are not always straightforward.

To understand this better, new research by the African Futures Project using the International Futures (IF) forecasting system explored Africa’s disease burden up to 2050. It found that eliminating life threatening communicable diseases such as HIV, malaria and tuberculosis in line with SDG targets will add 27 million people to Africa’s population – more than the number currently living in Angola – by 2050 and require far-reaching changes to health planning and expenditure.

Eliminating life threatening communicable diseases will add 27 million people to Africa’s population

So while achieving SDG targets will significantly improve development outcomes in Africa, these targets could dramatically impact the size and composition of current population structures.

In 2015, roughly 988 million people lived in sub-Saharan Africa and IFs forecasts that it could be as many as 1.4 billion (a more than 40% increase) by 2030 and more than 2.1 billion (more than 100% increase) by 2050. In short, sub-Saharan Africa’s expected population growth is extraordinary. Policymakers must anticipate additional potential drivers of demographic change and design strategies accordingly.

The prominence of the SDG health targets, and the attention they are likely to receive from the development community, will drive those changes in ways that are difficult to anticipate but critical to consider. Understanding the demographic changes will add context to the SDG agenda and help countries to effectively prioritise these targets when making policy decisions.

In Africa, high fertility rates drive rapid population growth. The continent also experiences high rates of unplanned urbanisation and low levels of access to basic services like clean water and improved sanitation facilities. These are all major drivers of a variety of diseases and could complicate efforts to reduce both communicable and non-communicable diseases.

One of the key findings of the African Futures research is the relationship between communicable and non-communicable diseases, particularly among vulnerable populations like young children.

Africa’s approach must incorporate prevention, treatment and management of all types of disease

Because children affected by a communicable disease are more prone to stunting, those same children are more likely to suffer from an early-onset non-communicable disease as well. Similarly, people who are affected by HIV/AIDS are significantly more vulnerable to nearly all disease types. Infectious diseases have also been linked to cancer cases in the developing world.

Eliminating communicable diseases in accordance with the SDGs will provide enormous benefits for Africa, but will also cause the burden of disease to shift toward non-communicable diseases about 10 years earlier than anticipated, in 2021.

This dramatic shift is shown in the figure below, which displays Africa’s disease burden on its current trajectory compared to an intervention where communicable diseases are reduced in accordance with SDG targets.

A change of this magnitude would thrust many African countries into a future where non-communicable diseases are the predominant concern of health systems. This will have a number of important implications.

One is that health care costs across Africa will rise because non-communicable diseases are generally more difficult and expensive to diagnose, treat and manage. Another concern is that non-communicable diseases typically affect older segments of the population, which could drive people out of the workforce and negatively impact productivity.

These factors highlight the need for countries in Africa to embrace a ‘horizontal’ approach to health management that incorporates prevention, as well as treatment and management of all types of disease.

With Africa’s double burden of disease, investment in ‘horizontal’ health programmes is crucial

In the past, disease reduction in Africa has typically been pursued through so-called ‘vertical’ strategies. These strategies target one specific disease (malaria is a good example) and provide support for rapidly reducing the incidence and ultimately prevalence of that disease.

Horizontal strategies, by comparison, involve improving the capacity of health systems to provide prevention and care for general health problems and target the long-term drivers of disease. Horizontal strategies typically include broad objectives that move beyond traditional disease treatment and include things like proper systems for human waste disposal, ensuring availability of quality drinking water and, perhaps most important, education about the causes and effects of different types of diseases.

Vertical programmes are necessary, but do not address the full scope of health issues faced by African countries. Considering Africa’s double burden of disease, investment in horizontal health programmes is crucial.

Zachary Donnenfeld, Researcher, African Futures and Innovation and Kanishka Narayan, Research Assistant, Pardee Center for International Futures

The African Futures project is a collaboration between the Institute for Security Studies and the Frederick S. Pardee Center for International Futures at the University of Denver.

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