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Epidemiology of chronic non-communicable diseases in low and middle income

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PUBLIC HEALTH IN THE 21ST CENTURY
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NON-COMMUNICABLE DISEASES
(NCDS) IN DEVELOPING
COUNTRIES
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Additional books in this series can be found on Nova‘s website
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under the Series tab.
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under the E-books tab.
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(NCDS) IN DEVELOPING
COUNTRIES
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NANCY PHASWANA-MAFUYA
AND
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DIMITRI TASSIOPOULOS
EDITORS
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Nova Science Publishers, Inc.

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Additional color graphics may be available in the e-book version of this book.
Library of Congress Cataloging-in-Publication Data

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Non-communicable diseases (NCDs) in developing countries / editors, Nancy

Phaswana-Mafuya, Dimitri Tassiopoulos.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61209-996-5 (hardcover)
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1. Chronic diseases--Developing countries. I. Phaswana-Mafuya, Nancy. II.

Tassiopoulos, Dimitri.
[DNLM: 1. Chronic Disease. 2. Developing Countries. WT 500]
RA644.8.D44N66 2011
614.5--dc22
2011010152
 New York
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CONTENTS
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Preface vii
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Foreword xi
Chapter 1 Epidemiology of Chronic Non-communicable
Diseases in Low and Middle Income
Countries – A Review 1
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N. Phaswana-Mafuya, D. Tassiopoulos,
S. Mkhonto, and A. Davids
Chapter 2 The Role of Chronic Non-Communicable Diseases
in Mortality Rates in South Africa, 1997-2006 39
Eric O. Udjo
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Chapter 3 An Overview of Chronic Disease Surveillance 53

Italia V. Rolle, Geraldine S. Perry,
Janneth Mghamba, Tiffany Gary-Webb,
Evelyn P. Davila and Peter Nsubuga
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Chapter 4 Interventions to Prevent and Control of Chronic

Non-Communicable Disease in South Africa 93
Thandi Puoane and Moise Muzigaba
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Chapter 5 Public Health Implications of Non-Communicable

Diseases (NCD) in Developing Countries 105
Laetitia Rispel, Geoffrey Setswe and Debashis Basu
Chapter 6 Implications of Chronic Non-Communicable
Diseases on Health Systems 129
Kebogile Mokwena
vi Contents
Chapter 7 Medicines for Chronic Non-Communicable Diseases 155

Andy Gray and Fatima Suleman
Chapter 8 Population Ageing: The Changing Profile of Chronic
Diseases in Developing Countries 179
Sebastiana Z. Kalula and Adesola Ogunniy
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Chapter 9 Towards Establishing an NCD Research Agenda 209
N. Phaswana-Mafuya, K. Mokwena, A. Davids,
C. Tabane and S. Mkhonto
Acknowledgment 223
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About the Editor in Chief 225
About the Contributors 227
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Index 235
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PREFACE
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This book focuses on chronic non-communicable diseases (NCDs) in Low
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Middle Income Countries (LMIC). Currently, NCDs appear to be permeating
the globe, with an increasing trend in LMIC. The increasing prevalence of
NCDs in these countries is attributed to rapid urbanization, population ageing,
globalization, industrialization which result in marked changes in patterns of
consumption of food and alcohol, increased tobacco use and sedentary
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lifestyles, high levels of stress and low levels of physical activity. The burden
of NCDs is likely to increase tremendously over the coming decades unless
there is appropriate action taken to address the risk factors. This book provides
an overview of NCDs and their implications in LMIC.
Chapter 1 shows that NCDs are becoming a significant burden in middle
income developing countries. The major groups of chronic NCDs are diabetes
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mellitus, cardiovascular diseases, cancers, and chronic pulmonary disease. The

increasing prevalence of NCDs in middle income countries is attributed to
rapid urbanization, globalization, industrialization which result in marked
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changes in patterns of consumption of food and alcohol, increased tobacco use

and sedentary lifestyles, high levels of stress and low levels of physical
activity. The burden of NCDs is likely to increase tremendously over the
coming decades unless there is appropriate action taken.
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Chapter 2 focuses on the role of chronic NCDs on mortality in South

Africa between the years 1997-2006 based on death records for the period.
The results indicate that although the percentage contribution of NCDs to
overall mortality has been declining due to rising trend in AIDS related
mortality, age standardised crude death rates from NCDs among persons aged
15 years and over have been increasing in South Africa. The highest death
rates from NCD are from cardiovascular diseases followed by respiratory
viii Nancy Phaswana-Mafuya and Dimitri Tassiopoulos
diseases and malignant neoplasms. As the demographic transition in South

Africa becomes more marked and ageing of the population progresses, death
rates from NCD would increase in the future. Furthermore, as the HIV
epidemic abates and AIDS related mortality loses momentum, mortality from
NCD would be more marked relative to mortality from CD in South Africa.
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NCD is therefore likely to pose a greater challenge to health care provision in
the future in South Africa.
Chapter 3 describes chronic disease surveillance, reviews chronic disease
data sources, describes current active chronic disease surveillance systems,
outlines the steps for developing and implementing chronic disease
surveillance and addresses challenges chronic disease surveillance in
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developing countries. The chapter is premised on the fact that infectious
disease systems in comparison to chronic disease systems are well developed
and resourced in low, middle, and high income countries. Chronic disease
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surveillance is established in high income countries but is in its infancy in
many LMIC. Surveillance of priority chronic diseases and risk factors are
important for developing and implementing interventions and primary
prevention.
Chapter 4 describes strategies and interventions for prevention and control
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of chronic non-communicable diseases in South Africa. Criteria for
considering intervention for this chapter included any primary prevention and
secondary prevention program that attempted to reduce the population burden
of non-communicable disease risk factor (i.e. blood pressure, smoking, total
blood cholesterol, physical activity, diet).Strategies for prevention and control
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of chronic non-communicable disease include policy action, facility and

community based interventions comprising of school based and workplace
interventions.
Chapter 5 concentrates on NCDs and their implications on human
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suffering and premature deaths, the health systems and the economy of a
country. The chapter demonstrates the need for the comprehensive
management of NCDs is undisputed. Public health measures for effective
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management of NCDs would require a comprehensive and integrated

approach. The experience in ‗developed‘ countries has shown the effectiveness
of a comprehensive public health response in reducing NCD morbidity and
mortality. Such a response includes inter alia: an enabling policy environment
supportive of NCD prevention and control; individual and population level
action to reduce the level of exposure to the common risk factors for NCDs
(e.g. tobacco consumption); a health system response that ensures that
prevention and appropriate health services are prioritised, socio-cultural
Preface ix
response, including action to address social attitudes and inequities; and

surveillance, monitoring and evaluation to provide the foundation for
advocacy, policy development and action.
Chapter 6 looks at the impact of NCDs on health systems infrastructure
and health service management. It demonstrates that undoubtedly NCDs place
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a heavy burdebn on the already overburdened health system. In this chapter, it
is recommended that the strategies to deal with chronic NCDs should
encompass all aspects of health systems planning (infrastructure, human
resources and disease management protocols and cost considerations), and
increased accessibility to quality health care. Success against NCDs can be
achieved by appropriately trained personnel, health curriculum reform and
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comprehensive coverage of NCDs. Health systems need to develop a
significant prevention component at all levels of health care service and extend
the management beyond clinical care.
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Chapter 7 deals with availability of medicines for chronic NCDS. In this
chapter, that authors advocate that access to uninterrupted supplies of suitably
selected, affordable essential medicines are critical to the management of
chronic NCDs. Ensuring access to these medicines at all levels of the
healthcare system requires close attention to financing options, but also to each
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of the steps in the logistic process – procurement and distribution. Ensuring
that prescribers adhere to well-designed standard treatment guidelines, and that
patients adhere to and persist with treatment also requires close attention. The
available evidence points to poor availability of medicines for chronic NCDs
in developing countries, but also to sub-optimal patient adherence in all
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settings.
Chapter 8 focuses on the changing profile of chronic diseases among the
ageing population. The chapter documents the predominant diseases in older
persons; highlight the changing profile of risk factors for chronic diseases;
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identify unmet health and social needs of the older persons, and suggest novel
ways of achieving satisfactory health provision for older persons. Obesity,
hypertension, coronary heart disease, and type 2 diabetes were predominant
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and were associated with increasing urbanization. Hypertension remains a

major killer disease accounting for 9% of total deaths in South Africa and high
levels in older persons particularly women were combined with poor levels of
awareness, monitoring, treatment and control. The prevalence of diabetes
increased with age in all South African ethnic groups. Smoking and alcohol
consumption were common and were responsible for substantial morbidity and
mortality. The problems of falls, depression and dementia were also
highlighted.
x Nancy Phaswana-Mafuya and Dimitri Tassiopoulos
Chapter 9 provides suggestions for future research endeavours. In this

chapter, the authors argue that the burden of NCDs require well planned and
executed research-informed responses. NCD research needs to be
contextualized to enable the identification of risk factors, and so chart the way
forward for the prevention, treatment and management, despite the financial,
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social and political factors inherent in health systems of developing countries.
An NCD research agenda for developing countries is needed in order to ensure
that an appropriate level of common oversight and understanding of NCD
research needs prevails and to provide best directed research.
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Refilwe (Nancy) Phaswana-Mafuya
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Director: Social Aspects of HIV/AIDS Research Alliance (SAHARA)
Social Aspects of HIV/AIDS and Health (SAHA)
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Human Sciences Research Council (HSRC)
44 Pickering Street, Newton Park, Port Elizabeth,6055
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FOREWORD
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Chronic Non-Communicable Diseases (NCDs) are still widely perceived
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as diseases of affluence and not therefore public health priorities for low and
middle income (developing) countries. This perception is reflected in policy
on international development, with the United Nations Millennium
Development Goals making no mention of NCDs. Yet, as this book shows
most people with NCDs live in developing countries, and NCDs are the
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leading cause of death in the majority of such countries, with the main
exceptions being the poorer African countries. However, even in the poorest
countries it is clear that the burden of NCDs is already high and rising, often at
age specific rates that are greater than those in more affluent parts of the
world. In addition, NCDs in developing countries disproportionately affect
adults of working age, impacting upon the social and economic well being of
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the individuals, their families and the broader community. In short, the blanket
characterization of NCDs as ‗diseases of affluence‘ is misleading and an
impediment to effective international public health action.
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As economies develop, life styles change, and populations age the burden
of NCDs in developing countries is growing exponentially. Although there is
always room to refine our knowledge on the aetiology and effective
management of NCDs, there is no doubt that the greatest challenge is in
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implementing what is already known. Enough is already known on what needs

to change in order to prevent NCDs and their complications, far too little is
known on how to do it, particularly within the social, economic and political
contexts of developing countries
This book is timely and practical. It is timely because it makes a strong
contribution to a growing awareness of the need for national and international
policy makers to take much more seriously NCDs in developing countries. It is
xii Nancy Phaswana-Mafuya and Dimitri Tassiopoulos
practical because it gets to the heart of the matter in considering the challenges
of prevention and management, not least the challenge of delivering effective
health care. In 2005, the Director General of the World Health Organization
wrote on the issue of NCDs, ‗the cost of inaction is clear and unacceptable.
Through investing in vigorous and well targeted prevention and control now,
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there is a real opportunity to make significant progress and improve the lives
of populations across the globe‘. Far too little has happened since he wrote
those words. I hope that this book will help raise awareness, stimulate debate,
and, most importantly, generate action.
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Nigel Unwin
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Chair of Public Health and Epidemiology
Cave Hill Campus
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University of the West Indies
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In: Non-Communicable Diseases (NCD‘s) … ISBN: 978-1-61209-687-2
Editors: Nancy Phaswana-Mafuya et al. © 2011 Nova Science Publishers, Inc.
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Chapter 1
EPIDEMIOLOGY OF CHRONIC NON-
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COMMUNICABLE DISEASES IN LOW AND
MIDDLE INCOME COUNTRIES – A REVIEW
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N. Phaswana-Mafuya, D. Tassiopoulos,
S. Mkhonto, and A. Davids
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ABSTRACT
Background: NCDs are increasing globally, with escalating trends in
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developing countries, which impose more constraints to an already

overburdened health care system. Many of these diseases can be
prevented by tackling their determinants and associated risk factors.
Methods: This a rapid review of available and accessible NCD
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epidemiology literature in low and middle income countries. Information

for this chapter was taken from scientific manuscripts, reports, and
chronic disease and surveillance related books. A review was conducted
using the following key words:
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Results: NCDs are becoming a significant burden in middle income

developing countries. The major groups of chronic NCDs are diabetes
mellitus, cardiovascular diseases, cancers, and chronic pulmonary
disease. The increasing prevalence of NCDs in middle income countries
is attributed to rapid urbanization, globalization, industrialization which
result in marked changes in patterns of consumption of food and alcohol,
increased tobacco use and sedentary lifestyles, high levels of stress and
low levels of physical activity. The burden of NCDs is likely to increase
tremendously over the coming decades unless there is appropriate action
2 N. Phaswana-Mafuya, D. Tassiopoulos, S. Mkhonto, and A. Davids
taken. Conclusion: Prominent causes for CVDs, diabetes, cancer and

pulmonary diseases can be prevented by developing efficient strategies
that deal seriously with the determinants of these diseases and their risk
factors. Although some risk factors, such as age, ethnicity, and gender,
obviously cannot be modified, most of the risk is attributable to lifestyle
and behavioral patterns, which can be changed.
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Keywords: chronic non-communicable diseases, developing countries,
risk factors
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1. 1. INTRODUCTION
For centuries, communicable diseases were the main causes of death
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globally. Consequently, attention, in terms of detection, treatment, control,
prevention, training, research, interventions, policy and programme
development was placed on these diseases. Medical achievements in terms of
vaccination, antibiotics, and improvement of life conditions have contributed
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towards the prevention and control of most communicable diseases (Boutayeb
and Boutayeb, 2005). Although infectious diseases are still responsible for the
largest burden of disease in most developing (low income) countries (see
Table 1 below providing a list of LIMC countries), NCDs are becoming a
significant burden in middle income developing countries (ibid). The major
groups of chronic NCDs are diabetes mellitus (DM), cardiovascular diseases
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(CVD), cancers, and chronic pulmonary disease (CPD). These have several
major risk factors in common and together account for around 50% of global
mortality
Currently, NCDs appear to be permeating the entire world, with an
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increasing trend in developing countries. NCDs progressed from 18.7% in

1990 to 25% in 2000 and this is projected to further increase to 36.6% in 2020
(Boutayeb and Boutayeb, 2005; Beaglehole, 2001; Unwin et al, 2006; WHO,
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2000). Undoubtedly, there is mounting evidence pointing to the rise in NCDs

in middle income countries (Unwin et al., 1999; Aspray et al., 2000; Edwards
et al., 2000 and Fourie and Steyn, 1995) (See Figure 1).
This transition imposes more constraints to deal with the double burden of
infectious and non-infectious diseases in a poor environment characterized by
ill-health systems . By 2020, it is predicted that NCDs will account for 80% of
the global burden of disease, causing seven out of every 10 deaths in
Epidemiology of Chronic Non Communicable Diseases … 3
developing countries, compared with less than half today (WHO, 2003). The
increasing prevalence of NCDs in developing countries is attributed to rapid
urbanization, globalization, industrialization which result in marked changes in
patterns of consumption of food and alcohol, increased tobacco use and
sedentary lifestyles, high levels of stress and low levels of physical activity
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(DOH, 2006; Steyn and Damasceno, 2006, Beaglehole,2001; Oelofse et al;
1996). Ageing of populations is also a key driver of the change – in general
these are diseases whose risk increases dramatically with age. The burden of
NCDs is likely to increase tremendously over the coming decades unless there
is appropriate action taken to address the risk factors. NCD risk factors are
largely preventable and modifiable (WHO, 2002). The early identification of
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risk factors is recognized as a primary strategy in the prevention of NCDs
(WHO, 1997). Furthermore, although early detection is an absolute necessity,
its only a necessity if early treatment actually helps, and this depends on both
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the existence of effective treatments and a health care system that can deliver
them to the right people. In the absence of early detection, many people are
diagnosed at advanced stages of cancer, cardiovascular diseases and diabetes
complications. It is estimated that eliminating key risk factors (poor diet,
physical inactivity, smoking) would prevent 80% of heart disease, strokes and
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type 2 diabetes, and over 40% of cancer cases.
In this chapter, the epidemiology of four major categories of NCDs
affecting developing countries is provided. This includes: disease prevalence,
morbidity, mortality and risk factors. At the beginning of each NCD category,
a description of the category and risk factors are provided.
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1.2. METHODOLOGY
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This a rapid review of NCDs. Information for this chapter was taken from
scientific manuscripts, reports, and chronic disease and surveillance related
books. A review was conducted using the following key words: non-
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communicable, chronic disease, surveillance, developing, developed, cancer,

diabetes, obesity, heart disease, hypertension, diabetes, nutrition, physical
activity, smoking, alcohol, vital statistics, disease registries, surveys,
administrative data collection systems, demographic surveillance systems,
demographic health surveys, burden of disease, laboratory, assessment,
implementation, and monitoring and evaluation. Other data search engines
included WHO Library and Information Networks for Knowledge Database
(WHOLIS) and Google scholar.
1.3. RESULTS
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Source: World Health Organisation (2008).
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Figure 1. NCD related deaths in Low, Middle and High Income Countries (2008).
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Table 1. Low and middle income countries
Income group Region Economy

Low income East Asia and Pacific Cambodia; Korea, Dem. Rep.
Lao PDR; Myanmar; Papua New Guinea;
Solomon Islands; Vietnam
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Europe and Central Asia Kyrgyz Republic; Tajikistan; Uzbekistan
Latin America and Caribbean Haiti

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Middle East and North Africa Yemen, Rep.
South Asia Afghanistan; Bangladesh; Nepal; Pakistan

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Sub-Saharan Africa Benin; Burkina Faso; Burundi; Central African

Republic; Chad; Comoros; Congo, Dem. Rep.;
Côte d'Ivoire; Eritrea; Ethiopia; Gambia; The;
Ghana; Guinea; Guinea-Bissau; Kenya; Liberia;
Madagascar; Malawi; Mali; Mauritania;
Mozambique; Niger; Nigeria; Rwanda; São
Tomé and Principe; Senegal; Sierra Leone;
Somalia; Tanzania; Togo; Uganda; Zambia;
Zimbabwe.
Income group Region Economy

Lower middle East Asia and Pacific China; Indonesia; Kiribati; Marshall Islands;
income Micronesia, Fed. Sts.; Mongolia; Philippines;
Samoa
Thailand; Timor-Leste; Tonga; Vanuatu
Europe and Central Asia Albania; Armenia; Azerbaijan; Bosnia and
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Herzegovina; Georgia; Macedonia, FYR;
Moldova; Turkmenistan; Ukraine
Latin America and Caribbean Bolivia; Colombia; Dominican Republic;

Ecuador; El Salvador; Guatemala; Guyana;
Honduras; Nicaragua; Paraguay; Peru
Middle East and North Africa Algeria; Djibouti; Egypt, Arab Rep.; Iran,
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Islamic Rep.; Iraq
Jordan; Morocco; Syrian Arab Republic;
Tunisia; West Bank and Gaza
South Asia Bhutan; India; Maldives; Sri Lanka
Upper middle
income
Sub-Saharan Africa
East Asia and Pacific
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Angola; Cameroon; Cape Verde; Congo, Rep.;
Lesotho; Namibia; Sudan; Swaziland
American Samoa; Fiji; Malaysia
Palau
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Europe and Central Asia Belarus; Bulgaria; Croatia; Kazakhstan; Latvia;
Lithuania; Montenegro; Poland; Romania
Russian Federation; Serbia; Turkey
Latin America and Caribbean Argentina; Belize; Brazil; Chile; Costa Rica;
Cuba; Dominica; Grenada; Jamaica; Mexico;
Panama; St. Kitts and Nevis; St. Lucia; St.
Vincent and the Grenadines; Suriname;
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Uruguay; Venezuela, RB
Middle East and North Africa Lebanon; Libya
Sub-Saharan Africa Botswana; Gabon; Mauritius; Mayotte;
Seychelles; South Africa
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Source: World Bank (2009).
The low and middle-income group economies are depicted in Table 1.

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This table highlights that Sub-Saharan Africa has the highest number of
economies in the low-income group. The table further shows that amongst the
lower middle income group, the East Asia and Pacific region has marginally
the most number of economies (it is further noted however that the Europe and
Central Asia, Latin America and Caribbean, and Middle East and North Africa
regions also have each a notable number of economies in this income group).
Finally, amongst the upper middle-income group, the Latin America and
Caribbean region is the most notable region as having the highest number of
economies in this income group. The Sub-Saharan African economies of

Botswana; Gabon; Mauritius; Mayotte; Seychelles and South Africa are also
part of the upper middle-income group.
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1.2. EPIDEMIOLOGY OF DIABETES MELLITUS
1.2.1. Description of Diabetes
Diabetes is a chronic (lifelong) disease marked by high levels of glucose
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in the blood. It is the inability to control the amount of glucose in the blood
such that the level can go too high (hyperglycaemia). This makes one pass
more urine (with glucose in it), thirsty and drowsy. At very high levels of
blood glucose one can become unconscious (coma). Diabetes is associated
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with a hormone called insulin which is produced by the pancreas to control
blood glucose (Debra, 2008). Diabetes can be caused by too little insulin and
insulin resistance. There various types of diabetes, including: Type 1 diabetes:
Type 1 diabetes mellitus is usually diagnosed in early childhood. Most patients
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are diagnosed when they are less than age of 20. With this disease, the
pancreas makes little or no insulin. Daily injections are needed. The exact
cause is variable. Genetic, viral infection and autoimmune problem may play a
role (CDC, 2008). Type 2 diabetes: Type 2 diabetes is far common than type
1. It makes up of most diabetes cases. It usually occurs in adulthood, but
young people are increasingly being diagnosed with this disease. In this case
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the pancreas does not make sufficient or enough insulin to keep blood glucose
levels normal, often because the body does not respond well to insulin (CDC,
2008). Gestational Diabetes: This is temporary diabetes that that is first comes
only during pregnancy. It increases the risk problems for the foetus, and even
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if it resolves after pregnancy, it hugely increases the risk of T2DM in later

life.. Although our knowledge of the epidemiology is not good, it varies
greatly between populations, it is estimated that gestational diabetes affects
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two to four per cent of all pregnancies and involves an increased risk of
developing diabetes for both mother and child. Gestational diabetes means
diabetes mellitus (high blood glucose) first found during pregnancy. In most
cases, gestational diabetes is managed by diet and exercise and goes away
after the baby is born. It is also called glucose intolerance of pregnancy
(Rother, 2007). Paediatric diabetes is a type of diabetes that is commonly
found in children or young adolescents. Young people with high blood glucose
levels usually have either type 1 or type 2 diabetes (NHIS, 1999).
1. 2.2. Diabetes Risk Factors
The rising prevalence of diabetes in the LMICs region is attributed to risk

factors such as: changes in lifestyle, rapid cultural changes, increased aging
populations, urbanization (which result in greater levels of obesity – eating
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patterns, decreased physical inactivity – changes in modes of work and
transport) and other changes in behavioural patterns. For instance, up to 90%
of cases of types 2 diabetes, could potentially be avoided through changing
lifestyle factors. In developing countries, the prevailing poverty, ignorance,
illiteracy and poor health consciousness further adds to the problem. These
risk factors must be addressed. Without effective prevention and control
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programmes, the incidence of diabetes is likely to continue rising globally and
at fastest rate in developing countries.
1. 2.3. Diabetes Prevalence
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Table 2. Diabetes Prevalence
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Globally Globally Sub-Saharan Africa
2005 2025 % 2005 2025 % increase
increase
250m 380m 55% 10.8m 18.7m 80%
Developing countries Developed countries
1995 2025 % increase 1995 2025 % increase
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Diabetes 84m 228m 170% 51m 71m 42%

prevalence
Age of diabetes 45-64 years ≥65 years
onset
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Source: WHO/IDF 2006.
Approximately 250 million people worldwide have diabetes (3.7% of the

total global population (WHO/IDF, 2006) and this is projected to increase to
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380 million (5.4%) by the year 2025 (WHO/IDF, 2006). In SSA, the IDF
estimates that 10.8 million people have diabetes and this would rise to 18.7%
by 2025, an increase of 80%, exceeding the predicted worldwide increase of
55%. Diabetes rates are projected to triple in developing countries. WHO/IDF
(2006) project that the prevalence of diabetes mellitus is expected to increase
by 170% in developing countries (from 84m to 228m) between 1995 and 2025
as compared to a 42% (from 51m to 71m) increase in the developed countries.
The developing world will be responsible for more than 75% of diabetes in
2025, up from 62% in 1995. Among developing countries, the highest increase
in prevalence percent will be in China followed by India. However, the
greatest increase in numbers will be seen in India, where the number of
diabetes will rise from 19 million in 1995 to 57 million in 2025, heading the
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list of countries with the greatest numbers of diabetes. Comparison is difficult
because of differing criteria (Gyaneshwar, 1988).
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Source: SASI Group and Newman (2006a).
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Figure 2. Territory size showing the proportions of all people over 15 years in the
world living with diabetes.
Within the last two decades, there has been an increase prevalence of type
2 diabetes among the children. Practice site reports and some regional studies
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indicate nearly 50% of newly diagnosed cases of diabetes in children to be

type 2 diabetes (Kaufman, 2002 and Neufeld et al,. 1999). More than half the
people with diabetes, sometimes as many as 80-90% (Aspray et al, 2000),
have not been diagnosed. Type 2 diabetes represents 85-95% of all diabetes.
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Contrary to popular perception, over 70-80% of people with diabetes live in

low- or middle-income countries. Additionally, the age of onset diabetes
occurs in middle age (45-64 years) in developing countries as compared to that
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of ≥65 years (above the age of retirement in developed countries (King et al,
1998).
The highest diabetes prevalence is in North America. Of the total North
American cases, 4% are in Canada, 33% are in Mexico, and 62% are in the
United States. The largest population of diabetes in 2001 was in India: 56
million people.
Territory size, as depicted in figure 2, shows the proportion of all people
over 15 in the world living with diabetes that live there. These data were
sourced from the World Bank‘s 2005 World Development Indicators. The
estimate for diabetes worldwide is 227 million, as the reported prevalence of
diabetes was applied to everyone aged 15 and over.
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1.2.4. Diabetes Morbidity
It was difficult to find data on diabetes morbidity in developing countries.

Among the 40 states, Washington DC, and two territories with ≥2 years of
2005-2007 data, the average annual incidence rate for 2005-2007 was 9.0 new
cases of diabetes per 1,000 population (95% confidence interval [CI] = 8.6-
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9.4). By U.S. Census region, the average age-adjusted incidence was greatest
in the South (10.5 per 1,000, CI = 9.9-11.1), followed by the Northeast (8.6, CI
= 7.8-9.4), West (8.5, CI = 7.7-9.3), and Midwest (7.4, CI = 6.6-8.2). By state,
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age-adjusted incidence ranged from 5.0 per 1,000 population (CI = 3.6-6.3) in
Minnesota to 12.8 (CI = 10.0-15.5) in Puerto Rico. The 10 states in the highest
quartile of age-adjusted diabetes incidence (10.3-12.8 per 1,000 population)
included nine of the 16 states in the South region: Alabama, Florida, Georgia,
Kentucky, Louisiana, South Carolina, Tennessee, Texas, and West Virginia.
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1.2.5. Diabetes Mortality
In 2002 Diabetes caused 2.6% of deaths in people over 60 years old and
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1.8% of all deaths in rich territories. Diabetes caused 1.7% of all deaths
worldwide in 2002, an average of 158 deaths per million people per year. This
is depicted in Figure 2. Apart from the day to day problems with the blood
glucose level being unsatisfactory, people with both types of diabetes are
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prone to secondary problems (complications), which can be very disabling.

Damage occurs to nerves and to blood vessels.
One can get chronic or recurring ulcers on the feet and sometimes part of a
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leg has to be amputated. Eye disease caused by diabetes commonly causes

blindness, and an important part of treatment is trying to prevent this. Having
diabetes commonly also causes kidney damage, which can lead to kidney
failure (SASI Group and Newman, 2006b). Diabetes can cause or contribute to
cardiovascular disease, but deaths due to those conditions are counted
separately. In 2002 Diabetes caused 2.6% of deaths in people over 60 years
old and 1.8% of all deaths in rich territories.
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N
Source: SASI Group and Newman (2006b).
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Figure 3. Territories sized in proportion to the absolute number of people who died
from diabetes in one year.
Diabetes caused 1.7% of all deaths worldwide in 2002, an average of 158

deaths per million people per year. The ten highest rates of death per million
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people in 2002, according to SASI Group and Newman (2006b), were in:
1) Trinidad and Tobago, 1020

2) Jamaica, 810
3) St Vincent and the Grenadines, 710
4) Grenada, 634
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5) Kiribati, 613
6) St Lucia, 593
7) Mexico, 548
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8) Antigua and Barbuda, 543

9) Dominica, 531
10) Armenia, 507
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1.2.6. Diabetes Economic and Social Burden
The exact costs of diabetes can not be easily pinned down (Boutayeb,
Twizell, Achouayb and Chetouani, 2004); however estimations can be
determined according to three levels. Level 1- cost directly related to the
diagnosis and management of diabetes without complications. This includes
in-patient and out-patient care, means of treatment by insulin or tablets and the
equipment of self control (blood and urine testing). Level 2 - costs generated
by complications of diabetes. These are difficult to quantify because diabetes
is linked to micro and macro vascular diseases such as heart disease, kidney
failure, eye disease and amputation. Moreover, diabetes may add a cost of care
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by complicating other unrelated medical situations like infections accidents
and surgery. Level 3 - indirect costs correlated to the quality of life and the
economic productivity which can be somehow estimated by the degree of
disability. Studies in different countries have shown that diabetes is a costly
disease accounting for between 2.5 and 15% of the total healthcare
expenditure. For the age category 20–79, the world annual direct cost is
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estimated to be over 153 billion and expected to double in 2025. According to
the National Institute of Diabetes and Digestive Kidney Disease (NIDDK) and
the American Diabetes Association, diabetes was the sixth leading cause of
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death in 1999 with a direct cost of US$44 billion and an indirect cost of
US$54 billion annually. The burden affects also developing countries. In
these, countries, until recently, it was widely believed that economic
development was a prerequisite for improving a population health status;
health affected by diabetes was often just classified as a non-productive sector.
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Diabetes mellitus (Koopmanschap, 2002), is a chronic metabolic disease that
makes many demands on lifestyle, poses debilitating and life-threatening
complications and has important implications for a patient's well-being and
social life. The treatments for diabetes and its associated health-risk factors are
often highly complex and require considerable patient education and frequent
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medical monitoring. In general, patients with diabetes have a poorer quality of

life than individuals without a chronic disease. The long-term complications of
diabetes, such as retinopathy, neuropathy, heart disease and stroke, have a
detrimental effect on quality of life. This is supported by the United Kingdom
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Prospective Diabetes Study (UKPDS). The burden of more than one

complication continues (Koopmanschap, 2002), often has an even greater
impact on quality of life. Although Type II diabetes is often incorrectly
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perceived as a relatively mild disease in comparison with Type I diabetes, the

consequences for the patient's HRQoL are likely to be considerable, consisting
of: psychological effects associated with reduced general well-being; family
life effects, arising from a lack of acceptance and support from family
members; social effects, such as reduced social function due to feelings of
isolation and withdrawal. Studies indicate that diabetic patients generally have
conditions such as depression and anxiety more often than the general
population of a similar age. Fatigue, loss of enjoyment and reduced leisure
pursuits also seem to correlate positively with the presence of Type II diabetes
as do feelings of restriction when complying with treatment strategies and self-
monitoring requirements.
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1.3. EPIDEMIOLOGY OF CVD
1.3.1. Definition
CVD is the name for the group of disorders or diseases of the heart and
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blood vessels and include, among others: ischaemic heart disease (or coronary
heart disease), hypertensive heart disease (high blood pressure),
cerebrovascular disease (stroke), congestive heart failure (CHF) and rheumatic
heart disease. Globally, CVD are rising sharply, leading to serious economic
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and social consequences.
1.3.2. CVD Risk Factors

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CVD are increasingly becoming the foremost cause of mortality in
developing countries as a consequence of lifestyle changes brought about by
industrialization and urbanization in developing countries engaged in the
socio-economic transition. The vast majority of CVD can be attributed to
conventional risk factors. High blood pressure, high cholesterol, extensive
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tobacco and alcohol use, and low vegetable and fruit consumption are already
among the top risk factors for the disease worldwide and in developing
countries (World Health Report, 2003; Lenfant, 2001; Reddy, 2002) .
Proportions of people with a tobacco habit, physical inactivity, high blood
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pressure, overweight, diabetes, and abnormal blood lipids are increasing in

these countries, placing many individuals at a high risk of developing CVD
over the next ten years. Information from more than 100 countries shows that
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more 13- 15-year-olds smoke than ever before, and studies show that obesity
levels in children are increasing markedly in countries as diverse as Brazil,
China, India, and almost all island states (Leeder et al, 2004). While tobacco
consumption is falling in most developed countries, it is increasing in
developing countries by about 3.4% per annum. Today, 80% of the 1.2 billion
smokers in the world live in poorer countries where smoking prevalence
among men is nearly 50% (48%) and 50% of the 5 million deaths attributed to
smoking in 2000 occurred in developing countries, also responsible for the
increase in deaths by more than one million during the last decade. Population
wide efforts are needed to reduce CVD risk factors.
1.3.3. CVD Prevalence
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At the beginning of the 20th century, CVD was responsible for less than
10% of all deaths worldwide in 1990, but by 2001 that figure was 30%. In
many developing regions, the proportion of CVD is projected to double, from
about 20% to about 40%, between 1990 and 2020 (Murray and Lopez, 1996).
Throughout the developed world the prevalence of CHF is about 2 to 3%
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(McMurray and Stewart 2000). The prevalence of CHF rise dramatically with
age. Prevalence is 27 per 1,000 population for those older than 65, compared
with 0.7 per 1,000 for those younger than 50 (McKelvie 2003). About 12
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million people in developing countries, most of them children, suffer from
Rheumatic Heart Disease (WHO). Steer and others' (2002) review of
developing countries suggests that RHD prevalence in children is between 0.7
and 14 per 1,000, with the highest rates in Asia.
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1.3.4. CVD Mortality
The annual incidence rate of CHF is 0.1 to 0.2 % (McMurray and Stewart
2000). CHF occurs more frequently in men, and incidence and mortality differ
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substantially according to gender and socioeconomic status.

Comparable data on morbidity from CVD are more difficult to collect
than mortality data, since there are many different measures of morbidity (e.g.
prevalence, incidence, DALYs, years of healthy life lost etc.). In 2002,
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according to the SASI Group and Newman (2006), heart attacks caused 8.3%
of deaths in adults aged 15 to 59 years, 20.1% of deaths in people over 60
years old, 22.8% of all deaths in rich territories, 9.7% of all deaths in poor
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territories and 9.3% of all deaths in very poor territories. Global Burden of
Disease estimated in 2002 Heart Attacks to cause 4.4% of all male, 3.4% of all
female, 9.1% of all Rich territory, 3.3% of all Poor territory and 2.9% of all
Very poor territory burden of disease (Disability Adjusted Lost Years). Heart
attacks caused 12.6% of all deaths worldwide in 2002, an average of 1158
deaths per million people per year.
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Source: SASI Group and Newman (2006c).
Figure 4. Territories are sized in proportion to the absolute number of people who died
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from CVD in one year.
Cardiovascular diseases caused 29% of all deaths worldwide in 2002, an

average of 2688 deaths per million people per year, this is graphically depicted
in figure 4. Cardiovascular diseases caused 29% of all deaths worldwide in
2002, an average of 2688 deaths per million people per year. The ten highest
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rates of death per million people in 2002, as per SASI Group and Newman
(2006c), were in:
1) Ukraine, 10324
2) Russian Federation, 9938
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3) Bulgaria, 9425
4) Belarus, 8871
5) Georgia, 8853
6) Latvia, 8454
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7) Estonia, 7780
8) Serbia and Montenegro, 7087
9) Romania, 7013
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10) Republic of Moldova, 6457
Cardiovascular diseases are diseases of the heart and blood vessels, and
are the sum of the following (with their contribution to the total
Cardiovascular diseases deaths in 2002).
1) Heart failure due to Rheumatic Fever (2% of deaths).

2) Strokes [Cerebrovascular disease] (33% of deaths).
3) Heart attacks [Ischaemic heart disease] (43% of deaths).

4) High blood pressure [Hypertensive heart disease] (5% of deaths).
5) Inflammation of the heart [Inflammatory heart disease] (3% of
deaths).
6) Other cardiovascular diseases (14% of deaths).
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In developing countries, CVD have become the leading cause of death
worldwide (Murray and Lopez, 1996; Mathers et al, 2006; Kearney et al,
2004; WHO). Of the 14 million global deaths due to CVD in 1990, about 9
million occurred in the developing countries (Murray and Lopez, 1996). About
80% of the CVD related deaths and 87% of the CVD related disability now
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occurs in the low and middle income countries. By 2020, these countries are
projected to contribute 19 million of the annual global toll of 25 million CVD
deaths (Reddy, 2004, 2005). In 1998, 86% of the DALYs caused by CVD
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were attributed to developing countries and in 1999 CVD contributed to a third
of global deaths with 78% in low- and middle-income countries. In 2002, 16.7
million deaths occurred from CVD, of a global total of 32 million deaths
(World Health Organisation, 2003). In Sub-Saharan Africa, deaths attributable
to CVD are projected to more than double between the years 1990 and 2020.
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Although HIV/AIDS is the leading overall cause of death in this region, CVD
is the second-leading killer and is the first among those over the age of 30.
Table 3. Overview of categories of CVD – description, overall mortality,

% global death per year
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CVDs Description Overall mortality % death per

year
Cerebrovascular disruption in the flow of In 2002 Strokes caused 33%
disease (Stroke) blood to part of the 13.3% of all deaths in
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brain affecting the rich territories, 13.8% of

delivery of oxygen and all deaths in poor
glucose to the brain, territories and 5.3% of
either because of the all deaths in very poor
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occlusion of a blood territories.

vessel (ischemic stroke)
or the rupture of a blood
vessel (hemorrhagic
stroke (Wolf, Abbott,
and Kannel, 1991).
Table 3. (continued)

year
Congestive heart CHF is the end stage of The exact magnitude of 2%
failure many heart diseases. It the problem is difficult
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is characterized by to assess because of the
abnormalities in lack of broad based
myocardial function and population estimates of
neurohormonal its prevalence, incidence
regulation resulting in and mortality rates.
fatigue, fluid retention, It is estimated that there
and reduced longevity. is nearly 23 million
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CHF is caused by people with CHF
pathological processes worldwide (Valentin
that affect the heart Fuster et al, 2004).
(McMurray and Stewart
2000)
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CHF is a disease of the
elderly and mortality
rates increase sharply
after 65 years of age;
The prognosis of
patients with heart
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failure is generally poor;
and in several series of
studies, 50% of the
patients with severe
symptoms died within
12 months. In less
severe heart failure,
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mortality approaches
50% in 3 to 4 years
(Mathews, 2009).
The prevalence of CHF
amongst men and the
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black population is
reported to be higher
It is estimated that the
burden of CHF will
increased in developed
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economies in the next

two decades (Valentin
Fuster et al, 2004).
(Inflammatory Heart involves inflammation According to 2001 3%
Disease of any part of the heart. estimates, RHD
caused by a reaction to accounts for 338,000
any external or internal deaths per year
factor like infection worldwide (WHO)
(Mayocarditis, RHD and ARF are the

year
pericarditis) most common causes of
It affects the connective cardiac disease among
tissue, mainly the joints children in developing
and the heart valves. countries (Ephrem, et al
The characteristics of 1990; Schneider and
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inflammation are Bezabih 2001; Steer and
redness, swelling, others 2002) and
warmth and pain. account for almost 10%
The two leading of sudden cardiac deaths
manifestations of IHD (Kaplan 1985; Carapetis,
are angina and acute Currie, and Kaplan
myocardial infarction. 1999).
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The common
inflammation examples
are arthritis
(inflammation of the
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joints), asthma
lungs) and tonsillitis
tonsils) (Ephrem,
Abegaz, and Muhe
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1990).
Ischaemic heart It is a condition that In 2001, IHD was 43%
disease (coronary affects the supply of responsible for 7.3
heart disease/heart blood to the heart. million deaths and 58
attack) This results from the million DALYs lost
blood vessels being worldwide (WHO).
narrow or blocked due In 2002 Heart attacks
to the deposition of caused 8.3% of deaths in
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cholesterol plaques on adults aged 15 to 59

their walls. years, 20.1% of deaths
It reduces the supply of in people over 60 years
oxygen and nutrients to old, 22.8% of all deaths
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the heart which is play in rich territories, 9.7%

an important role for the of all deaths in poor
proper functioning of territories and 9.3% of
the heart (WHO). all deaths in very poor
territories.
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75% of global deaths

and 82% of the total
DALYs resulting from
IHD occurred in the
LIMC
Table 3. (continued)

year
Hypertensive heart refers to the late stage of High blood pressure 5%
disease hypertension (high caused 1.6% of all
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blood pressure) when deaths worldwide in
the heart is affected. 2002, an average of 146
It is caused by the strain deaths per million
the high blood pressure people per year.
puts on the heart.
This causes the heart to
initially get larger, but
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eventually it can fail
because it is not strong
enough to cope with the
increased resistance to
the blood going through
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the arteries
It results from the
increased heart‘s
workload, the heart
muscle is working
through.
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The higher the blood
pressure the greater the
risk
The heart is pumping
very hard against the
elevated pressure in the
blood vessels. (Seedat,
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Seedat and Hackland,

1982)
Others Undefined undefined 14%
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Cardiovascular diseases, as depicted in Table 3, caused 29% of all deaths

worldwide in 2002, an average of 2688 deaths per million people per year. The
prevalence rates of the various categories of cardiovascular diseases, according
to the SASI Group and Newman (2006) are (with their contribution to the total
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cardiovascular diseases deaths in 2002):

Heart attacks caused 12.6% of all deaths worldwide in 2002, an average of
1158 deaths per million people per year. In 2002 , states SASI Group and
Newman (2006d) heart attacks caused 8.3% of deaths in adults aged 15 to 59
years, 20.1% of deaths in people over 60 years old, 22.8% of all deaths in rich
territories, 9.7% of all deaths in poor territories and 9.3% of all deaths in very
poor territories.
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N
Source: SASI Group and Newman (2006d).
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from ischaemic heart disease (heart attacks) in one year.
Global Burden of Disease estimated in 2002 Heart Attacks to cause 4.4%

of all Male, 3.4% of all Female, 9.1% of all Rich territory, 3.3% of all Poor
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territory and 2.9% of all Very poor territory burden of disease (Disability
Adjusted Lost Years).
Heart attacks caused 12.6% of all deaths worldwide in 2002, an average of
1158 deaths per million people per year. Territories, as depicted in figure 5,
are sized in proportion to the absolute number of people who died from
ischaemic heart disease (heart attacks) in one year.
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In 2002, indicate SASI Group and Newman (2006e) blood pressure

caused 2.6% of deaths in people over 60 years old, 1.7% of all deaths in rich
territories and 2.7% of all deaths in poor territories with reasonable life
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expectancy. High blood pressure caused 1.6% of all deaths worldwide in 2002,
an average of 146 deaths per million people per year.
The ten highest rates of death per million people in 2002 were in:
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1) Seychelles, 1124
2) Turkmenistan, 1057
3) Tajikistan, 1013
4) Dominica, 996
5) Romania, 753
6) Grenada, 645
7) Slovakia, 608
8) Bulgaria, 591
9) Democratic People's Republic of Korea (North Korea), 584
10) Nauru, 557
Territories, as illustrated in figure 6, are sized in proportion to the absolute
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number of people who died from hypertensive heart disease in one year
Inflammatory heart diseases caused 0.71% of all deaths worldwide in
rates of death per million people in 2002, according to SASI Group and
Newman (2006f) were in:
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1) The former Yugoslav Republic of Macedonia, 1573
2) Bosnia Herzegovina, 825
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4) Slovenia, 399
5) Latvia, 286
6) Estonia, 234
8) Armenia, 189
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9) San Marino, 179
10) Azerbaijan, 177
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O
PR
Source: SASI Group and Newman (2006e).
from hypertensive heart disease in one year.
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N
Source: SASI Group and Newman (2006f).
from inflammatory heart disease in one year.
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Territories, as illustrated in figure 7, are sized in proportion to the absolute
number of people who died from inflammatory heart disease in one year.
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1.3.6. CVD Economic and Social Burden
As the CVD epidemics advance, all sections of the society are affected. In
the more matured forms of the epidemics, the poor will become the vulnerable
victims both because of factors which increase exposure to risk (inability to
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access knowledge; economic factors which promote consumption of unhealthy

foods and reduce availability of healthy foods at affordable prices; higher
levels of tobacco consumption) as well as decreasing access to healthcare
(high cost of diagnosis and treatment for risk factors as well as diseases).
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Many of the CVD related deaths in the developing countries occur at a much
earlier age than in the developed countries. A large proportion of the victims
are middle-aged and in the prime of their working lives. Consequently these
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countries experience a large loss in productive years of life. This will be

further compounded as the epidemics of CVD advance across these regions by
2020 (Leeder et al., 2004). Such a large burden of premature death and
disability not only has serious adverse consequences for the affected
individuals and their families but also undermines national development. As
the health transition rapidly transforms the global profile of dominant diseases,
the poor among countries and the poor within countries are becoming the
major victims of CVD across the world.
1.4. EPIDEMIOLOGY OF CHRONIC RESPIRATORY

DISEASES
1.4.1. Description of Chronic Respiratory Diseases
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Chronic respiratory diseases are diseases of the lungs not caused by
infection. The two major chronic respiratory diseases are Chronic obstructive
pulmonary disease (COPD) and Asthma. COPD is a disease state
characterized by airflow limitation that is not fully reversible (Pauwels et al,
2001). The airflow limitation is usually both progressive and associated with
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an abnormal inflammatory response of the lungs to noxious particles or gases.
A diagnosis of COPD should be considered in any patient who has symptoms
of cough, sputum production, or dyspnea, and/or a history of exposure to risk
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factors for the disease. Asthma is a disease that affects the breathing passages
of the lungs (bronchioles) that inflames and narrows the airways. It causes
recurring periods of wheezing (a whistling sound when you breath), chest
tightness, shortness of breath, and coughing. Coughing usually happens at
night or early in the morning. The cause of asthma is not known but what
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triggers asthma are : exposure to tobacco or wood smoke, breathing polluted
air, inhaling other respiratory irritants e.g. perfumes and cleaning products,
breathing in allergy-causing substance (allergens) such as mold and dust,
exposure to cold, dry weather, emotional excitement or stress and physical
exertion or exercise.
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1.4.2. Chronic Respiratory Disease Risk Factors

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Chronic obstructive pulmonary diseases (COPD) are a major cause of

chronic morbidity and mortality throughout the world. The global initiative for
chronic obstructive lung diseases (GOLD) was established to prepare
evidence-based documents on the diagnosis, management and prevention of
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this disease (Pauwels, 2001). The main risk factors of COPD is tobacco smoke
(GOLD, 2008; Vineis, et al, 2005). This includes smoke from cigarettes, pipes,
cigars and environmental tobacco smoke. A second risk factor is prolonged
exposure to occupational chemicals and dusts in the form of fume, irritants and
vapours. A third risk factor, although contributing less to COPD, is outdoor air
pollution. Other factors that can contribute to the development of COPD are
low birth weight and respiratory infections as they may affect lung growth
(GOLD, 2008). Sandford, Weir and Paré (1997) also identified genetic risk
factors for COPD as several genes are implicated in the pathogenesis of
COPD.
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1.4.3. Chronic Respiratory Disease Prevalence
Respiratory diseases cause 15% of the global burden of disease.

Worldwide, it is estimated that 600 million people suffer from COPD and 2.5
million deaths were attributed to these diseases in 2000. In the Global Burden
of Disease Study conducted under the auspices of the WHO and the World
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Bank (Aït-Khaled, Enarson, and Bousquet, 2001), the worldwide prevalence
of COPD in 1990 was estimated to be 9.34/1,000 in men and 7.33/1,000 in
women. However, these estimates include all ages and underestimate the true
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prevalence of COPD in older adults. The prevalence of COPD is highest in
countries where cigarette smoking has been, or still is, very common, whereas
the prevalence is lowest in countries where smoking is less common, or total
tobacco consumption per individual is low.
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Table 4. The estimation of asthma in children 13 to 14 years (1998)
Region Estimated Prevalence (%)

Oceania 25.9
North America 16.5
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Latin America 13.4

Western Europe 13.0
Eastern Mediterranean 10.7
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Africa 10.4
Pacific Asia 9.4
South East Asia 4.5
Eastern Europe 4.4
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Source: International Study of Asthma and Allergies in Childhood (1998).

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leading cause of DALYs lost in 2001!
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Source: Global Initiative for Asthma (GINA) – 2004. Asthma was the 25th ranked
Figure 8. Global prevalence of clinical asthma.

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1.4.4. Chronic Respiratory Disease Morbidity
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Source: Aït-Khaled, Enarson, and Bousquet, 2001.
Figure 9. projected COPDa mortality rates foe sub-Saharan Africa.

Table 5. Estimates of the burden of respiratory diseases

(in DALYs – 1999)
Region COPD Asthma

Africa 0.5 0.6
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South East Asia 1.5 0.8
Western Pacific 8.5 1.3
Eastern Mediterranean 1.3 0.9
Europe 4.0 1.6
The Americas 1.8 1.0
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World 2.7 0.9
Source: World Health Report 2000.
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1.4.5. Chronic Respiratory Disease Mortality
Most developing countries have no standard protocols for assessing and

managing chronic non-communicable respiratory diseases such as Chronic
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Obstructive Pulmonary Disease (COPD) and Asthma. In these countries, the
population afflicted by poverty and illiteracy, having very little (or no) access
to health services, will die before the age of 40 years. They comprise 15% of
the population in Latin America, 34% in Arab world, 45% in Sub-Saharan
Africa and south-east Asia ( Ait-Khaled et al, 2001; La Bronchopneumopathie
Chronique Obstructive, undated).COPD is currently the fourth leading cause
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of death in the world (3), and further increases in the prevalence and mortality
of the disease can be predicted in the coming decades (2, 32). In the United
States, COPD death rates are very low among people younger than 45 yr of
age but then increase with age, and COPD becomes the fourth or fifth leading
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cause of death among those over 45 (1). By 2020, COPD is expected to

become the third most common cause of mortality in the world.
Respiratory diseases caused 6.48% of all deaths worldwide in 2002, an
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average of 595 deaths per million people per year. Chronic bronchitis [Chronic
obstructive pulmonary disease caused 74% of deaths, Asthma caused 7% of
deaths and Other respiratory diseases caused 19% of deaths. Chronic
bronchitis [Chronic obstructive pulmonary disease] (74% of deaths), Asthma
(7% of deaths) and other respiratory diseases (19% of deaths).
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Source: SASI Group and Newman (2006g).
Figure 10. Territories are sized in proportion to the absolute number of people who
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died from respiratory disease in one year .
The ten highest rates of death per million people in 2002, according to
SASI Group and Newman (2006g) were in:
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1) The former Yugoslav Republic of Macedonia, 1573
2) Bosnia Herzegovina, 825
4) Slovenia, 399
5) Latvia, 286
6) Estonia, 234
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8) Armenia, 189
9) San Marino, 179
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10) Azerbaijan, 177
Inflammatory heart diseases caused 0.71% of all deaths worldwide in

2002, an average of 65 deaths per million people per year.
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Territories, as illustrated in figure 10, are sized in proportion to the

absolute number of people who died from inflammatory heart disease in one
year.
1.4.6. Chronic Respiratory Disease Economic and Social Burden
The economic burden of COPD in developing countries is lacking because

of the lack of accurate data and thefore only stimates based on data from
developed countries can be made. Aït-Khaled, Enarson and Bousquet (2001)
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cites figures that the economic burden to the USA was 23.9 million US dollars
in 1993. The same source estimates that te costs per varied between 813 US
Dollars in The Netherlands to 1522 US Dollars.
In general, evidence from Russia (Abegunde and Stanciole, 2008)
suggests that chronic diseases have a detrimental impact on household
healthcare and non-healthcare expenditure. Chronic disease tends to impact the
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economically active population by limiting opportunities for labour
participation and to transfer income.
1.5.1. Description of Cancer O

1.5. CANCER
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Malignant neoplasms are different types of cancer. Cancer is not one
disease but a group of over 100 diseases that have in common the uncontrolled
multiplication of abnormal cells. The human body is made up of billions of
cells of many types. In a particular cancer there will be a particular type of
abnormal cell. Usually cancers start with a localized tumour or swelling
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consisting of abnormal cells, which increases in size and spreads. Further

tumours can appear away from the original site; these are called metastases.
Most untreated cancers cause death within months or a few years of diagnosis.
Treatment is sometimes completely successful (when there are no live cancers
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cells remaining), sometimes prolongs life by a number of years, sometimes

just eases particular symptoms (which may be its purpose), or sometimes turns
out to be ineffective in a particular case. There is often a much better chance of
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successful treatment if treatment is started when a cancer is still small and

before it has spread anywhere (no metastases).
1.5.2. Cancer Risk Factors
In developed countries, smoking causes over 80% of lung cancers and

generally, heavy smoking increases the risk by around 30-fold making lung
cancer a major problem in developing countries where the consumption of

tobacco is flourishing. Breast cancer is assumed to be mainly related to dietary
factors which account to up to 80% of the between-country differences in
rates. Substantial evidence suggests that stomach cancer risk is increased by
high intakes of some traditionally preserved salted food and that risk is
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decreased by high intakes of fruit and vegetables. In developing countries,
ingestion of contaminated food is an important liver cancer risk factor together
with active hepatitis virus infection whereas, alcohol consumption is the main
diet-related risk factor in the world. In developed countries, oral cavity,
pharynx and oesophagus cancers are mainly correlated to alcohol and tobacco
(up to 75% of such cancers are attributable to these two lifestyle factors).
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Between 80 and 90 % of oesophagus, larynx and oral cavity are caused by
tobacco and alcohol (Boutayeb and Boutayeb, 2005). In developing countries,
an estimated one-third of all cancer deaths was attributable to smoking in
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1995. In developing countries, around 60% of oesophageal cancers are thought
to be a result of micronutrient deficiencies related to a restricted diet that is
low in fruit and vegetables and animal products. There is also consistent
evidence that consuming drinks and foods at a very high temperature increases
the risk for these cancers (World Health Organization, 2003). Pancreatic,
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endometrial, prostate and kidney cancers are more common in industrialized
countries. However, the fact that overweight/obesity is an established risk
factor, their incidence is expected to increase in developing countries engaged
in the socio-economic transition (World Health Organization, 2003). One-third
of cancers could be avoided by eating healthily, maintaining normal weight,
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and exercising throughout life.
1.5.3. Cancer Prevalence

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Between 2000 and 2020, the total number of cases of cancer in the
developed world is predicted to increase by 29% whereas in developing
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countries an increase by 73% is expected (largely as a result of an increase in

the number of old people and as a result of urbanization and change in dietary
habits). According to the International Agency for Research on Cancer
(IARC), there were over a million new cases of breast cancer in the world in
the year 2000, making it the second most common in the world and the most
common among women with 47% in developing countries. Although rates are
five times higher in industrialized countries, the burden of disease is heavier in
poorer countries because breast cancer is highly curable if detected early and,
unfortunately, about 80% of the cases are detected at advanced stages in

developing countries. Breast cancer ranks at the third place, with incidence
rates tenfold higher in developed than in developing countries. Twenty years
ago, stomach cancer used to be the most common in the world. At the
moment, it is the fourth most common in the world but the second most
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common in developing countries. Approximately 75% of cases of liver cancer
occur in developed countries, the rate vary over 20 fold between countries.
1.5.4. Cancer Morbidity
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The incidence of cancer world-wide in 2000 was 12.3% lung cancer,
10.4% breast cancer, 9.4% colorectal cancer, 8.7% stomach cancer, 5.6% liver
cancer, 5.4% prostate cancer, 4.7% cervical cancer, 4.1% cancer of the
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oesophagus, 3.9% head and neck, 3.3% bladder and 32.2% other. The
contribution of morbidity in developing countries is 53% for incidence. In
South Africa, colorectal cancer was the sixth leading cancer among males
(5.3%) and the fifth leading cancer among females (6.6%) in terms of deaths
(Bradshaw et al., 2003). In 1997, colorectal cancer comprised 3.6% of all
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cancer incident cases, and ranked 3rd and 5th in females and males,
respectively. The age-standardised incidence rate for colorectal cancer in
women was 6.5/100,000 while males had a higher rate of 9.1/100,000 (Mqoqi
et al., 2003).
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1.5.5. Cancer Mortality
Cancer is now a major cause of mortality throughout the world. In the

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developed world, cancer is generally exceeded only by CVD but developing

countries are responsible for the globally increasing trend. Over 10 million
new cases and over 7 million deaths from cancer occurred worldwide in 2000
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(The World Health Report, 2003; World Health Organization, 2003; World
Health Organization and International Agency for Research on Cancer, 2003;
Parkin et al, 1999; Sankaranrayanan et al, 2001). The contribution of
developing countries was 56% for deaths . From 1990 to 2000, the incidence
and deaths increased by 2.4% per annum. The South African National Burden
of Disease study (SANBD) found that in the year 2000, cancers as a group
accounted in South Africa for 41 691 (8%) of all deaths and were ranked as
the fourth leading cause of death for all persons and the second leading cause
of death among older (60+ years) persons (Bradshaw et al., 2003). Lung
cancer is currently the most common cancer in the world. According to studies
conducted in Europe, Japan and North America, 83–90% of lung cancers in
men and 57–80 in women, are imputable to tobacco. In South Africa, breast
cancer age-standardised mortality rates were highest in the coloured urban
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females (26,4/100 000) from 1984-1986 . They were followed closely by
whites (26,0/100 000), and then urban Asians (14,6/100 000), while African
urban females had the lowest rates (9,6/100 000) (Bradshaw et al., 1995). In
2000, the age-standardised mortality rates appeared to have increased since
1984/86, although the 2000 national rates were not available by urban/rural
residence, and the rate in urban females is probably higher than the national
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average. As previously, the age-standardised death rates for white females
were almost three-fold higher than in Africans in 2000: whites had the highest
rates (33/100 000), followed closely by coloureds (31/100 000) and Asians
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(27/100 000), and African females had the lowest rates (12/100 000)
(Bradshaw et al., 2003). In as far as cervical cancer is concerned, 80% of the
new cases and deaths are occurring in developing countries where it
constitutes a major health problem. In developed countries, screening
programmes and early detection have led to a noticeable decline in cervical
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cancer incidence and mortality, whereas, the trend is stable or increasing in
low- and middle-income countries owing to their limited health care resources
but also to their ill-health systems generating inefficient (or no)strategies
(Sankaranrayanan et al, 2001). In South Africa, oesophageal cancer was the
second leading cause of cancer deaths in males (17.2% of all male cancer
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deaths) and the fourth leading cause of cancer deaths in females (10%) in 2000
(Bradshaw et al. 2003).
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Source: SASI Group and Newman (2006h).

Figure 11. Territories sized in proportion to the absolute number of people who died
from cancer in one year .
Malignant neoplasms (cancers) caused 12% of all deaths worldwide in

2002, an average of 1144 deaths per million people per year. There are
geographic differences in the incidence of certain types of cancer. Within
territories there are differences between the sexes, various ethnic groups,
different occupations, smokers and non smokers. There are many predisposing
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factors which alter the risks of getting particular cancers.
Many cancers, as they spread, according to SASI Group and Newman
(2006h), cause one to loose weight (cachexia) and get gradually weaker.
Specific symptoms (pain and loss of function) usually depend on the actual
site of the original cancer and of the secondaries from it. Without treatment
death often occurs months after the start of symptoms, with gradually
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increasing weakness and often pain.
The 17 categories (with the percentage of deaths attributed to each) are:
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1) Mouth cancer [Mouth and oropharynx cancers](4% of deaths).
2) Throat cancer [Oesophagus cancer](6% of deaths).
3) Stomach cancer (12% of deaths).
4) Bowel cancer [Colon and rectum cancers] (9% of deaths).
5) Liver cancer, (9% of deaths).
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6) Pancreas cancer (3% of deaths).
7) Lung cancer [Trachea, bronchus and lung cancers] (17% of deaths).
8) Skin cancer [Melanoma and other skin cancers] (1% of deaths).
9) Breast cancer (7% of deaths).
10) Cancer of the cerxix [Cervix uteri cancer] (3% of deaths).
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11) Cancer of the uterus [Corpus uteri cancer] (1% of deaths).

12) Ovary cancer (2% of deaths).
13) Prostate cancer (4% of deaths).
14) Bladder cancer (3% of deaths).
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15) Lymphomas [includes multiple myeloma] (5% of deaths).

16) Leukaemia (4% of deaths).
17) Other malignant neoplasms (10% of deaths).
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Malignant neoplasms (cancers) caused 12% of all deaths worldwide in

rates of death per million people in 2002, according to SASI Group and
Newman (2006h), were in:
1) Hungary, 3136
2) San Marino, 2941
3) Denmark, 2940
4) Croatia, 2775
5) Czech Republic, 2773
6) Belgium, 2753
7) Italy, 2678
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8) Germany, 2642
9) United Kingdom, 2561
10) Latvia, 2533
Territories, as depicted in figure 11, are sized in proportion to the absolute

number of people who died from cancer in one year.
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1.5.6. Cancer Economic and Social Burden
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Although the costs of cancer are difficult to quantify, they can be
classified into three categories (Greenwald, Kramer and Weed, 1995). Direct
costs result from the use of resources for medical care to prevent, diagnose and
treat cancer and for the continuing care, rehabilitation and terminal care of
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patients. Indirect costs come from the loss of resources – the time and
productivity lost or foregone by the patient, family, friends and others from
employment, volunteer activities, leisure and housekeeping. Psychosocial
costs come from reduced quality of life from disability, suffering and pain
which force undesirable changes in lifestyle such as economic dependence,
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social isolation, changes or loss of job opportunities or changed conditions of

living. Morasso (1999) found that terminal cancer patients most frequently had
unmet needs which were: symptom control (62.8%), occupational functioning
(62.1%), and emotional support (51.7%). The less frequently reported needs
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were those related to personal care (14.6%), financial support (14.1%), and
emotional closeness (13.8%). Furthermore, a low functional state was
significantly associated with a high proportion of patients with unmet needs of
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personal care, information, communication, occupational functioning, and

emotional closeness. Patients with unmet needs showed significantly higher
psychological and symptom distress for most needs.
CONCLUSION
The epidemiological situation of NCDs in developing countries is getting
worse and the incidence of NCDs is increasing. There is a need for concerted
effort to address NCDs.
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―Without concerted action, some 388 million people will die of one or
more NCDs in the next 10 years,‖ according to Nizal Sarrafzadegan,
Professor, Isfahan University of Medical Sciences, Iran. ―With concerted
action, the number of premature deaths prevented by 2015 would total at least
36 million – a number of people roughly equal to the population of Canada,
Algeria or Kenya.‖ Noting the economic impact of chronic NCDs, Robert
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Beaglehole, former WHO Director (Department of Chronic Diseases and
Health Promotion), says that unless serious action is taken now, over the next
decade China, India and the U.K. will lose an estimated $558 billion, $237
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billion and $33 billion respectively in foregone national income due to heart
disease, stroke and diabetes.
―While these challenges are applicable to all countries, different nations
should identify local priorities for immediate attention, depending on resources
and disease patterns,‖ says John Bell, Regius Professor of Medicine,
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University of Oxford and Chair, Oxford Health Alliance.
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Chapter 2
THE ROLE OF CHRONIC
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NON-COMMUNICABLE DISEASES IN
MORTALITY RATES IN SOUTH AFRICA,
1997-2006
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Eric O. Udjo
ABSTRACT
Mortality from non-communicable diseases is associated with
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epidemiologic transition. Global estimates indicate that mortality patterns

have changed since the 1990s, with chronic non-communicable diseases
exceeding communicable, maternal, and perinatal causes, except in sub-
Saharan Africa. It is predicted that by 2020, non-communicable would be
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causing seven out of every 10 deaths in developing countries.

There has been a steady increase in mortality in South Africa since
the 1990s and this increase became substantial after 2001 such that life
expectancy at birth in 2006 was lower than the level in the 1980s and
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1990s. This study examines trends in mortality from non-communicable

diseases in South Africa during in 1997-2006 based on death records. The
results indicate that death rates from non-communicable diseases among
persons aged 15 years and over have been increasing in South Africa.
Keywords: Non-communicable diseases, HIV/AIDS, crude death rate,

South Africa
40 Eric O. Udjo
2.1. INTRODUCTION
2.1.1. Definition of NCD
NCD are diseases that are not transmissible directly or indirectly from one
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person to the other. According to the ICD-10 classification, the broad
categories of these diseases include malignant neoplasms, other neoplasm,
diabetes mellitus, endocrine disorders, neuropshiatric conditions, sense organ
diseases, cardiovascular diseases, respiratory diseases, digestive diseases,
genitourinary diseases, skin diseases, musculoskeletal diseases, congenital
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anomalies and oral conditions.
The pre-eminence of mortality attributable to non-communicable diseases
(NCD) is usually associated with epidemiologic transition. The theory of the
epidemiologic transit posits that during the transition, a long term shift occurs
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in mortality and disease patterns whereby pandemics of infection are
progressively (but not completely) displaced by degenerative and man-made
diseases as the leading causes of death (Omran, 1982). Two major factors –
demographic and social – have been identified to be responsible for the
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emergence of chronic diseases in different settings (Ebrahim and Smeeth,
2005; Yang et al, 2008). The demographic factor has to do with the
demographic transition – the transition from high to low fertility and mortality
resulting in the structural change of population from a youthful to an ageing
population as life expectancies increase. As longevity increases, NCD gain
increasing prominence. Furthermore, as longevity increases in a population
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there is a rapid increase in man-made diseases due to changes in life style

behaviour (risk factors). Thus, demographic transition and life style behaviour
reinforce the increase in NCD.
Capilheira et al (2008) have observed that mortality patterns have changed
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since the 1990s, with chronic NCD exceeding communicable, maternal, and
perinatal causes, except in sub-Saharan Africa. Chronic diseases account for
over half of global deaths (Ghaffar, Reddy and Singhi, 2004; Ebrahim and
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Smeeth, 2005; Capilheira et al, 2008; Nabel, Stevens and Smith, 2009).
According to Marquez and Suhrcke (2005), non-communicable diseases
among people of working age, drive high rates of adult mortality in Eastern
Europe and citing Currie and Madrian (1999) observed that morbidity from
NCD reduces the productivity and active participation of people in work.
It is estimated that 80% of NCD globally occur in low-income and
middle-income countries (Nabel, Stevens and Smith, 2009). By 2020, it is
predicted that NCD would be causing seven out of every 10 deaths in
The Role of Chronic Non-Communicable Diseases … 41
developing countries (Boutayab and Boutayab, 2005). It is clear from the

above overview that globally, mortality from NCD is gaining increasing
prominence and poses challenges for health care provision especially in the
less developed countries.
Turning to South Africa, access to basic social services including health
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care was racially discriminatory during the apartheid era and according to the
American Association of the Advancement of Science (2008), the apartheid
policies of the South African government had a deleterious effect on the health
of the majority of South Africans. Since the South Africa health systems were
divided according to race, geographic area, the public sector and the private
sector, inequalities in the provision of health care emerged between blacks and
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whites, between rural and urban areas, between primary and tertiary health
care programmes and between the homelands and the rest of South Africa.
Despite apartheid policies, the crude birth rate which was close to 40 per
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thousand in 1970 declined steeply in the 1980s to less than 30 per thousand
around 1985 and levelled off in the 1990s to its current level of about 25 per
thousand (Udjo, 2006a). Also, while the crude death rate was about 12 per
thousand in the 1970s, it declined to about 9 per thousand in the early 1990s
(Udjo, 2006a). This demographic transition has resulted in a structural change
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of South Africa‘s population from a youthful population to an intermediate
stage of ageing with a population median age of 24 years and persons aged 60
years and over constituting about 7% of South Africa‘s population in 2004
(Udjo, 2006a).
However, since the late 1990s, there has been a steady increase in
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mortality in South Africa, which became quite substantial after 2001 such that
life expectancy at birth in 2006 was lower than the level in the 1980s and
1990s. The increase in mortality in recent years is partly attributable to AIDS
as South Africa is one of the countries worst affected by HIV in sub-Saharan
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Africa and in the world (Udjo, 2006a). Although HIV prevalence among
pregnant women in South Africa appears to have declined in the past two
years, the prevalence among pregnant women estimated as 29.3% in 2008
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(National Department of Health, 2009) is about the second highest compared

to other countries in the world. While communicable diseases will continue to
play a key role in the overall mortality of South Africa, non-communicable
diseases would probably become increasingly important as Governments‘
efforts to redress past racial inequalities in access to basic social services and
reduce poverty related mortality among other measures yield fruits. It is
against this background that this study has been undertaken.
42 Eric O. Udjo
The purpose of this study is to examine the role of chronic non-

communicable diseases in mortality rates in South Africa during the period
1997-2006. Specifically, the study examines the contribution of NCD relative
to communicable, maternal, perinatal nutritional conditions (CD) to overall
mortality in South Africa during the period 1997-2005. The study also
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examines trends in age standardised mortality relates attributable to NCD
during the period 1997-2005 as well as in 2006. Lastly, the study presents an
overview of risk factors in NCDs.
2.2. METHODOLOGY
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2.2.1. Data Sources
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The sources of data for this study are death records for the period 1997-
2006. Death records constitute an important source for examining leading
causes of death in a population as information on causes of death may not be
meaningfully collected comprehensively in surveys and censuses. In South
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Africa, death records are obtained through its vital registration that dates back
to 1910 though was not uniform throughout the country until 1924 (Khalifani,
Zuberi, Bah and Lehohla, 2005).
The vital registration system in South Africa requires that all deaths be
certified and notified to the register of deaths at the Department of Home
Affairs. The death notification forms among other variables contain the
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medical certification of cause of death which includes the immediate cause of

death as well as underlying causes of death. The underlying causes of death
are broken down into second, third, fourth and other conditions (cause) leading
to death.
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2.2.2. Coding, Compilation and Publishing of Death Records

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Statistics South Africa has the legal mandate to publish vital statistics
based on deaths reported to the Department of Home Affairs (Statistics South
Africa, 2005). Statistics South Africa obtains the death notification forms from
the Department of Home Affairs and processes. The processing includes
capturing, cleaning and coding of the causes of death. The coding of the cause
of death is based on the 10th revision of the International Classification of
Diseases (ICD-10). Statistics South Africa derives the underlying causes of

death automatically using a software programme called Automated
Classification of Medical Entities developed by the Unites States National
Center for Health Statistics (Statistics South Africa, 2005). The analysis and
results presented in this study are based on the ICD-10 coding of the death
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records undertaken by Statistics South Africa.
2.2.3. Completeness of Death Notification Records
One of the problems in using death notification records from vital
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registrations in the less developed countries is incompleteness. Incompleteness
may either be due to incomplete coverage of the entire population by such
systems (for example, the system may be concentrated on urban areas), or
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where there is coverage, people either fail to register such events, or register
such events long after the occurrence of the event. In a study evaluating the
completeness of death notification in South Africa, Udjo (2006b) observed that
whereas the registration of female deaths in 1997 appeared to be about 74%
complete, it was about 84% complete for males in the same period. The study
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further observed that completeness of death registration of female deaths may
have increased to about 84% in 2002 and for males, to about 92% in the same
period. In another study, Udjo (2008) estimated the completeness of death
registration as approximately 66.5% and 92.5% for males whose reported age
at death were 0-44 years and 45 years and over respectively in 2004. For the
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same period, the study estimated the completeness of death registration as

approximately, 58% and 85.8% for females whose reported age at death were
0-34 years and 35 years and over respectively. On the basis of these
evaluations, the estimated death rates from NCD presented in this study need
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to be interpreted as lower limits of the death rates from NCD in South Africa.
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2.2.4. Age Standardised Death Rates
Mortality varies with age and crude death rates are sensitive to age
structure as they do not take into account the variation in age structure of the
population. Since the age structure of a population varies over time, it would
be mis-leading to compare crude death rates over time in a population without
taking into account the changing age structure. To enable appropriate
comparison of crude death rates attributable to NCD over time in the present
44 Eric O. Udjo
study therefore, age standardised death rates were computed. Standardisation

is a statistical method for controlling for changes or differences in the age
structure of the population in the phenomenon being analysed.
Indirect standardization was used in the present study which entailed: (1)
defining a standard set of age specific death rates from NCD; (2) computing
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the expected number of cases of NCD on the basis of the standard rates; (3)
computing standardized mortality ratios (SMR) as:
SMR = S/E.
where S is the standard crude death rate from NCD in the index population
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(index population), and E is the expected crude death rate from NCD; (4)
Computing the age standardized crude death rate from NCD as:
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SMR * S.
The age standardised death rates were based on the age group 15 years and
over broken down into 15-49, 50-59 and 60 years and over. The population of
South Africa in 1997 was used as the index population for the death rates
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during the period 1997 to 2005. For the comparison of death rates from NCD
by sex and geographical areas in 2006, the index population was the national
population in 2006. The population estimates used as denominators for the
rates were based on the national population estimates by sex and by province
produced by Udjo (2009).
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2.3. RESULTS
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2.3.1. Contribution of NCD to Total Mortality and Trends in

South Africa
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The percentage contributions of NCD to overall mortality among persons

aged 15 years and over in South Africa during the period 1997-2005 are
illustrated in Figure 1. As seen in the graph, for each of the years during the
period 1997-2003, the percentage contribution of NCD as immediate causes of
deaths was higher than the corresponding contribution of CD. Whereas in
1997, NCD contributed 46% of the total registered immediate causes of death,
the corresponding contribution of CD was 23%. In 2003, whereas NCD‘s
contribution to overall mortality declined to 38%, CD‘s contribution increased
to 40%. There was a cross over after 2003 whereby NCD contributed
proportionately less deaths than CD to overall mortality. The cross-over period
corresponds to a period of very high levels of HIV prevalence (28% or higher
among pregnant women attending public antenatal services) in the country
with AIDS related deaths contributing about 14% of total registered deaths
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during the period.
Despite increasing ageing of South Africa‘s population, Figure 1 indicates
that the contribution of NCD as immediate causes of death continues to
decline while the contribution of CD as immediate causes of death continues
to increase. The divergent trends between NCD and CD is partly due to the
rising trend in AIDS related mortality in South Africa – the contribution of
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AIDS related deaths to total registered deaths increased from about 8% in
1997 to about 14% in 2005.
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Figure 1. Percentage contribution of non-communicable diseases (NCD) and

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communicable, maternal, perinatal and nutritional conditions (CD) to immediate

causes of deaths in South Africa, 1997-2005.
A similar pattern was observed regarding underlying causes of death when

the contributions of NCD and CD to total mortality overtime were compared.
In view of this, only the results pertaining to immediate causes of death from
NCD are presented in the following sections.
46 Eric O. Udjo
2.3.2. Trends in Standardised Death Rates from NCD
The absolute numbers of deaths due to NCD should increase over time
due to population increase. Population ageing in a demographically
transitional population should also increase the absolute numbers of deaths as
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well as alter the age structure of the population. Excess mortality due to AIDS
related death also has impact on the age structure of populations that
experience high levels of HIV prevalence. All of these conditions are present
in South Africa. To control for these factors that alter the age distributions of
populations, age standardized death rates were computed to enable appropriate
examination of crude death rates from non-communicable diseases. The
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following pattern emerged from the results.
Although the percentage contribution of NCD to total registered deaths
has been declining as indicated in Figure 1, crude death rates from NCD
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increased in each successive year during the period 1998-2005 compared with
the rate in 1997. The results suggest that while in 1997, the crude death rate
from NCD was at least 516 per 100,000 persons aged 15 years and over, by
2005, the rate was at least 605 per 100,000 persons aged 15 years and over.
The standardise mortality ratios (Table 1) suggest that the crude death rate
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from to NCD in 2005 was about 17% higher than the rate in 1997 controlling
for changes in age structure.
2.3.3. Variation and Trend in Standardised Death Rates in NCD

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Broad Categories
Although examination of the overall magnitude of death rates from NCD

is useful, it is also important to examine the variation in death rates in NCD
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broad categories so that policies and intervention programmes can be more

focused.
The highest death rates were during the period 1997-2005 were from
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cardiovascular diseases in comparison with death rates from any other broad
category of NCD while during the same period, the lowest death rates were
from non-malignant neoplasms. While the death rate from cardiovascular
diseases was at least 284 per 100,000 persons aged 15 years and over in 2003,
the death rate from non-malignant neoplasms was 1.8 per 100,000 persons
aged 15 years and over during the same period. Respiratory diseases had the
second highest death rates while malignant neoplasm had the third highest
death rates. Thus, there is a large variation in death rates from the NCD broad
categories in South Africa.
Although cardiovascular diseases had the highest death rate during the
period, the death rates from cardiovascular diseases declined slightly during
the period. Whereas the age standardized crude death rate was about 290 per
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100,000 persons aged 15 years and over in 1997, it was about 256 per 100,000
persons aged 15 years and over in 2005 (i.e. an annual decline of about 1.5%
during the period 1997-2005).
Aside from cardiovascular disease, the trend in death rates from
neoplasms were stable during the period 1997-2005 but the death rates from
the other NCD broad categories (including diabetes mellitus, endocrine
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disorders, neuropsychiatric conditions, respiratory and digestive diseases)
increased slightly in varying degrees during the period.
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Table 1. Standardised mortality ratios (SMR) from NCD 1997,2005
Year SMR
1997
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1998 1.05
1999 1.09
2000 1.11
2001 1.13
2002 1.15
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2003 1.22
2004 1.20
2005 1.17
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2.3.4. Variation in Current Death Rates from Cardiovascular

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Diseases by Sex and Province
As already indicated, cardiovascular diseases had the highest death rate

compared with other broad NCD categories during the period 1997 – 2005.
The following section examines variation in current death rates from
cardiovascular diseases by sex and geographical area.
This study estimates that the death rate from cardiovascular diseases was
at least 307 per 100,000 persons aged 15 years and over in South Africa in
48 Eric O. Udjo
2006. There is a slight variation in death rate from cardiovascular diseases by

sex (310 per 100,000 males aged 15 years and over and 302 per 100,000
females aged 15 years and over in 2006). The higher cardiovascular death rate
among females may be partly due to the higher longevity among females. In
2006, the estimated life expectancy at age 15 was 44.8 years among males
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while for females it was 51.5 years (Udjo, 2008). As longevity increases, death
from NCD including cardiovascular diseases should increase.
Figure 3 indicates that the top three provinces with the highest death rates
from cardiovascular diseases in 2006 were the Northern Cape, Mpumalanga
and the Free Sate in that order.
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Figure 2. Death rates due to non-communicable diseases, 1997-2005.
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Figure 3. Death rate from cardiovascular diseases by province, 2006.

Of all the nine provinces in South Africa, Limpopo (which until recently
had the highest fertility and the second lowest proportion of elderly persons)
had the lowest death rate from cardiovascular diseases in 2006.
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2.4. RISK FACTORS
Rising trend in death rates from NCD in various countries have been
linked by several studies to changes in behavioural life style as the main risk
factor. The main risk factors include changing diet resulting in overweight and
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obesity, decreased physical activity, alcohol abuse and smoking. Boutayeb and
Boutayeb (2005), for example, observed that despite different levels of
cardiovascular diseases, diabetes, cancer and chronic respiratory diseases in
developing countries, a common denominator is the risk factors namely,
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tobacco, alcohol, high blood pressure, diet and physical inactivity at different
levels as risk factors. Capilheira et al (2008) detected a high prevalence of the
main risk factors for chronic diseases among persons aged 15-69 years in
Brazil as smoking, overweight/obesity, and physical inactivity. The increase in
the proportion of overweight and obesity in China between 1992 and 2002 was
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linked to reduced physical activity (Gonghuan et al, 2008).
It is not possible to link these factors directly to the emergence and trend
in NCD in South Africa. However, the report on the 1998 South Africa‘s
Demographic and Health Survey (National Department of Health: undated)
indicates that 25% of South African adults smoke and the province with the
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highest prevalence of tobacco use is the Northern Cape (65% of adult males,
and 43% of adult females). The report also indicates that 28% of adults (45%
male and 17% female) South Africans were currently consuming alcohol with
a third of current drinkers drinking at risky levels (National Department of
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Health: undated). (Risky level is defined as drinking five or more standard

drinks per day for men and three or more drinks per day for women
(Department of Health: undated)). Using the World Health Organisation
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standard, the survey results indicate that 29% of men and 56% of women were
overweight with obesity being highest in the Western Cape, KwaZulu-Natal
and Gauteng (National Department of Health: undated).
The smoking status of deceased persons can be obtained from the death
records in South Africa. About 17% of deceased persons who died from
cardiovascular diseases in 2006 were smokers five years ago before they died.
Thus there is a high prevalence of tobacco use among persons aged 15 years
and over who died from cardiovascular diseases in 2006 compared with
50 Eric O. Udjo
deceased persons who died from respiratory diseases (8%), malignant

neoplasms (6%), endocrine disorders (5%) and digestive disorders (3%) who
were smokers.
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2.5. DISCUSSION AND CONCLUSION
The results from this study indicate that although the percentage
contribution of NCD relative to CD to overall mortality has been declining due
to rising trend in AIDS mortality in South Africa, crude death rates
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(standardized for changing age structure) from NCD among persons aged 15
years and over have been increasing. The highest death rates from NCD are
from cardiovascular diseases followed by respiratory diseases and malignant
neoplasms. Of all the provinces in South Africa, the Northern Cape has the
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highest death rates from NCD (as well as the highest prevalence of tobacco
use) followed by Mpumalanga and the Free State.
As the demographic transition in South Africa becomes more marked and
ageing of the population progresses, death rates from NCD would increase in
the future. Furthermore, as the HIV epidemic abates and AIDS related
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mortality loses momentum, mortality from NCD would be more marked
relative to mortality from CD in South Africa. NCD is therefore likely to pose
a greater challenge to health care provision in the future in South Africa. The
risk factors that have been identified for increasing prevalence of NCD in
different parts of the world are changing diet, overweight and obesity, alcohol
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abuse as well as smoking. These conditions are also present in South Africa
though the magnitudes of these risk factors and their relationship to NCD in
South Africa have not been systematically explored. More research in this
regard in the Southern African context is therefore required.
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ACKNOWLEDGMENT
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This author wishes to thank Statistics South Africa for providing access to
its data for this study. The views expressed in this paper are those of the author
and do not necessarily reflect those of Statistics South Africa.
REFERENCES
Boutayab, A. and Boutayab, S. (2005). The burden of non communicable
diseases in developing countries. International Journal For Equity in
Health, 4(2): pp 1-8
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Capilheira, M.F.; Santos, I.S.; Azevedo Jr, M.R.; and Reichert, F.F. (2008).
Risk factors for chronic non-communicable diseases and the CARMEN
initiative: a population-based study in South of Brazil. Cadernos de Saude
Publica, 24 (12): 1-5.
Currie, J. and Madrian, B.C. (1999). Health, health insurance and the labor
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market. In: Ashenfelter O, Card D, eds. Handbook of labor economics,3:
3309-3415. New York: Elsevier Science.
Ebrahim, S. and Smeeth, L. (2005). Non-communicable diseases in low and
middle-income countries: a priority of a distraction. International Journal
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of Epidemiology, 34 (5): 961-966.
Ghaffar, A.; Reddy, K.S. ;and Singhi, M. (2004). Burden of non-
communicable diseases in South Asia. British Medical Journal, 328
(7443): 807-810.
Khalifani, A.K.; Zuberi, T.; Bah, S.; and Lehohla, P.J. (2005). Population
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statistics. In, Zuberi, T., Sibanda, A., Udjo, E. (eds). The demography of
South Africa. New York: M. E. Sharpe.
Marquez, P.V. and Suhrcke, M. (2005). Combating non-communicable
diseases. British Medical Journal, 331.doi: 10.1136
National Department of Health. (Undated). South Africa demographic and
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health survey 1998. Pretoria: National Department of Health.

National Department of Health. (2009). 2008 National antenatal sentinel HIV
and Syphilis prevalence survey. Pretoria: National Department of Health.
Nabel, E.G.; Stevens, S.; and Smith, R. (2009). Combating chronic diseases in
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developing countries. Available from: www. The Lancet.com, June 2009

[Accessed on 11 August 2009 ]
Omran, A.R (1982). Epidemiologic transition theory. In International
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Encyclopedia of Population. Ross JA (ed.),1: 172.183. The Free Press,

New York.
Statistics South Africa. (2005). Mortality and causes of death in South Africa,
1997-2003: Findings from death notification. Pretoria: Statistics South
Africa.
The American Association for the Advancement of Science. (2008). Human
rights and health: the legacy of apartheid. Available from:
http//shr.aaas.org/loa/contents.htm [Accessed on 11 August 2009]
52 Eric O. Udjo
Yang, G., Kong L., Zhao W., et al. (2008). Emergence of chronic non-
communicable diseases in China. The Lancet, 372 (9650): 1697-1705.
Udjo, E.O. (2006a). Demographic impact of HIV/AIDS on the young and
elderly populations in South Africa. Journal of Intergenerational
Relations, 4 (2): 23-39.
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Udjo, E.O. (2006b). Estimation of mortality from vital registrations in South
Africa. Current HIV Research, 4: 469-474.
Udjo, E.O. (2008). A re-look at recent statistics on mortality in the context of
HIV/AIDS with particular reference to South Africa. Current HIV
Research, 6: 143-151.
Udjo, E.O. (2009). Impact of AIDS on orphanhood and implications for social
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grant. Paper presented at the Fourth Annual Conference of the Population
Association of Southern Africa, University of the Western Cape, 8-10
July.
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Chapter 3
AN OVERVIEW OF CHRONIC DISEASE
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SURVEILLANCE
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Italia V. Rolle1, Geraldine S. Perry2,
Janneth Mghamba3, Tiffany Gary-Webb4,
Evelyn P. Davila5 and Peter Nsubuga6
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1
Center for Global Health, Centers for Disease Control and Prevention
Atlanta, Georgia, USA
2
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention, Atlanta, Georgia, USA
3
Department of Epidemiology, Ministry of Social Welfare and Health
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Dar es Salaam, Tanzania

4
Mailman School of Public Health, Columbia University
New York City, New York, USA
5
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6
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ABSTRACT
Chronic diseases are projected to be the major causes of morbidity
and mortality in low and middle income countries (LMICs) in the next 20
years. Given the growing burden of chronic diseases, surveillance of
54 Italia V. Rolle, Geraldine S. Perry, Janneth Mghamba et al.
priority chronic diseases and risk factors is warranted for developing and
implementing interventions in LMICs. However, in reality, chronic
disease surveillance is in its infancy in many LMICs despite being well
established in high income countries (HICs). The main objectives of this
chapter are to: (1) describe chronic disease surveillance; (2) review
priority chronic disease data sources and surveillance systems in LMICs
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and HICs; and (3) outline the steps for developing and implementing
chronic disease surveillance in LMICs. Data for this chapter were
obtained through literature reviews conducted using the World Health
Organization and Library of Medicine databases, chronic disease
reference books, and reports from selected chronic disease surveillance
programs in LMICs and HICs. The findings from this review indicate
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there are several mechanisms for obtaining chronic disease surveillance
data including death registration, continuous risk factor health surveys,
disease registries, and health facility- based administrative data. The 2007
WHO assessment report of chronic disease surveillance capacity revealed
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that LMICs lagged well behind HICs in this area. This may be mainly
due to a lack of resources and tools for having an effective chronic
disease surveillance system in LMICs. Consequently, efforts are needed
to provide LMICs with the appropriate tools, skills, personnel, and
funding to implement essential chronic disease surveillance systems
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comparable to those in HICs. These added resources will aid countries in
developing intervention programs to prevent and control chronic diseases
while considering the limited resources available in LMICs. LMICs
should collaborate with HICs in order to benefit from their knowledge of
successful chronic disease surveillance.
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Keywords: chronic disease, surveillance system, risk factors

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3.1. INTRODUCTION
The terms non-communicable disease or chronic disease appear to be used
interchangeably throughout the literature. For the purposes of this chapter, the
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authors will use the term chronic disease.

Surveillance is defined as the ―ongoing systematic collection, analysis,
and interpretation of health data that are essential to the planning,
implementation, and evaluation of public health practice‖ (Brownson et al.,
1998, Thacker and Berkelman, 1988). Infectious disease surveillance focuses
on communicable diseases (e.g., cholera, influenza, measles, human
inmmunodeficiency virus (HIV), tuberculosis); whereas, chronic disease
An Overview of Chronic Disease Surveillance 55
surveillance focuses on non-communicable health events, diseases, and/or risk

factors (M‘ikanatha et al., 2007). Examples of chronic diseases and risk factors
that are monitored include: hypertension, cardiovascular disease, mental
disorders, diabetes, cancer, obesity, tobacco use, alcohol use, physical activity,
and other nutrition related factors. A risk factor is ―an aspect of personal
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behavior or life-style, an environmental exposure, or an inborn or inherited
characteristic, which on the basis of epidemiologic evidence is known to be
associated with health-related condition(s) considered important to prevent‖
(Porta, 2008). These factors can be modifiable or non-modifiable (Magnusson,
2009). In the United States, research has shown that modifiable behaviors such
as tobacco use, poor diet, physical inactivity, excessive alcohol use, and sexual
N
behavior are major predictors of health and mortality, and have important
influences on the mortality trends observed in the United States (McGinnis
and Foege, 1993; Mokdad et al., 2004). These behaviors can be changed
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whereas non-modifiable factors such as age and family history cannot be
changed. For example, a person that has a family history of type 2 diabetes
would benefit the most from making lifestyle behaviors that decrease the risk
of developing type 2 diabetes, such as following a healthy diet, engaging in
regular physical activity, and monitoring blood glucose regularly. Various risk
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factors play an important role in the development of chronic diseases and, in
order for countries to effectively tackle chronic diseases, surveillance of both
the diseases and risk factors is necessary.
While surveillance of infectious diseases is well established in low and
middle income countries (LMIC), chronic disease surveillance is in its infancy.
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There is growing evidence suggesting a need to develop and implement

chronic disease surveillance systems in addition to infectious disease
surveillance in LMICs. In an ideal setting, LMICs would have effective
functioning chronic disease surveillance systems as observed in high income
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countries (HIC). The World Bank classifies countries with a 2008 gross
national income (GNI ) per capita of $975 or less as low income, those with a
GNI per capita of $976-$11,905 as middle income, and a GNI per capita of
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$11,906 or more as high income (World Bank, 2010). Low income countries
include: Afghanistan, Bangladesh, Cambodia, Democratic Republic of the
Congo, Ethiopia, Madagascar, United Republic of Tanzania, Uganda, and
Zimbabwe (World Bank, 2010). Middle income countries include: Albania,
Argentina, Bolivia, Cameroon, Cuba, Fiji, Jamaica, Jordan, Lithuania,
Panama, Serbia, Thailand, Turkey, Turkmenistan, Ukraine, and Venezuela
(World Bank, 2010). The more westernized countries such as Australia,
Bahamas, Canada, Denmark, Finland, Italy, Japan, United Arab Emirates, and
the United States are classified as high income (World Bank, 2010).
Chronic diseases are likely to become a priority of LMICs in the twenty-
first century, given the increasing burden of these diseases globally (Mathers
and Loncar, 2006). Recent data suggest LMICs are currently experiencing a
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double burden of infectious and chronic diseases (Frenk et al., 1989;
Bouttayeb, 2006; Abegunde et al., 2007; Young et al., 2009) and some
researchers are now indicating a triple burden with the addition of injuries
(Lopez et al., 2006). Table 3.1 shows the leading causes of death in LMICs
and HICs as classified by the World Bank country income classification. In
both LMICs and HICs, heart disease is the leading cause of death (Lopez et
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al., 2006). Findings from the global burden of disease study indicate that
LMICs and HICs differ in that the deaths resulting from chronic diseases are
occurring in a younger age group (15-59 years) in LMICs when compared to
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HICs (Lopez et al., 2006).
Table 3.1. Leading Causes of Death in Countries by World Bank

Classification
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LMICs HICs
1.Ischemic heart disease 1. Ischemic heart disease
2. Cerebrovascular disease 2. Cerebrovascular disease
3. Lower respiratory infections 3. Trachea, bronchus, lung cancers
4. HIV/AIDS 4. Lower respiratory infections
5. Perinatal conditions 5. Chronic Obstructive Pulmonary
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Disease
6. Chronic Obstructive Pulmonary 6. Colon and rectal cancers
Disease
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7. Diarrheal diseases 7. Alzheimer‘s disease, dementia

8. Tuberculosis 8. Diabetes
9. Malaria 9. Breast cancer
10. Road traffic accidents 10. Stomach cancer
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*Taken from Global Burden of Disease and Risk Factors, Lopez et al., 2006.
Table 3.2 shows the leading contributors to the growing burden of disease
based on disability-adjusted life years lost (DALY). This measure is
comparable to a person losing one year of life without any disability or illness
(Lopez et al. 2006). The global burden of disease study obtained information
on the major causes of death and illness via death registration systems (vital
registration and sample registration), surveys, and research studies (Lopez et

al., 2006). Ischemic heart disease is listed in the top five causes of the burden
of disease in both LMICs and HICs. A recent 2009 review of the burden of
chronic diseases in South Africa indicated that heart disease was also a major
contributor to the burden of disease in that country (Mayosi et al., 2009). Data
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sources used in that study included vital registration, Agincourt Health site
demographic surveillance system (DSS), South African demographic health
survey (DHS), the South African stress and health survey, and the South
African national burden of disease study (Mayosi et al., 2009).
Table 3.2. Leading Contributors to the Burden of Diseases in Countries
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Using the World Bank Income Classification based on DALY
LMICs HICs
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1.Perinatal conditions 1. Ischemic heart disease
2. Lower respiratory infections 2. Cerebrovascular disease
3. Ischemic heart disease 3. Trachea, bronchus, lung cancers
4. HIV/AIDS 4. Lower respiratory infections
5. Perinatal conditions 5. Chronic Obstructive Pulmonary
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Disease
6. Chronic Obstructive Pulmonary 6. Colon and rectal cancers
Disease
7. Diarrheal diseases 7. Alzheimers, dementia
8. Tuberculosis 8. Diabetes
9. Malaria 9. Breast cancer
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10. Road traffic accidents 10. Stomach cancer

*Taken from Global Burden of Disease and Risk Factors, Lopez et al., 2006.
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The increase in chronic diseases among LMICs is due in part to

epidemiological (Caldwell, 2001) and nutrition transitions (Popkin, 2008),
urbanization (Allender et al., 2008; Belue et al., 2009), globalization (Metoo,
2008), and the projected higher burden of chronic diseases in LMICs as
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compared to previous years (Lopez and Murray, 1998; Mathers and Loncar,
2006). Evidence to fully document the increase in chronic diseases among
LMICS is lacking as chronic disease surveillance sorely lags behind infectious
disease surveillance for numerous reasons. First, infectious diseases, until
recently, were the major cause of the disease burden in LMICs (Nugent,
2008). Second, major infectious diseases such as human immunodeficiency
virus (HIV), tuberculosis, and malaria, received unprecedented amounts of
funding for control and prevention in LMICs (Vitoria et al., 2009). Funding
for these programs tended to result in disease-specific programs and could not
be used for other diseases or overall health systems strengthening (Biesma et
al., 2009). Third, there is a misconception that chronic diseases are diseases of
the affluent and, therefore, occur only in HICs (Caldwell, 2001; Metoo, 2008).
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Fourth, there is a lack of urgency equated with chronic diseases as compared
with infectious diseases. If an infectious disease outbreak occurs, swift action
is taken to contain it before it spreads. Chronic diseases usually take years to
develop and, in general, these are conditions in which affected persons are on
medications for the remainder of their lives. It is critical that chronic diseases
are targeted for prevention and treatment and programs are developed to
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address this need as the chronic disease burden increases in LMICs. This
chapter provides an overview of chronic disease surveillance that is currently
being practiced in LMICs and HICs.
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3.2. METHODS
This chapter has the following objectives: (1) to describe current chronic
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disease surveillance practices; (2) to review selected chronic disease data
sources and current chronic disease surveillance systems in LMICs and HICs;
and (3) to outline the steps for developing and implementing chronic disease
surveillance in LMICs. A systematic review was conducted through Library of
Medicine databases using the following key words: non-communicable
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disease, chronic disease, surveillance, developing, developed, cancer, diabetes,

obesity, heart disease, hypertension, diabetes, nutrition, physical activity,
smoking, alcohol, vital statistics, disease registries, surveys, administrative
data collection systems, demographic surveillance systems, demographic
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health surveys, burden of disease, laboratory, assessment, implementation, and

monitoring and evaluation. Other data search engines included the World
Health Organization Library and Information Networks for Knowledge
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Database (WHOLIS) and Google scholar. The dates for the search were May
2009 through June 2010. The number of potentially relevant articles that
resulted from the searches included 396 books and articles. Articles or books
that presented data from research studies and surveys conducted only once
were excluded. As a result, the final number of books and articles included in
the chapter were 87.
3.3. RESULTS
3.3.1. Chronic Disease Surveillance Systems in LMICs
The surveillance of chronic diseases was found to be minimal in LMICs.
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In 2001 and 2007, the World Health Organization (WHO) published reports
that assessed the capacity of its member regions to prevent and control chronic
diseases. The 2001 report revealed that about half of the countries labeled as
LMICs indicated there were no chronic disease surveillance systems in place
(WHO, 2001). Data collection during the survey period for chronic disease
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risk factors reported via annual reporting country systems to WHO ranged
from 0% in some countries in the African region to 48% in countries in the
Western Pacific region. The findings from the 2007 report (assessment
conducted 2005-2006) showed more promising results, including an increase
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in countries having chronic disease surveillance systems and reporting of
chronic disease data from a baseline survey reported in 2001 (WHO, 2007).
The 2007 report also showed that the number of chronic disease surveillance
systems still differed considerably among the WHO regions. The African
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region showed the most improvement in having routine chronic disease
surveillance systems, increasing from 29% (2000-2001) to 50% (2005-2006).
The South-East Asia region was second, with an increase from 67% (2000-
2001) to 83% (2005-2006). The European (87%), South-East Asia (83%), and
the Western Pacific (86%) regions had the greatest number of countries with a
chronic disease surveillance system in place in 2005-2006. The 2005-2006
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assessment specifically examined if the following risk factors and chronic

diseases were included in the surveillance system: tobacco use, inadequate
diet, lack of exercise, alcohol, diabetes, hypertension, malnutrition
(overweight and obesity), elevated cholesterol levels, heart disease, stroke,
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cancer, and chronic respiratory diseases. Results from the assessment revealed
that tobacco use had consistently higher percentages of being included in
surveillance by the WHO regions compared to diet, exercise, and alcohol. Data
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on diabetes, hypertension, heart disease, and cancer were more commonly

covered in WHO regions than chronic respiratory diseases, stroke,
malnutrition (overweight and obesity), and elevated cholesterol levels. From
2001-2006, all of the regions show an increase in chronic disease surveillance,
specifically for hypertension, diabetes, and cancer.
3.3. 2. Description of Chronic Disease Surveillance
Brownson and others in 1998 provided a list of suggested indicators for

chronic disease surveillance. Four major types of data were considered:
mortality, morbidity, risk factors, and preventive health practices. A short
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description of each of these indicators follows.
(1) Mortality data refers to deaths occurring in a population. Data are

usually captured through death certificates in countries with vital
registration systems (CDC, 1995). Other data sources that may also
collect and/or estimate death data include DSS [Bairagi et al., 1997;
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Ngom et al 2001], DHS [Obermeyer et al., 2010], and burial
surveillance systems (Araya et al., 2004). Vital registration systems
tend to be ongoing and active surveillance systems in which
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information on deaths, births, and marriages is collected. In LMICs,
DHS and DSS may also collect information on mortality. The DSS
are active, continuous surveillance systems in which data are collected
routinely. The DHS estimate mortality in a population but the timing
of the surveys is not necessarily frequent.
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(2) Morbidity data refers to collecting data on illness and can also
describe the length and time of the illness (Porta, 2008). This type of
data can be captured using disease registries (e.g., cancer), periodic
health surveys (e.g., WHO STEPwise approach; United States
National Health and Nutrition Examination Survey [NHANES];
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United States National Health Interview Survey [NHIS]),

administrative health data (e.g., hospital discharge data, insurance
data), DSS, DHS, health management information systems, risk factor
surveillance systems (United States Behavioral Risk Factor
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Surveillance System [BRFSS]) and laboratory surveillance data. The

most common registries collect information on cancer. An example is
the Surveillance Epidemiology and End Results (SEER) registry
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(Ehrlich et al., 2009). Registries have also been used for congenital
malformations such as the Metropolitan Atlanta Congenital Defects
Program (MACDP) [Correa-Villasenor et al., 2003] and for diabetes,
the New York City Blood Glucose A1C Registry (Chamany et al.,
2009).
(3) Risk factors are generally behavioral or environmental factors that
impact health. Chronic disease surveillance usually includes the
modifiable risk behaviors that are behavioral in nature and can be
changed, such as smoking, drinking, physical activity, and diet

(Thacker et al., 1995). The BRFSS and WHO STEPwise approach
surveys collect information on risk factors.
(4) Preventive health practices refer to screenings and regular doctor
visits. The WHO STEPwise survey and BRFSS also collects data on
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preventive health practices including mammography screening.
3.3.3. Data Sources and Current Chronic Disease Surveillance

Systems in LMICs and HICs
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Surveillance data can come from various sources such as death
registration systems, disease registries, ongoing periodic health surveys,
administrative data, and sentinel surveillance systems such as the DSS. These
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data sources have various indicators of interest and may or may not be
population-based, with various degrees of feasibility for low and middle
income countries (Table 3.3).
Death Registration
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Surveillance systems that collect information on the number of deaths and
cause of death include vital registration, sample registration, burial
surveillance, DSS, and in some cases, surveys. Vital registration systems are
focused on collecting birth and mortality data. This type of system is usually
population-based and data are typically extracted from birth and death
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certificates (Lopez et al., 2006). Cause of death is determined using the

International Classification of Diseases (ICD) procedures (Lopez et al. 2006).
The United States has an established vital registration system. Using data from
this system, researchers investigated causes of death among foreign-born and
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US-born Hispanic adults residing in Texas and California (Eschbach et al.,

2007). Results from this investigation showed that foreign-born Hispanics had
a lower rate of death due to chronic diseases than US-born Hispanics
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(Eschbach et al., 2007).In LMICs, vital registration systems that cover all
persons in a country are lacking (Mathers et al., 2005). For example, China has
a sample death registration system (Yang et al., 2005). This system, known as
the Disease Surveillance Point system, represents a fraction of China‘s
population (8%) but it is a representative randomized sample (Yang et al.,
2005). This sample death registration system includes 145 rural and urban
locations. In 2006, a validation study of the system revealed a few potential
issues. The death registration system (i.e., persons inputting the data) recorded
cerebrovascular disease and cancer more accurately than ischemic heart

disease, hypertension, diabetes, liver disease, and kidney disease (Rao et al.,
2007). Turkey also has vital registration system, however it is not able to
provide mortality estimates for the entire country. As a result, researchers in
Turkey applied statistical models and used multiple data sources to assist with
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the estimation of mortality in the country (Razum 2000, 2001; Akgün et al,
2007). In 2000, the major causes of death for men and women in Turkey
included ischemic heart disease, cerebrovascular disease, chronic obstructive
pulmonary disease, hypertension, cancer, and diabetes (Akgün et al, 2007). In
Ethiopia, there is no vital registration system that covers the entire country.
The Addis Ababa Mortality Surveillance Program, a burial surveillance
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system, collects death information from all of the cemeteries in Addis Ababa,
the capital city of Ethiopia (Araya et al., 2004). In Ethiopia, cremations are not
practiced and it is thought the information collected from the cemeteries
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provides a reasonable estimate of the number of deaths occurring in Addis
Ababa. In this case, cause of death is recorded on the cemetery records and
verbal autopsies are used on a sample of the cemetery deaths to validate
reported cause of death. Recently, the program has compared computer
algorithms to the verbal autopsies to determine its feasibility in lieu of the
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verbal autopsies that are time consuming and expensive (Tensou et al., 2010).
The results from the use of computer algorithms is promising.
Disease Registries
Disease registries can include morbidity, mortality, and preventive health
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practices indicators (Wegner et al., 2010). They can be hospital- or population-

based and are expensive to operate and maintain. Valssecchi and Steloarova-
Foucher (2008) provide a thorough review of cancer registries and advocate
for their expansion in LMICs. The argument the authors present is that, for
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those countries that are able to afford them, cancer registries are an essential
service rather than a choice if adequate resources are available when
developing a chronic disease surveillance infrastructure. Examples of cancer
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registries include the Danish Cancer registry (Wihlborg and Johansen 2009),
the Ocean Road Cancer Institute registry (Kazaura et al., 2007), and the
Surveillance, Epidemiology, and End Results registry (SEER) (Ehrlich et al.,
2009). Examples of diabetes registries include the Hong Kong diabetes
registry (Yang et al., 2010) and New York‘s city blood glucose level (A1C)
registry (Chamany et al., 2009).
Ongoing Health Surveys

Ongoing periodic health surveys can collect morbidity, risk factor, and
preventive health practices data. These surveys can be population-based. The
DHS are considered important sources of health data in LMICs but do not
represent true surveillance. The DHS are intermittent surveys that occur on a
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regular basis in some countries, but in others there may be many years
between surveys. It is important to note that studies conducted once are not
considered surveillance even if they are representative of a population
(Thacker et al., 1995). Ziraba and colleagues (2009), comparing DHS data
from 1992/1993 to data from 2003 or later, showed that overweight and
obesity increased in Burkina Faso, Ghana, Kenya, Malawi, Niger, Senegal,
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and Tanzania.
Risk factor surveillance is the preferred method for on-going health
surveys for chronic disease surveillance (McQueen and Puska, 2003).
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Examples of risk factor surveillance include the United States BRFSS and
WHO STEPwise approach. The BRFSS is a state-based, ongoing random digit
dialed telephone survey (to both land lines and cell phones), administered by
all 50 states, the District of Columbia, and three United States territories
(Puerto Rico, the United States Virgin Islands, and Guam) (Chowdhury et al.,
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2010). The BRFSS was implemented in 1984 and it is the largest health
surveillance system in the world, collecting health information on over
400,000 non-institutionalized adults annually (Mokdad, 2009). The system
primarily collects information related to the leading causes of death—heart
disease, cancer, stroke, diabetes, injury, infectious diseases, and other
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important health issues, including health risk behaviors such as tobacco use,
alcohol consumption, dietary factors, and physical activity; preventive health
practices such as women's health issues, doctors‘ office visits, immunization,
hypertension awareness; health care access; and health-related quality of life
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(including physical and mental health). Most recently, data have been
collected on depression and psychological distress. Data are collected monthly
by each state using:
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1) A standardized core questionnaire designed by a state coordinators‘

working group. All states are required to administer the core
questionnaire without modification which includes the fixed core, a
rotating core, and an emerging core of a set of up to five questions
focusing on a ―late breaking issue‖ (such as questions related to an
epidemic);
2) Optional modules - sets of questions related to a specific topic (such

as depression, psychological distress, days of insufficient rest or sleep,
binge drinking and cardiovascular disease) developed by appropriate
CDC Divisions;
3) State-specific questions defined by the state health department.
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Data are transmitted on a monthly basis to the CDC for data checks,
cleaning and are entered into a central database. The data are available to
individual states but are also available as a national public use dataset. States
use the data for public health programs and policy development, planning,
implementation, and evaluation. The most recent report in 2007 showed the
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median prevalence levels of several chronic diseases and conditions among
adult Americans including diabetes (8.1%), hypertension (28.3%), elevated
blood cholesterol (37.8%), coronary heart disease (6.4%), stroke (2.6%),
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arthritis (27.5%), asthma (8.3%), and obesity (26.8%) (Chowdhury et al.,
2010). Median prevalence levels reported for specific health behaviors
included smoking (19.7%), heavy alcohol drinking (5.2%), no physical
activity (23.0%), and consuming 5 servings or more of fruits or vegetables/day
(24.3%) (Chowdhury et al., 2010).
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In order to examine the association between lifestyle risk factors, chronic
diseases, and health-related quality of life (HRQOL), the Jordan Ministry of
Health in 2002 implemented the Behavioral Risk Factor Survey (BRFS), an
adaptation of the United States BRFSS; (Belbeisi et al., 2006). The Jordan
BRFS and the BRFSS currently conducted in the United States both have
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similar questions. Findings from the Jordan BRFS indicated that high blood
pressure, high blood cholesterol, diabetes, heart disease, and asthma were
major chronic diseases affecting the adult population of Jordan (Belbeisi,
2006).
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The WHO STEPwise approach for risk factor surveillance is the

recommended survey method for conducting chronic disease surveillance for
countries worldwide (WHO, 2010; Armstrong and Bonita, 2003). The
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approach includes three steps. The first step includes a core set of questions
that collect self-reported health data. The second step involves physical
measurements and the third step includes biochemical tests. The survey has a
complex sampling design. It is expected that countries will accomplish at least
the first step to aid in determining the prevalence of self-reported chronic
diseases and related risk factors. In Mongolia, a WHO STEPwise survey
indicated chronic diseases are a major health problem in that country
(Bolormaa et al., 2008). Among participants aged 15 to 64 years, it was
estimated that 20% had three or more risk factors placing them at an elevated
risk for developing a chronic disease. Major risk factors included smoking
(24%), low levels of exercise (23%), and less than adequate fruit and vegetable
consumption (3%). Around 30% of Mongolians were overweight or obese
when body mass index was measured. In comparison, results from an Eritrean
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survey showed positive findings. The Eritreans were less likely to smoke
(7.2%), and more likely to exercise (90%) than Mongolians (Usman et al.,
2006). The Iranian Ministry of Health used an adapted version of the WHO
STEPwise approach (Alikhani et al, 2009). Their major findings included
elevated levels of hypertension (24%), overweight/ or obesity (55%), and
smoking (18%) among adult Iranians.
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Administrative Data
Administrative data systems collect morbidity and, in some cases, risk
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factor data. These data do not tend to be population-based but rather health
facility-based, and serves the purposes of the hospital for financial billing and
record keeping. Examples of administrative data include hospital discharge
data and health insurance records. In Germany, a review of insurance data
indicated that there were gender differences in chronic disease prevalence and
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medication costs (Stock et al., 2008). German women were more likely to
have a chronic disease such as diabetes when compared to men, however, men
spent more money on medications compared to women. A comparison of
administrative data from Denmark and California showed that chronic diseases
were more prevalent among patients in California than patients in the
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Denmark health system (Frolich et al., 2008). A study conducted in 2005 to

determine the proportion of chronic diseases among older persons using
Medicare insurance from the United States had chronic diseases found the
following: cancer (6%), depression (11%), diabetes (24%) and heart failure
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(18%) (Schneider et al., 2009). Hospital data from Zimbabwe showed that
patients died of not only infectious diseases but also chronic diseases (Bardgett
et al., 2006).
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Sentinel Surveillance
Sentinel surveillance uses groups in a particular area, region, and/or
country to provide a representative sample of a health event that is under
surveillance (Porta, 2008). The representative surveillance area should be
randomly selected (Truelsen et al., 2001). This type of surveillance has been
used for infectious diseases and is also now being considered and used for
chronic disease surveillance. An example of sentinel surveillance in LMICS is
the DSS that collects longitudinal data to assess demographic changes in a

particular area under study. Examples include the International Network for
the Demographic Evaluation of Populations and Their Health in developing
countries (INDEPTH) DSS Network which uses data from 17 countries
(INDEPTH, 2010).
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Table 3.3. Priority Data Sources for Chronic Disease Surveillance
in LMICs
Data Source Indicator Population Feasibility in Example

based LMICs
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Vital Mortality Yes Yes but are lacking Birth
registration due to the financial certificate,
costs and trained death
personnel. certificate
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Disease Morbidity; Yes but can Yes, but are SEER1
registries Mortality; also be expensive.
Preventive hospital
health based.
practices
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Ongoing Morbidity; Yes Yes, it is key that BRFSS2
periodic health Risk the survey is NHANES3
surveys Factors; repeated in a timely WHO STEPS
Preventive manner to be DHS4
health viewed as
practices contributing to
surveillance.
O
Administrative Morbidity; No Yes, but data in Insurance and

data Risk many LMICs not hospital
Factors; available discharge
Mortality electronically records
O
limiting its use for

surveillance.
Sentinel Mortality; Yes but Yes, but only for INDEPTH
5
surveillance Morbidity; representative countries that have Network:
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Risk of small the necessary Ghana

Factors areas. funds. Usually Tanzania
associated with Vietnam
universities.
1
– Surveillance, Epidemiology and End Results registry (cancer); 2 – Behavioral Risk
Factor Surveillance System; 3 – National Health and Nutrition Examination
Survey; 4- Demographic Health Survey; 5- International Network for the
Demographic Evaluation of Populations and Their Health in developing countries.
In 2009, a supplement produced by the journal Global Health Action

highlighted the use of the WHO STEPwise approach within the DSS to obtain
baseline information on chronic diseases and risk factors in rural Asian
settings in Bangladesh, India, Vietnam, Indonesia, and Thailand (Ng et al.,
2009). It should be noted that DSS are often used to evaluate interventions but
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are not necessarily representative of the general population in the countries
where they are established.
Case Study 3.1. Tanzania: Addressing the Challenges of Establishing

Sustainable Chronic Disease Surveillance
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The government of Tanzania saw a need to collect data on cause-specific
morbidity and mortality to assist with planning and policy development
(AMMP, 1997). In 1992, sentinel surveillance was implemented with the
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establishment of five DSS sites via the Adult Morbidity and Mortality Project
(AMMP). The AMMP was a collaboration between the Tanzania Ministry of
Health and Social Welfare (MOHSW), Muhimbili University (local Tanzanian
university,) and the University of Newcastle upon Tyne, United Kingdom
(Setel et al., 2000a). The study sites for the AMMP included low and middle
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income population areas and monitored more than 300,000 Tanzanian
residents. The AMMP was operational from 1992-2002. Several key results
from this surveillance project demonstrated that (1) a routine system for
collecting information on illness and death were lacking in Tanzania; (2)
HIV/AIDS, maternal mortality, and injuries were major causes of death
(Moshiro et al., 2000, AMMP, 1997); (3) chronic diseases such as diabetes and
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disabling conditions such as stroke were prevalent in the study population

(Walker et al., 2000 a, b); (4) low educational level was associated with
increased total mortality and maternal mortality (Setel et al, 2000b); and (5)
adult mortality appeared to affect younger groups in Tanzania when compared
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to more developed countries (Kitange et al., 1996). In response to findings

from the AMMP showing that chronic diseases in were becoming a problem in
Tanzania,the Tanzania MOHSW established a chronic disease section within
the ministry. Additionally, a national strategy for non-communicable diseases
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was developed and published (Tanzania MOHSW, 2008). Currently, the

government is completing their first WHO STEPwise survey, as well as
conducting a pilot study in three districts to assist in developing a model for
chronic disease surveillance.
3.4. STEPS FOR DEVELOPING AND IMPLEMENTING

CHRONIC DISEASE SURVEILLANCE
WHO, in its 2008-2013 action plan for chronic disease, addresses
surveillance as its sixth objective in assisting with the prevention and control
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of chronic diseases globally (WHO, 2008). The surveillance objective notes
the need for chronic diseases and determinants such as risk factors to be
monitored and the importance of evaluation. The countries are responsible for
strengthening chronic disease surveillance systems; using WHO standardized
tools for risk factors, disease incidence, and mortality by cause; reporting
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descriptive information on chronic diseases and risk factors; and providing
evidence for national strategies (WHO, 2008). In order to develop and
implement chronic disease surveillance, countries will need to follow the basic
principles of surveillance as outlined below.
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True surveillance is a continuous mechanism to understand trends in
incidence or prevalence of diseases and risk factors. This information is
collected to monitor and improve the health of a population (Thacker, 2000).
Three important steps associated with the practice of surveillance include data
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collection, data analysis, and data dissemination (Thacker and Berkelman.,
1988). Two basic methods used for obtaining surveillance data are referred to
as passive and active (Groseclose et al., 2000). Passive surveillance is defined
as one in which relevant stakeholders (e.g., health care providers, hospitals,
and health centers) are required to submit numbers of affected persons with the
reportable condition or disease to a responsible public health agency. The
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responsible group/agency does not actively request the data from the group.
An example of passive surveillance is use of hospital discharge data and
insurance records. In Canada, information on stroke prevalence and
classification was obtained using administrative data (Kokotailo, 2005). Active
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surveillance, on the other hand, involves a responsible group or agency

reaching out to the relevant stakeholders to collect data and ensuring that they
are collected in a timely manner. Iran‘s population-based cancer registry is an
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example of active surveillance that is used to determine the incidence of

cancer for the country (Sadjadi et al., 2007). Prostate cancer was estimated at
5.1 per 100,000 person years in Iran using data from the registry from 1996-
2000.
Figure 3.1 shows a flow chart of a generic public health surveillance
system taken from the CDC‘s publication on evaluating surveillance systems
(CDC, 2001). In this figure, it is important to note the health-related event
could be an infectious or a chronic disease, a risk factor, or any other factor

that is important for the monitoring of a population‘s health. After the event
occurs, it is confirmed, through investigation, laboratory testing, and/or self
reporting. Whether collected by active or passive surveillance, this information
is reported, to the responsible public health agency through paper-based forms,
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electronic transmission (batch data files), email, mobile/cellular phones
(Aanensent et al., 2009), fax machines, or telephone land lines. Usually data
are collected at peripheral levels (districts, villages), then transferred to the
next level (regional, provincial), until finally reaching the central/national
level.
Surveillance officers, community nurses, doctors, nutritionists,
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epidemiologists, and community health workers are involved in the monitoring
and evaluating of surveillance systems. At each level of data transmission,
staff must be dedicated to ensure that the data are complete (minimal missing
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data) and clean (free of data errors such as checking outliers for confirmation
of plausibility) (Groseclose et al., 2000). Additionally, security mechanisms
must be in place to protect confidentiality by making sure that only those
authorized will have access to data that have personal identifiers such as name,
address, and, social security number (Wojcik et al, 2007). The public health
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agency/unit generally acts as a clearing house for surveillance data. The
agency collects and amasses the data submitted by health facilities and enters
them into a central database. After the data are cleaned, the first step is to
analyze the data using descriptive epidemiology methods describing the
information by person, place, and time (Janes et al., 2000). Descriptive
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methods include distribution of the number of persons with the disease or

condition, the prevalence, or percent by selected demographics (e.g., age,
gender, socio-economic status, education). For example, data from the United
States 2003 BRFSS showed that 24% of American women surveyed had high
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blood pressure, 7% diabetes, and 24% high cholesterol levels (Hayes et al.,
2006). The results of these descriptive analyses should determine the actions
necessary to monitor, control, and prevent the health-related event or the
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populations who need to be targeted. For example, it may be found that

individuals who live in urban regions and are older in age are more likely to
have a disease in a given time period. This would direct public health
practitioners to direct attention to individuals with these characteristics and
greater preventative efforts such as public health education to prevent the
disease or its severity. Finally, the data should be disseminated to the relevant
stakeholders along with recommendations for action (Goodman et al., 2000).
This is a crucial step in the process. Surveillance data are intended to guide
public health policy, actions, and interventions and not to lie dormant. Periodic
evaluations of the surveillance system are conducted to ensure the surveillance
system is meeting its objectives. The major steps needed to conduct a
surveillance evaluation include (1) engaging the stakeholders in the
evaluation; (2) describing the surveillance system to be evaluated; (3) focusing
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the evaluation design; (4) gathering credible evidence regarding the
performance of the surveillance system; (5) justifying and stating conclusions,
and making recommendations; and (6) ensuring use of evaluation findings and
sharing lessons learned (CDC, 2001). The performance of a surveillance
system is judged by the following attributes: simplicity, flexibility, data
quality, acceptability, sensitivity, predictive value positive, representativeness,
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timeliness, and stability (CDC, 2001). Surveillance is key to documenting the
burden of chronic diseases and can provide the evidence to inform appropriate
health interventions.
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In developing a surveillance system for either infectious diseases or
chronic diseases, several vital components to consider include (1) establishing
goals, (2) developing case definitions, (3) selecting appropriate staff, (4)
acquiring tools and clearances for collection, analysis, and dissemination, (5)
implementing surveillance systems, and (6) evaluating surveillance activities
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(Nsubuga et al., 2006). Additionally, it is important for countries to assess
their capacity for developing and implementing chronic disease surveillance
systems. Key issues include funding, human resources, existence of baseline
data, and support from both the government and private industries. In order to
take active measures for preventing chronic diseases, adequate surveillance
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systems are needed. In 2005 and 2008, a core group of chronic disease experts
developed seven steps for building chronic disease surveillance capacity
globally (Choi et al., 2005, 2008).
The steps included: (1) a strategy for advocating for chronic disease
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surveillance; (2) ensuring a network of important stakeholders that includes

not only government but also non-governmental agencies and groups; (3)
creating access to chronic disease surveillance data; (4) creating an awareness
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of the increasing chronic disease burden through training and education; (5)
being innovative and thinking outside the box to prevent and control chronic
diseases; (6) improving modes of communication and translation of chronic
disease data to the appropriate agencies and communities; and (7) conducting
periodic evaluations in order to inform the process of chronic disease
surveillance and interventions.
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An infectious, chronic, or zoonotic disease;
N
Occurrence of health
related event injury; adverse exposure; risk factor or
protective behavior; or other event associated with
public health action
Health event
confirmation
Identification by whom and how
Audienc
es
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Reporting sources
Physicians Reporting process

Health-care providers  Data entry and editing possible
Feedback and dissemination of information for public health
Veterinarians
 Assurance of confidentiality
Survey respondents
Laboratories
Hospitals
Health-care organizations
Schools
Vital records and Other
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Data recipients
action
Data management
Primary level  Collection
(e.g., District, Zonal)  Entry
 Editing
 Storage
 Analysis
 Report generation
Secondary level
 Report dissemination
(e.g., Province, Region)
 Assurance of confidentiality
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Tertiary level
(e.g., National)
Periodic Evaluations
**Adapted from CDC‘s Updated Guidelines for Evaluating Public Health Systems (CDC, 2001).
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Figure 3.1. Flow chart for a generic surveillance system..
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Choosing which indicators to monitor for the chronic diseases surveillance

system is important. In the United States, the Council of State and Territorial
Epidemiologists in collaboration with their partners developed a core set of
indicators for chronic disease surveillance. The major areas for the indicators
include physical activity and nutrition, tobacco and alcohol, cancer,
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cardiovascular disease, diabetes, arthritis, overarching conditions, and other
diseases and risk factors. WHO has also provided a list of indicators for its
member countries to use for chronic disease surveillance. Examples of
indicators from this list include levels of physical activity, prevalence of
overweight/obesity, and preventive screening for cervical cancer (WHO,
2008).
N
CONCLUSION
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Chronic diseases will become a priority of LMICs as the disease burden
shifts from mainly infectious diseases to include chronic diseases. Chronic
diseases are projected to be in the top ten causes of morbidity and mortality in
LMICs in the next 20 years. This disease transition will require that
FS
surveillance of diseases in LMICs incorporate chronic diseases and their
associated risk factors into their data collection systems. This will be essential
for monitoring emerging chronic diseases in these countries in order to
effectively plan, develop and implement interventions to address the health
needs of the population. The WHO STEPwise approach, described previously,
O
is intended to assist LMICs in achieving this goal. Although most of the

countries in the WHO regions have committed to implementation of the
STEPwise program approach, this commitment has not come to fruition in the
majority of the countries. WHO data shows that only 41 countries have
O
reported data from their WHO STEPSwise surveys (WHO, 2010).

Additionally, efforts are needed to ensure that the countries conducting the
WHO risk factor survey are able to repeat it in a timely manner for it to be
PR
used for surveillance purposes. To assist with redirecting focus and resources
to chronic diseases, accurate statistics on disease burden is key to show its
predicted increase in LMICs. More efforts are needed to provide LMICs with
the appropriate tools, skills, and funding to implement chronic disease
surveillance in order to intervene and control chronic diseases. Many of the
HIC countries have efficient chronic disease surveillance systems in place.
LMICs should collaborate with HIC in order to benefit from their knowledge
of successful chronic disease surveillance.
ACKNOWLEDGMENT
The authors would like to thank the library staff at the CDC library and
Emma Konan, Georgia State University intern for their assistance with the
literature review.
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Chapter 4
INTERVENTIONS TO PREVENT AND
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CONTROL OF CHRONIC NON-
COMMUNICABLE DISEASE
IN SOUTH AFRICA
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Thandi Puoane and Moise Muzigaba
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ABSTRACT
Background: Chronic non-communicable diseases are a major
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contributor to the burden of disease in developed countries, and are

increasing rapidly in developing countries. It is predicted that globally,
deaths from non-communicable diseases (NCD) will increase by 77%
between 1990 and 2020 and that most of these deaths will occur in the
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developing regions of the world. There is strong evidence that showing

that chronic non-communicable diseases can be prevented through
actions that seek to reduce the risk throughout the entire population.
Objectives: To describe strategies and interventions for prevention
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and control of chronic non-communicable diseases in South Africa.

Method: This chapter is based on a literature reviewed. Criteria for
considering intervention for this chapter included any primary prevention
and secondary prevention program that attempted to reduce the

School of Public Health, University of the Western Cape, Bellville, South Africa. Tel: 021 959
2809, Fax: 021 959 2872, E-mail: tpuoane@uwc.ac.za.
84 Thandi Puoane and Moise Muzigaba
population burden of non-communicable disease risk factor (i.e. blood

pressure, smoking, total blood cholesterol, physical activity, diet).
Key findings: Strategies for prevention and control include policy action,
facility based and community based interventions comprising of school based
and workplace interventions.
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Keywords: Non-communicable diseases, interventions, programmes,
community-based
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4.1. INTRODUCTION
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Chronic non-communicable diseases are a major contributor to the burden
of disease in developed countries, and are increasing rapidly in developing
countries. It is predicted that globally, deaths from non-communicable
diseases (NCD) will increase by 77% between 1990 and 2020 and that most of
these deaths will occur in the developing regions of the world (World Health
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Organization, 2009).
The cost associated with these conditions to the individual, family and
society is enormous, and the burden that they impose is especially critical in
countries that are economically less well off (Sabri, 2009). Long-term
treatment of these conditions exerts pressure to the already overburden health
system and drain the workforce of manpower, as they affect people in their
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productive age.
Chronic non-communicable diseases are due to multiple preventable risk
factors, which operate at different levels, from the most proximal (i.e.
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biological), to the most distal (i.e. structural). These risk factors can be
classified according to ‗modifiable‘ and ‗non modifiable‘. Modifiable
determinants include factors that can be altered such as, individual and
community influences, living and working conditions and socio-cultural
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factors. On the other hand, non modifiable determinants include those factors
that are beyond the control of the individual such as age, sex and hereditary
factors. Modifiable biological risk factors include high blood pressure, high
blood cholesterol and overweight while major behavioral risk factors include
unhealthy diet, physical inactivity and tobacco use (Puoane et al. 2009).
There is strong evidence that showing that chronic non-communicable
diseases can be prevented through actions that seek to reduce the risk
Interventions to Prevent and Control of Chronic … 85
throughout the entire population. These programs address the causes rather
than the consequences of these conditions (World Health Organization, 2005).
Without action, it is estimated 388 million people will die from chronic
diseases in the next 10 years, and that many of these deaths will occur
prematurely, affecting families, communities and countries. Actions to prevent
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cardiovascular diseases now could result in the fulfillment of a global goal: an
additional 2% reduction in chronic disease death rates annually until 2015
(World Health Organization, 2002).
WHO recommends an integrated approach to respond not only to the need
of intervention on major common risk factors with the aim of reducing
premature mortality and morbidity of chronic non-communicable diseases, but
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also the need to integrate primary, secondary and tertiary prevention, health
promotion, and related programmes across sectors and different disciplines
(Xia et al. 2004).
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4.2. OBJECTIVES
1. To describe the types of interventions that is aimed at reducing the
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risk of chronic NCDs in populations
2. To identify strategies and programmes for control and prevention and
control of non-communicable diseases in South Africa
3. To describe some examples of intervention programmes to address
chronic non- communicable disease in Developing Countries
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programmes for prevention of in developing countries
4.3. METHODS
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Information for this chapter was gathered by means of literature review

using web-based database such as Google scholar, PubMed and MEDLINE as
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well as reviewing scientific book. Key words like ―community‖,

―intervention‖, ―programmes‖ non-communicable disease, cancer, diabetes,
obesity, nutrition, smoking, alcohol, schools, community, workplace, facility,
clinical, sub-Saharan Africa; were used during the web-based search. A
community-based intervention for non-communicable disease prevention and
control was defined as any primary prevention and secondary prevention
program that attempted to reduce the population burden of CVDs by
modifying at least one cardiovascular risk factor (i.e. blood pressure, smoking,
total blood cholesterol, physical activity, diet) and providing health services to
individuals who are already suffering from non-communicable diseases so as
to prevent further complications.
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4.4. RESULTS OF THE REVIEW
Programmes to prevent major chronic non-communicable diseases focus
on reducing the key risk factors in a well-integrated manner, and include:
school –based interventions, work place interventions, community-based
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programmes, and clinical/facility based interventions. These will be described
in the following paragraphs.
4.4.1. Interventions
School-Based Intervention O
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School-based programmes can be an efficient way of reducing risks for
chronic NCDs among large numbers of children. Various types of school –
based programmes are being implemented in developing countries to reduce
obesity, improve nutrition and increase physical activity. Although they vary
from one country to another, almost all include four basic components: health
policies, health education, supportive environments and health services The
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World Bank comparative public health interventions revealed that school

health programme are highly cost effective (World Health Organization,
2005).
One example of a successful programme is the China health-promoting
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school implemented in Zhejiang Province, which improved nutrition among

7500 students and their families and 800 teachers and school staff personnel.
The success of this programme lies in the involvement of target groups in
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planning, implementation and evaluation of the interventions. The programme

interventions lead to improvement nutrition knowledge, attitudes and
behaviour among the target groups (Xia et al, 2004; Glasauer et al. 2004).
Workplace Interventions
Workplace interventions for chronic disease prevention and control are a
feasible and often successful means of improving the health of employed
adults (World Health Organization, 2005). These interventions are often aimed
at reducing risk for chronic diseases that substantially inhibit productivity and
incur the most serious health and economic burdens. These interventions can
benefit in the short and long term both the employees and employers. They
often improve worker productivity, reduced levels of absenteeism, therefore
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save costs associated with absenteeism. Workplace interventions have the
added benefit of creating a workplace environment that is health-conscious,
providing for easier follow-up with participants. Successful workplace
interventions are those that address multiple risk factors for chronic diseases
with maximum worker participation. Such programmes allow employees to
decide what risk factors they want to improve and define their own goals
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(World Health Organization, 2005). An example of a successful workplace
intervention programme is the Johnson and Johnson‘s Health and Wellness
Program (Ozminkowski and Goetzel, 2002; Jacobson and Aldana, 2001)
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which demonstrated that a well-conceived health and wellness program that
focuses on prevention, self-care, risk factor reduction, and disease
management can produce substantial benefits for employers and their
employees.
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Community-Based Programmes
Community-based programmes for chronic non-communicable disease
prevention and control focus on risk factor reduction, community mobilization
and participation. Integrated community-based programmes aim to reach the
general population as well as targeting high-risk and priority populations in
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schools, workplaces, recreation areas, and religious and health-care settings.

They also enable communities to become active participants in decisions
concerning their health, and promote simultaneous use of community
resources and health services, as well as coordinating different activities by
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means of partnerships and coalitions. Community-based NCD programmes

should be planned, run and evaluated according to clear principles and rules,
collaborate with all sectors of the community, and maintain close contact with
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the national authorities The North Karelia Project in Finland is an example of

a successful community based, which during the first five years of the project
(1972-7) the programme effectively reduced the population mean values of the
major coronary risk factors. At 10 years the effects had persisted for serum
cholesterol concentrations and blood pressure and were increased for smoking
(Puska et al. 1983; Nissinen et al 2001)
Clinical/Facility Based Interventions

Facility based programmes are designed either to reduce the risk of
disease onset or to reduce complications of disease through early diagnosis of
an established NCD in people living with disease. These interventions include
medical and behaviour modification with the aim of reducing the risk of
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recurrent of NCD events in patients with established NCD. Guidelines for the
prevention and control of the most prevalent and relevant NCD conditions and
risk factors should be developed or adapted and regularly updated at the
national level (African Health Monitor, 2008).
The above strategies and actions to reduce the impact of chronic diseases
provide strong evidence that actions to prevent and control chronic non-
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communicable diseases have positive results. We can learn from these
interventions.
The next session will examine evidence –based strategies and
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interventions for non-communicable prevention in the South African context.
Selected intervention programmes will be presented including their strength
and weaknesses.
The programmes and prevention strategies are based on literature search
using Pub med and MEDLINE using subject heading ―community‖,
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―intervention‖, ―programmes‖ non-communicable disease. A community-
based intervention for non-communicable disease prevention and control is
defined as any primary prevention and secondary prevention program that
attempted to reduce the population burden of CVDs by modifying at least one
cardiovascular risk factor (i.e. blood pressure, smoking, total blood
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cholesterol, physical activity, diet) and providing health services in the

community.
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4.5. RESULTS SECTION

4.5.1. Strategies and Programmes for Control and Prevention
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and Control of Non-Communicable Diseases in South Africa
South African actions to prevent chronic non- communicable diseases

include (i) policy actions (ii) facility based and (iii) community based
interventions.
(i)Policy actions to prevent and control NCDs include putting the following
policies into place:
Alcohol Control
The Liquor Act (Act 59 of 2003) was formulated mainly to reduce the
socio-economic impact of alcohol abuse in South Africa, and to promote the
development of a responsible and sustainable liquor industry (Republic of
South Africa 2003).
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The Act prohibits advertising of alcohol in a manner that attracts minors
(The Department of Trade and Industry. National Liquor Authority, 2007)
Alcoholic beverages are heavily taxed ‗sin taxes‘ as a preventive measure to
alcohol abuse. Alcohol trading hours are also restricted including age limits of
persons who can purchase alcohol beverages.
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Food-Based Dietary Guidelines
The guidelines are used widely to disseminate educational messages
related to the prevention of chronic diseases, particularly the prevention of
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ischaemic heart disease and type 2 diabetes Barriers to the implementation of
such guidelines, including poverty, food insecurity and poor communication
skills of practitioners (Keller and Lang, 2007).
Tobacco Control
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The Tobacco Products Control Act (Act 83 of 1993) was amended in 1999
and 2007, and created one of the most effective tobacco control policies in the
world (Republic of South Africa, The Tobacco Products Control Act, 1993
and Republic of South Africa, Tobacco Products Amendment Act, 2007). The
Act protects children and adolescents, by banning advertising and also ensures
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the rights of non-smokers to a clean environment, unpolluted by tobacco

smoke. These actions have had an impact in reducing tobacco consumption in
South Africa. High prices of tobacco products have been used as a disincentive
to cigarette smoking. In addition, ‗sin taxes‘ for tobacco have increased every
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year as part of the policy for reducing the use of tobacco (Malan and Leaver,
2003).
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(ii)Facility based management of non-communicable diseases

The national Department of Health (NDoH) has put the control of chronic
non-communicable diseases as one of the priority areas to be strengthened in
their strategic planning goals for 2004-09 (Department of Health, Directorate
Chronic Diseases, 2006). National guidelines for control and management of
each condition (i.e. diabetes, hypertension and asthma) have been produced
and disseminated in all health facilities, to assist health workers in diagnosing
and treating these conditions.
(iii) Community-based interventions

Community-based interventions for chronic disease prevention focus on
risk factor reduction, community mobilisation and participation. Integrated
community-based programmes aim at reaching the general population, as well
as targeting high-risk and priority populations in schools, workplaces,
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recreation areas, and in religious and health care settings. They are
characterised by active community participation in planning and implementing
decisions concerning their health, resulting in empowerment and ownership of
the programmes. Evidence shows that population-wide approaches are not
only effective in reducing the risk among targeted population, but are also
suitable for resource constrained settings (Nissinen et al. 2001).
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4.6. SOME EXAMPLES OF INTERVENTIONS FOR CHRONIC
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NON-COMMUNICABLE DISEASE PREVENTION AND
CONTROL IN DEVELOPING COUNTRIES
Table 1 displays some of the interventions for prevention of chronic non-
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communicable disease in developing countries.
4.6. CONCLUSION AND RECOMMENDATIONS

The South African strategies for prevention and control of non-
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communicable diseases includes, implementation of policies for reducing

tobacco and alcohol use, facility and community-based interventions and
initiatives focusing in school children, and in adults at the workplace. The
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initiative to educate the public about risk factors, for example, South African
food-based dietary guidelines, have also been used widely to educate the
public about healthy living.
Secondary prevention approaches include identification of personal risk
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factors, individual management of risk, early diagnosis and appropriate

management of disease. Despite these initiatives, a range of improvements is
needed to the overall prevention control and management of non-
communicable diseases in South Africa:
 More workplace interventions to increase awareness in employees

about risk factors and prevention of NCDs, especially among the rural
population
 Routine screening for risk factors in all individuals in the health
services for early identification of those at risk and those who are
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already affected but do not present with the symptoms of the disease
yet
 The public should be educated about the need for routine physical
examination to detect disease early and initiate appropriate care.
 Strategies and programmes for prevention and control of NCDs
should involvement of other sectors (i.e.intersectoral collaboration).
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The problem of non-communicable diseases seems to be the problem
of the health sector alone, yet there are multiple factors that lead to its
development.
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 Policies to deal with trade in, and marketing of, certain products such
as processed foods and foods with high fat content.
 Improving the environment to make it easy for healthy choices.
 The curricula of nurses and doctors should be revised to include, a
comprehensive approach to the control of chronic non-communicable
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diseases. Priority should be placed on human resource development
for the prevention and control of chronic non-communicable diseases.
4.7. LIMITATIONS
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The initiatives and programmes presented in this chapter include only

published programmes. There are many other strategies and programmes that
are effective but may have been excluded because they are not published.
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ACKNOWLEDGMENT
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David Sanders and Lungiswa Tsolekile, School of Public Health,

University of the Western Cape, Bellville, South Africa
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Table 1. Some intervention programmes to address chronic non-communicable disease in Developing Countries
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Description of the intervention/program/study Strengths Weaknesses
Community-based interventions
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Community Health This program aims at promoting health through Some of the strengths for There is still need for
Intervention regular physical activity. It was developed by this program are that it expansion and outreach to more
Programme (CHIPs) 1 the Sports Science Institute of South Africa. It targets population at rural areas.
encompasses five components designed to different levels of the
address the needs of people at various levels. lifecycle and is very much
Healthnuts for children , comprehensive. The
Optifit outreach for adults, program has about 40
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Live it up for older adults, and branches, and thus far
Wakey-Wakey which is a group-based health trained more than 300
awareness program. leaders and impacted on
The theory behind these programs is that 8685 individuals.
prevention of chronic diseases can be achieved
education to increase awareness about risks
associated with chronic non-communicable
diseases, as well as the need for regular
physical activity.
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Tobacco control in the In the Philippines, a number of laws and
Philippines 10 regulations have been instituted to control
tobacco smoking.
In 1990 the Philippines Clear Air Act was
instituted. This Act aims at establishing
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designated smoking areas in restaurants and
other indoor areas. This act also imposes taxes
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on cigarettes.
In 2003 a tobacco Regulatory Act was
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instituted with an objective to increase public
education measures, ban all tobacco
advertising, encourage tobaccos manufacturers
to place warning labels on tobacco products,
and prohibit tobacco sales to minors.
During the same year, a school based
intervention was initiated to promote smoke
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free environments around campuses as well as
to foster training for students and teachers
about the dangers of smoking. Levied penalties
for smoking were also established.
All these interventions are reportedly
considered successful in reducing the
prevalence of smoking in the Philippines. A
significant drop in the number of students who
reported being current cigarette smokers or
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using other tobacco products over the period
2000-2003 was realized. The percentage of
students who had never smoked but were likely
to begin smoking in the next year also
decreased from 27% in 2000 to 14% in 2003.
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Table 1. (Continued)
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Soul city health This program used television soap series disseminate The strengths of this The program has poor
promotion program 2 messages pertinent to both undernutrition and particular program emanate sustainability as it is not
overweight. The aim of this programme is to increase from its nation-wide coverage broadcasted on a regular basis.
awareness health related issues to specific groups, using mass media (both radio Although the program targeting the
particularly low income groups. The program also and television). community it still does not embrace
had coverage on radio to cater for those without sufficiently the aspect of
access to television. community involvement.
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The program is not a
Promoting physical This is a multilevel physical activity intervention that standalone intervention. It is
activity in Brazil 11 was designed for the 34 million citizens of Brazil‘s closely linked to the national
Sao Paulo state. The program was launched in 1996 program to promote healthy
to increase awareness among the public on the diets in schools,
benefits attached to exercise. It also aimed at communication of guidelines
expanding fitness activities by encouraging the for healthy eating, and
public to do 30 minutes of moderate physical activity encouragement of innovative
at least five times a week. Three settings were chosen community-based initiatives.
for promotion of physical activity: home, After four years of its
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transportation and leisure time. Agitol, a prescription inception, 55.7 percent of
for exercise, was developed for physicians to those surveyed had heard
dispense about the program, 37 percent
knew its purpose, and those
who knew of the program's
purpose were more likely to
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be active (Matsudo et al.
2002)
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Vuka South Africa Move The use of a multisectoral There is still a need for expansion
for your health 3 This is a government initiative aimed at promoting approach involving the and outreach to more rural areas.
healthy lifestyle through educating individuals on the Department of Education and
health and fitness benefits of exercise and to promote Sport and Recreation,
the implications of physical activity programmes. stakeholders from various
The core message of Move for Health is to centres of higher learning,
encourage individuals to accumulate 30 minutes of The private sector, non-
moderate physical activity on most days of the week. governmental and community
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The program came about in 2005 as a joint initiative based organisations.
from the department of education, sports and
recreation, the civil society and other stakeholder
from higher learning institutions.
Promoting Healthy A community-based project to increase community Ssustainability of the Since the CHWs participate in the
Lifestyles: A Community awareness about primary prevention of Chronic programme is maintained by running of this intervention
Health Workers Diseases was implemented in Khayelitsha, a poor CHWs who reside in the program on voluntary, once they
Intervention Programme urban township of Cape Town. This intervention was township in which the find paid employment elsewhere
for Primary Prevention of initiated in response to a request from some members programmes is implemented they stop volunteering
NCDs in Khayelitsha of the community who had noticed an increased
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Township, Cape Town 4 number of people suffering from diabetes and
hypertension in the township and to implement the
WHO global strategy for prevention and control of
chronic diseases
Workplace interventions
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Chronic disease risk This was implemented by the Exercise Science and Early determination of the Employees volunteer to participate
factors, healthy days and Sports Medicine at the University of Cape Town in health and risk status of in the wellness days, thus the
medical claims in South collaboration with the Medical Research Council in employees which could results may be biased towards those
African employees Tygerberg. South Africa. assist in identifying the willing to participate
presenting for health risk It involved employees from 18 companies who were appropriate interventions to
screening 5 invited to take part in a wellness day, which included reduce the risk of NCDs
a health-risk assessment. Self-reported health among employees
behaviour and health status was also recorded.
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Clinical measures included cholesterol finger-prick
test, blood pressure and Body Mass Index (BMI)
School-based interventions
Woolworth Health This program was initiated in conjunction with the Involvement of the whole There is still need for expansion of
Promotion Program 6 Department of Education, Woolworths and Sports family, that is children, the program coverage in order to
Science institute of South Africa. The program entails caregivers, parents and cater for individuals in remote areas
outcome-based education, interactive classroom teachers about some of the
activities and workshops with parents in order to ways to adopt physical The use of digital media may not
improve the lifestyle and wellbeing of young learners activity as part of daily be feasible in poor settings where
as well as their communities. The program utilized a routine activity.. the majority can not afford or able
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nutrition education approach and creative methods to to utilize this kind of technology.
involve children in regular physical activities.
The program also employs
creative methods of physical
exercise which makes the
experience more fun and
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accessible.
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The school-based The school-based nutrition and physical activity Educators were actively He programme included only
nutrition and physical (NAP) intervention was developed and designed engaged in practical selected schools that had
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activity (NAP) to introduce various methods of physical sessions and at the end acquired Health-Promoting
intervention in activity and healthy nutritional habits within the they were provided with School status.
KwaZulu Natal, South school‘s existing curriculum. Classroom-based booklets containing
Africa 7 intervention materials were developed to classroom based physical
provide cost-effective and, more importantly, a activities.
sustainable intervention. The intervention School staff were also
incorporated the following steps: actively engaged in
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Curriculum training, to provide grade dialogues aimed at
appropriate learning materials containing transforming the food
information on nutrition and physical activity. environment within
Nutrition, the focus of which was to promote schools for example a
availability of healthy food and decrease nutrition policy aimed at
availability of unhealthy food products. banning fizzy drinks in
School policies, to promote a health promoting schools.
environment in the schools through physically
active and healthy learners, educators and
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principals.
Facility/clinic-based programs
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The South African This program was adapted from an Australian- The long term benefits of Very little has been achieved in
Chronic disease based outreach program which ran under the this program would be the area of education and focus
outreach primary banner of KDRP, Kidney Disease Research and cost effective on the part groups on weight reduction.
prevention program 8 Prevention (which later on changed to become of the government. This is partly ascribed to failure
the Chronic Disease Outreach Program). The to adopt systematic, dynamic,
program involves mass community screening to The program is sustained and flexible
detect high-risk groups and providing treatment computerized and this approaches to disseminating
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The program offers services to reduce the renders monitoring and information to patients regarding
harmful effects of chronic lifestyle diseases, evaluation more weight reduction and benefits
particularly diabetes, high blood pressure and effective. attached to this.
kidney disease. The elements of the program Shortages of trained staff to run
that were adapted by South Africa include the the program.
following:
Regular testing of all adults for chronic disease
and risk factors and treatment for those in need
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Primary health care clinicians follow algorithms
for testing and treatment
Use of a limited number of medicines to
maximize familiarity and to save costs
Nurse coordinators provide backup, from a
distance, so that one serves several
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communities/regions
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Doctors provide backup for problematic cases

and treatment questions, so that one can serve
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an entire region
Maximum use of telephone, fax, e-mail and web
for communications
Computerized database
Constant evaluation of individual profiles,
community profiles, processes and outcomes
Non-communicable A district NCD programme which came into The use of existing
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disease management in existence in 1993 following a reassessment of primary health care
resource-poor settings: NCD management by patients and health services to incorporate
a primary care model workers. the management of
from rural South The objectives of the programme were: patients with NCDs
Africa: Hlabisa district To develop diagnostic and treatment algorithms Involving the patient in
in Kwazulu Natal 9 that enable nurses to manage most patients with agreeing to the acceptable
NCDs; treatment regimen greatly
To transfer patients to their local village clinic improved the adherence
for continued NCD care; and with treatment
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To improve patient-reported adherence to
treatment.
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Improving diabetic A ―crusade for the quality of health services‖
care in Mexico 10 was initiated by the Mexican Secretariat of the
health to improve better health care for people
with chronic diseases. The program started with
a one year pilot project to conduct an in-service
training of primary care personnel and
implement a structured diabetes education
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program. Training involved improving skills of
primary health care staff so as to enable them to
adopt a quality improvement methodology. The
intervention involved: the organization of
diabetes clinics, collective medical visits for
self-support groups of people with diabetes, and
training people with diabetes to be community
health workers.
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There was a 287% to 39% increase in the
number of people with diabetes and good
control in the intervention group. On the other
hand, the group that received usual care had
realized a relatively slight increase of 21% to
28%. There was also more improvement in the
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proportion of patients using insulin in the
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intervention group than the control and foot care

education increased by 76%.
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1) (Sports Science Institute of South Africa. Outreach, 2008)
2) (Soul City. Soul City Series 4, 2008)
3) (Department of Health, University of Cape Town and World Health Organization, 2005).
4) (Puoane et al. 2007)
5) (Kolbe et al. 2008)
6) (Quaide, 2008; Lambert et al. 2001).
7) (Naidoo et al. 2008).
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8) ( Katz et al. 2006)
9) (Coleman et al. 1998)
10) (WHO, 2005)
11) (Matsudo et al. 2002
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1999). Government Gazette 406 (No.19962). available from URL:
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Republic of South Africa. Tobacco Products Amendment Act (Act 23 of

2007). Government Gazette 512 (No. 30821). URL: http://www.info.
gov.za /gazette/acts/2007/a23-07.pdf
Sabri, B. (2007). Health, poverty and development WHO EMRO. Eastern
Mediterranean Health Journal. 13(6): available from: Available from:
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on 2009 Apr 23]
Soul City. Soul City Series 4 - The Story. Available from: URL:
www.soulcity.org.za/programmes/the-soul-city-series/soul-city-series-4/
tv-story [accessed on 2008 Apr 23].
Sports Science Institute of South Africa (2007). Outreach: Community Health
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Intervention Programme (CHIPs).Available from: URL: http://www.ssisa.
com/index.asp [accessed on 2008 Apr 23].
Strategic Perspectives for Preventing and controlling non-communicable
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Diseases in Africa, African Health Monitor January-June (2008).
Available from: indexmedicus.afro.who.int/iah/fulltext
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Information Circular 2. c2007Available from URL: http://www.thedti.
gov.za/nla/CHILDRENTHELIQOURACT.pdf. Accessed on 2008 May
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Tobacco Products Control Act 83 of 1993 available from : 752005213029_
257.pdf
WHO (2009). Action Plan for the Global Strategy for the Prevention and
Control of non-communicable Diseases: 2008-2013 Available from:
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http://www.who.int/nmh/Actionplan-PC-NCD-2008.pdf [Accessed on
2009 April 2]
WHO. (2002). The World Health Report 2002: "Reducing Risks, Promoting
Healthy. Available from: Life"www.who.int/whr/2002/en/
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WHO. (2005). Preventing Chronic Diseases. A Vital Investment: WHO Global

Report.Geneva: World Health Organization. Geneva, Switzerland.
Xia, S.C.,; Zhang, X.W.; Xu, S.Y.; Tang, S.M.; Yu, S.H.; Aldinger, C. et al.
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(2004). Creating health-promoting schools in China with a focus on

nutrition. Health Promotion International 19: 409-418.
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Chapter 5
PUBLIC HEALTH IMPLICATIONS OF NON-
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COMMUNICABLE DISEASES (NCD) IN
DEVELOPING COUNTRIES
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Laetitia Rispel,Geoffrey Setswe and Debashis Basu
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ABSTRACT
Background: Non-communicable diseases (NCDs) constitute a
growing public health problem and are one of the most neglected areas of
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public health in developing countries.

Objectives: To review public health implications of NCD and to
determine what public health measures can prevent or delay the
development of these diseases.
Methods: A systematic review was conducted in several databases to
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locate studies relevant to NCDs in developing countries.

Results: In 2005, there were 28 million annual deaths from NCDs in
developing countries, the majority due to cardiovascular disease, cancer,
chronic lung diseases and diabetes mellitus. The number of chronic
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diseases is greatest in adults aged 30-59, with similar disease rates in men
and women.

Corresponding author: Professor Laetitia Rispel, Centre for Health Policy, School of Public
Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South
Africa, Street Address: Centre for Health Policy, Physical Education Building Enoch
Sontonga Road, Gate 9, West Campus Wits University, Braamfontein, 2050. Postal
Address: Centre for Health Policy, Physical Education Building, Private Bag X3, Wits,
2050, Phone:+27 11 717 3436, Fax: +27-11-717 3429, Email:laetitia.rispel@wits.ac.za.
106 Laetitia Rispel, Geoffrey Setswe and Debashis Basu
Conclusions: A public health response includes an enabling policy

environment supportive of NCD prevention and control; prioritisation of
appropriate health services, addressing social determinants of health; and
surveillance, monitoring and evaluation for advocacy, policy
development and action.
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Keywords: non-communicable diseases; public health; developing
countries; chronic diseases
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5.1. INTRODUCTION
―African countries have the opportunity to learn from the mistakes made
in developed countries and to act early before the growing ‗epidemic‘ of non-
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communicable disease gets out of control. Governments need to shift their
main public health focus to include preventative measures that can be applied
to the whole population. A coherent government-led strategy including
legislation, regulation, protection of human rights, and education of the
public is needed‖ (WHO, 2006: 77).
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Non-communicable diseases (NCDs) and injuries constitute a growing
public health problem, but at the same time represent one of the most
neglected areas of public health in developing countries (Bousquet et al, 2005;
WHO, 2006; WHO, 2008a). This chapter focuses on NCDs i.e. diseases or
conditions that affect, individuals over an extended period of time and for
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which there are no known causative agents that are transmitted from one
individual to another (Global Alliance for Chronic Diseases, 2009). In 2005,
cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases,
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caused an estimated 35 million deaths worldwide (WHO 2005; WHO 2008a)

and these diseases constitute the major focus of the chapter.
WHO projections show that NCD deaths will increase by 17% over the
next ten years, with the largest increase in the African region (27%) and the
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Eastern Mediterranean region (25%) (WHO, 2005). The global response to

NCDs remains inadequate despite growing evidence of their epidemiological
and economic impact (Yach et al, 2004; WHO 2008a). It has been argued that
attention to ‗chronic diseases‘ has to come on top of an ‗unfinished agenda‘ of
communicable diseases, and maternal, newborn and child health (WHO,
2008b) and that addressing NCDs will lead to major health gains worldwide
(Nissenen et al, 2001).
Public Health Implications of Non-Communicable Diseases … 107
This chapter analyses the public health implications of NCDs in

developing countries, and is based primarily on a review of the literature. The
term ‗public health‘ refers to the art and science of preventing disease;
protecting individuals and populations from hazards; prolonging life; and
promoting and improving health through organised efforts of society (Nuffield
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Council on Bioethics, 2007; National Institute for Health and Clinical Ethics,
2009). Section 1 sets the scene for the chapter, while section 2 summarises the
methods used. The results section highlights available information on the
burden of NCDs in developing countries, presents a conceptual framework for
examining the public health implications of NCDs is presented, taking into
account the drivers of NCDs and in order to inform appropriate public health
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action for NCD prevention and control. Section 4 summarises the key public
health implications and interventions needed to mitigate common NCD risks
and to address the growing problem of NCDs in developing countries.
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5.2. METHODOLOGY
Different sources of published and unpublished research literature were
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searched to locate studies relevant to NCDs in developing countries. These
include scientific manuscripts, reports, and chronic disease and surveillance
and public health related books.
The search included an iterative process using various combinations of the
following key words: non-communicable, chronic disease, public health
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implications; surveillance, developing, cancer, diabetes, obesity, heart disease,

hypertension, nutrition, physical activity, smoking, alcohol, demographic
surveillance systems, demographic health surveys, burden of disease, health
services and monitoring and evaluation. Electronic databases that were
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searched include WHO Library and Information Networks for Knowledge

Database (WHOLIS) (1990 to December 2008); Google scholar (1990 to
December 2008); PubMed (1990 to December 2008) and Medline (1990 to
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December 2008). However, the literature review was neither systematic nor
exhaustive.
5.3. RESULTS
5.3.1. The Public Health Burden of NCDs in Developing
Countries
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Although there are relatively few published studies to estimate the
prevalence and incidence of NCDs in developing countries, all point to the
increase in the prevalence of NCDs in these countries where an estimated 28
million people die annually from NCDs (Yach et al, 2004; WHO, 2005;
Mayosi et al, 2009).
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Figure 1 shows the projected main causes of global burden of disease
measured in disability adjusted life years (DALYs), which combines the
number of years of healthy life lost to premature death with time spent in less
than full health (WHO, 2005). As can be seen, almost half of the global
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disease was caused by chronic diseases, with cardiovascular diseases as the
leading contributor (WHO, 2005: 39). The number of DALYs caused by
chronic diseases is greatest in adults aged 30-59, with similar disease rates in
men and women (WHO, 2005: 40). In 2005, in all World Bank income groups,
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chronic diseases were a major contributor to disease burden (WHO, 2005: 43).
It has been suggested that developing countries will struggle
concomitantly with the unfinished agenda of communicable diseases such as
HIV & AIDS, malaria and tuberculosis and a major increase in NCD disability
and premature mortality in the next two decades, (Lucas, 2006; Mulligan et al,
2006). Both China and India have witnessed huge increases in age-specific
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death rates from common chronic diseases (Yach et al, 2004; WHO, 2005). By
2030, the absolute number of people with diabetes is expected to increase from
2.8% to 6.5% of the world‘s population and more than 80% of these
individuals will live in developing countries (Yach et al 2004; WHO, 2005).
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Similarly, cancer incidence and death and disability due to chronic obstructive
pulmonary disease are increasing across most regions (Yach et al, 2004;
WHO, 2005).
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With the exception of the Africa region where HIV & AIDS dominated,
chronic diseases accounted for the major burden of disease in 2005 (WHO
2005: 42).Causes of death in African demographic surveillance sites continue
to differ from those in Bangladesh, where there was some evidence of a health
transition from communicable diseases to NCDs, whereas in the African sites,
HIV continues to dominate (Adjuik et al, 2006). However, NCDs such as
stroke, diabetes, cancer and heart disease are becoming increasingly common
throughout the WHO‘s African Region (WHO, 2006). In 2002, NCD and
injuries accounted for 27% of the Africa Region‘s total disease burden (WHO,
2006).
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Source: WHO 2005: 39.
Figure 1. Projected main causes of global burden of disease (DALYs), worldwide, all
ages, 2005.
In sub-Saharan Africa, the burden of NCDs is likely to increase hugely

over the coming decades, with projections suggesting that by the year 2020 the
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proportion of the overall NCD burden will increase to between 26% and 34%,
and among adults aged 15– 59 years to between 37% and 42% (Unwin et al,
2001). In the Africa region, the prevalence of hypertension ranges from 25%
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to 35% in adults aged 25–64 years, with people living in urban areas at greater
risk of cardiovascular diseases than those in rural areas (WHO, 2006).
Epidemiological data from at least two African countries suggest that in
predominantly urban areas there has been a marked increase in diabetes and
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hypertension over the past 5–10 years (Unwin et al, 2001). In Nigeria, a
community-based survey of the prevalence of selected chronic diseases drew
attention to the growing threat of diabetes, cardiovascular diseases and other
chronic diseases (Lucas, 2006: 4).
NCDs are the largest cause of death in the world, with the majority due to
cardiovascular disease, cancer, chronic lung diseases and diabetes mellitus
(Yach et al, 2004; WHO, 2005; WHO, 2008a). Eighty percent of deaths due to
NCDs occur in low- and middle-income countries, with a disproportionate

burden on poor and disadvantaged populations, thus contributing to widening
health gaps between and within countries (CSDH, 2008; WHO, 2005). The
mortality from ischaemic heart disease is expected to increase by more than
100% in developing countries in the 30 year period between 1990 and 2020
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(Yach et al, 2004).
In sub-Saharan Africa, the probability of death from NCDs was higher
than in established market economies (Unwin et al 2001), with NCDs
accounting for 15–25% of all adult deaths (i.e. in persons aged 15–59 years) in
the Tanzanian areas covered by the demographic surveillance system (Unwin
et al, 2001). In South Africa, the mortality profile reveals a quadruple burden
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of disease consisting of HIV & AIDS, chronic diseases, poverty-related
conditions and injuries. After HIV & AIDS deaths (29.8%), cardiovascular
disease (16.6%), infectious and parasitic diseases (10.3%), malignant
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neoplasms (7.5%), intentional injuries (7.0%) and unintentional injuries
(5.4%) were the leading cause of death in 2000 (Bradshaw et al, 2003).
A study on trends in age-specific mortality in a rural South African
population from 1992 to 2003, found significant increases in mortality for both
sexes since the mid-1990s, a decline in life expectancy and a ‗‗protracted
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transition‘‘ with simultaneous emergence of HIV & AIDS together with
increasing non-communicable disease in older adults (Kahn et al, 2007).
In the urban province of Gauteng, an annual reported incidence of diabetes
of 112 per 100,000 and of hypertension of 200 per 100,000 was found in 2008
in the population 45 years and older (Gauteng Department of Health, 2008).
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These figures are comparable to those found in developed countries. A

community based screening programme found 7.1% undiagnosed diabetes,
which implies a possibly higher magnitude of the problem.
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5.3.2. Risk Factors

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The causes of the main chronic disease epidemics are known, and the
most important modifiable risk factors are unhealthy diet and excessive energy
intake; physical inactivity and tobacco use.
These causes are expressed through the intermediate risk factors of raised
blood pressure, raised glucose levels, abnormal blood lipids and overweight
(body mass index ≥25 kg/m2) and obesity (body mass index ≥30 kg/m2)
(Nissenen et al, Yach et al, 2004; WHO, 2005; WHO, 2006; WHO 2008a).
This is illustrated in Figure 2.
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Under-lying Common modifiable Inter-mediate Main chronic
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determinants risk factors risk factors diseases
 Globalization  Unhealthy diet  Raised blood pressure  Heart disease
 Urbanization  Physical inactivity  Abnormal blood glucose  Stroke
 Population ageing  Tobacco use  Abnormal blood lipids  Cancer
 Policy environment Non-odifiableRisk  Endicrinopathy  Chronic respiratory
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Factors  Overweight/obesity  diseases
 Osteoporosis
 Age  Diabetes and other
 Heredity endocrine and metabolic
diseases
Source: WHO 2005:48.
Figure 2. Causes of chronic diseases.
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The dietary transition in developing countries is linked to social and

economic changes, including globalisation, migration and urbanisation, new
food items, new marketing methods and new dietary habits such as eating
outside the home and snacking (Pekka et al, 2002). The WHO Africa Region
has seen an alarming increase in obesity since the early 1990s (WHO, 2006).
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The trend towards an unhealthy diet rich in saturated fat, sugar and salt and
poor in fruit and vegetables- termed an African paradox- means that in some
countries, such as South Africa and Kenya, children are overweight but
malnourished because they receive excessive calories but insufficient
necessary nutrients to grow into healthy adults (WHO, 2006). Obesity is a
major risk factor for type-2 diabetes, and in Mauritius and Seychelles almost a
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quarter of middle-aged people are affected (WHO, 2006).
A South African review and analysis of secondary data over time relating
to diet, physical activity and obesity found that there have been negative shifts
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in dietary intake occurring with apparent increasing momentum among black
South Africans who constitute three-quarters of the population (Bourne et al,
2002). Among urban black South Africans, fat intakes have increased from
16.4% to 26.2% of total energy (a relative increase of 59.7%), while
carbohydrate intakes have decreased from 69.3% to 61.7% of total energy (a
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relative decrease of 10.9%) in the past 50 years (Bourne et al, 2002).
Cancer is the second leading cause of morbidity and mortality due to
NCDs (Yach et al, 2004; WHO, 2005; WHO, 2006). Tobacco use is the single
largest causative factor, accounting for about 30% of all cancers in developed
countries and an increasing number in the developing world (Yach et al, 2004;
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WHO, 2005; WHO, 2006). In Africa, there were 200 000 tobacco-related
deaths in 2000 (WHO, 2006). The prevalence of tobacco use was 29% in
males and 7% in females in 2000. The Global Youth Tobacco Survey showed
that smoking in 13–15-year-olds ranged from 13% in Kenya to 33% in Uganda
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(WHO, 2006).
The estimated annual number of deaths due the main risk factors is shown
in Table 1 below.
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5.3.3. Conceptual Framework for Public Health and NCDs
The classical public health model of disease causation has been that of
agent (e.g. mycobacterium tuberculosis), host (the individual) and
environment (Mausner and Kramer, 1985:33). However, this model is best
suited to infectious diseases with bacterial causes (Mausner and Kramer,
1985:33). Over the years, new models have been developed that stress the
multiplicity of interactions, including the web of causation, the wheel model of
human-environment interactions; the stewardship model of public health, and
the 2008 model of the Commission on Social Determinants of Health that
emphasises the influence of social factors affecting health and health equity
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(Mausner and Kramer, 1985; Nuffield, 2007; CSDH, 2008; NICE, 2009). The
public health NCD conceptual framework proposed in this chapter (Figure 3)
combines NICE‘s framework for public health guidance (2009), Nuffield‘s
stewardship model (2007) and the WHO‘s action plan (WHO 2008a).
Table 1. Estimated annual number of deaths due to risk factors
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Risk factors Annual number of deaths
Tobacco use 4.9 million
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Physical inactivity 1.9 million
Low fruit and vegetable consumption 2.7 million
Overweight or obesity 2.6 million
Raised blood pressure 7.1 million
Raised blood cholesterol 4.4 million
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Source: WHO 2005: 52.
Enabling policy environment: Provides guidance for policy, legislative

and financial measures to ensure an environment supportive of NCD
prevention and control
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Individual factors include genetics, age, behaviour, occupation, etc. The

model implies measures to reduce the level of exposure of individuals to the
common risk factors for NCDs, namely tobacco consumption, unhealthy diet,
physical inactivity, and to improve working conditions and their determinants
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through inter alia the provision of information and advice at an individual level
Population factors: Reduce the level of exposure of populations to the
common risk factors mentioned above for NCDs, namely tobacco
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consumption, unhealthy diet and physical inactivity, and their determinants

through community/ population-based campaigns to provide information and
advice, and programmes and opportunities to help people overcome addictions
and other unhealthy behaviours.
Figure 3: The public health NCD conceptual framework
Enabling
policy
environment
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Population
level factors Surveillance,
Socio- Individual factors
cultural
Monitoring and
factors Evaluation
Organisational level
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factors
a
Sources: AdaptedSources:
from:Adapted from: Nuffield
Nuffield (2007); (2007);
WHOWHO 2008 ; NICE (2009)
2008a; NICE (2009).
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Figure 3. The public health NCD conceptual framework.
Organisational (health system) response: Ensures that prevention is

prioritised, that people have access to appropriate package and level of health
care services; and provides norms and guidelines for integrated cost-effective
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NCD interventions, including human and financial resources.
Socio-cultural response: Includes action to address social attitudes and
inequities due to gender or migrancy.
Surveillance, monitoring and evaluation: Provides the foundation for
advocacy, policy development and action, and includes information on disease
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prevalence, trends and determinants, as well as evaluation of action or

interventions and is a cross-cutting issue.
Although these areas overlap, each of these is discussed separately in
section 4 below.
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5.4. PUBLIC HEALTH IMPLICATIONS OF NCDS

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IN DEVELOPING COUNTRIES
5.4.1. Enabling Policy Environment
Analysts have pointed out that failure to take action on NCDs, particularly
in sub-Saharan Africa would mean that the development of effective public
health measures for preventing and managing these diseases will be
compromised (Unwin et al, 2001; Yach et al 2004). Such inaction would have
several negative consequences, including uncontrolled marketing of health
damaging products, such as tobacco, continued growth in clinical services for
NCDs which may not necessarily be clinically or cost-effective and which
exacerbate health inequities (Unwin et al, 2001). Hence, policymakers face the
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twin challenge of implementing policies that support economic development
while simultaneously taking action against consumption of tobacco, excessive
alcohol, and foods high in fat and sugar (Yach et al, 2004).
In public health terms, an enabling policy environment implies a focus on
the upstream causes of chronic diseases, including reorienting efforts within
the health sector, inter-sectoral collaboration and engaging civil society in
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mainstreaming health into all public policies (CSDH, 2008). One of the most
effective measures that governments can take to prevent chronic diseases is to
control the marketing of tobacco, alcohol, and salty, sugary and fatty foods
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(Yach et al, 2004; WHO, 2005; WHO, 2008c).
It has been argued that the reduction of tobacco use is a top priority for
public health and for political leaders in every country of the world (Chan,
2008). Tobacco use is a risk factor for six of the eight leading causes of death
in the world, and is the leading preventable cause of death in the world (WHO,
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2008c). The most effective intervention against tobacco use is a combination of
tobacco taxation, bans of tobacco sales to teenagers, comprehensive bans on
advertising and dissemination of health information on the dangers of smoking
(Mulligan et al, 2006; WHO, 2006; Jamison et al, 2006). WHO has proposed
the MPOWER package of six proven policies to deal with the harmful effects
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of tobacco (Box 1).
Box 1. WHO’s MPOWER plan to reduce tobacco use and save lives
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 Monitor tobacco use and prevention policies,

 Protect people from tobacco smoke
 Offer help to quit tobacco use
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 Warn about the dangers of tobacco,

 Enforce bans on tobacco advertising, promotion and sponsorship
 Raise taxes on tobacco.
Source. WHO 2008.
Globally, there have been encouraging developments such as the

ratification of the 2003 WHO‘s Framework Convention on Tobacco Control,
increase in tobacco taxes, establishment of smoke-free public places,

mandated health warnings on tobacco packs and prohibition on tobacco
advertising (WHO 2008c). Box 2 below shows the progress that can be made
when there is political will and legislative measures to control the tobacco
industry.
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Box 2. Learning from South Africa’s experience of Tobacco Control
1. The South African Tobacco Control Amendment Act provides for the
prohibition of:
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 advertising and promotion of tobacco products
 advertising and promotion of tobacco products in relation to
sponsored events
 free distribution of tobacco products
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 Receipt of gifts or cash prizes in contests, lotteries or games to or by
the purchaser of a tobacco product in consideration of such purchase.
2. The Act also provides for the prescription of maximum yields of tar,
nicotine and other constituents in tobacco products
3. In 1994, the government also imposed a tax increase on tobacco products
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amounting to 50% of the retail price. This action, combined with overall
price increases, has doubled the price of tobacco products over a decade.
4. Tobacco control legislation together with tax increases have resulted in a
reduction in smoking prevalence.
 Among adults surveyed, smoking prevalence declined from 34% in
1996 to 24% in 1998.
 Similarly, the proportion of school children reporting first smoking
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cigarettes before the age of 10 declined from 18.5% in 1999 to 16.2%

in 2002.
 Cigarette consumption fell by 5% to 7% for every 10% increase in the
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price of cigarettes, resulting in a sharp decline in consumption, with

the largest smoking decreases among the young and the poor.
Sources: Tobacco Products Control Amendment Act, No. 12 of 1999; WHO, 2006;
WHO, 2008.
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There is global recognition that obesity is one of the most challenging

health concerns, largely related to changing consumption patterns, nutrition
transition in urban areas and reduced physical activity, exacerbated by poor/
inappropriate urban design, safety concerns and poor socio-economic
conditions (CSDH, 2008). It has been argued that obesity prevention and
reduction of existing levels require multi-sectoral approaches that include an
ecologically sustainable, adequate, and nutritious food supply; material
security; healthier food options; ability to participate in physical activity; and a

family, educational, and work environment that positively reinforces healthy
living and empowers all individuals to make healthy choices (Friel et al, 2007)
Another public health intervention is the reduction in salt consumption
through simple changes in diet - such as avoiding salty food and not adding
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salt at the table (Asaria et al, 2007). Such a reduction could be achieved by a
voluntary reduction in the salt content of processed foods and condiments by
manufacturers, plus a sustained mass-media campaign aimed to encourage
dietary change within households and communities (Asaria et al, 2007).
Modelling of the effect of a 15% reduction in salt consumption on blood
pressure in 23 low-income and middle-income countries that account for 80%
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of the burden of chronic diseases in developing countries showed that over 10
years (from 2006 to 2015) 8.5 million deaths could be averted at a relatively
low cost of less than one US dollar per person per year in developing countries
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(as of 2005) (Asaria et al, 2007).
5.4.2. Individual and Population Level Action

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Individual and population level action includes public health action to
reduce the level of exposure of individuals and populations to the common risk
factors for NCDs, namely tobacco consumption, unhealthy diet and physical
inactivity, and their determinants, and possibly continual stress through inter
alia the provision of information and advice, and programmes and
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opportunities to help people overcome addictions and other unhealthy

behaviours (WHO, 2005). In the case of nutrition change, it has been pointed
out that community members need: information on the links between, for
example, diet and health; clear messages about the practical and culturally
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appropriate means to change their diet; and the skills to make the needed
changes and a combination of creative mass media strategies (Puska et al,
2002).
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The experience of North Karelia in Finland over a 25 year period has

shown that epidemiological information on prevalence and risk factors
combined with carefully planned community-based programmes, including re-
orientating health and other services, school-based programmes, innovative
media campaigns and inter-sectoral action to address modifiable risk factors
were critical in achieving the reduction in chronic disease mortality and their
risks (Puska, 2002). Legislation and other public policy have supported the
developments, which have been monitored carefully (Puska, 2002). The

experience is captured in Box 3.
Box 3. Learning from 25 year experience of preventing NCDs in North

Karelia, Finland
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 A comprehensive community-based prevention programme was
implemented in 1972 in response to the exceptionally high coronary heart
disease mortality rates in the area.
 Communities were integrally involved and stakeholders included local
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and national authorities, experts and the World Health Organization.
 Comprehensive activities included health and other services, schools,
NGOs, innovative media campaigns, collaboration with the food industry
and agriculture reforms.
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 Smoking has greatly reduced from 52% among middle-aged men in 1972
to 31% in 1997.
 Dietary habits have changed from about 90% of the population reporting
that they use mainly butter on bread in 1972 to less than 7% currently.
The dietary changes have led to about 17% reduction in the mean serum
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cholesterol level of the population.
 Elevated blood pressures have been brought well under control and
leisure time and physical activity has been increased.
 By 1995, there had been a 73% reduction in the annual mortality rate of
coronary heart disease in the male population younger than 65 years in
North Karelia, with a an 8% average annual decline in CHD mortality in
North Karelia.
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 Lung cancer mortality has also reduced, more than 70% in North Karelia:
and nearly 60% in the whole of Finland.
 A comprehensive monitoring and evaluation system was part of the
programme.
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Source: Puska, 2002; Puska et al, 2002.

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The Italian experience, which includes the introduction of organic food

into school meals, a sustainable food system in the countryside, supporting
local economies, promotion of healthy eating habits in young children, have
led to improved attitudes towards healthy diets, and has also increased
consumer awareness of environmental issues (Prince Mahidol Conference,
2009).
Similarly, there have been encouraging and innovative experiences in
developing countries (WHO, 2008a). In Thailand, the Thai Health Promotion
Foundation (ThaiHealth) was established in 2001 as a statutory, independent

public organization (WHO 2008a). Funding comes from a 2% excise tax on
alcohol and cigarettes. The main goal is to support activities that reduce NCD
risk factors and promote healthy behaviour, in collaboration with government
and community-based and non-governmental organizations. ThaiHealth has
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played a leading role in the movement against tobacco use, the campaigns to
prevent drunken driving and to reduce alcohol consumption, and activities to
promote physical activity (WHO 2008a).
Studies in India (Ramachandran et al, 2006) and China (Li et al, 2008)
have demonstrated the effectiveness of controlling progression to diabetes
from impaired glucose tolerance by behavioural interventions in comparison to
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drug treatment. However, easy availability of blood-glucose testing in primary
care setting to detect glucose intolerance is a key to the success of this type of
intervention. In many high-income countries, non-insulin-dependent diabetes
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is routinely managed in primary care, often largely by nurses. A similar
approach has been used for diabetes, hypertension, and asthma in rural South
Africa and resulted in successful control of the disorders in a high proportion
of patients (Coleman et al, 1998). Mexico provides an example of the
application of chronic disease management approaches to diabetes in a
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primary health-care setting (Pan American Health Organization, 2007). More
evidence of cost-effectiveness and sustainability of such approaches in low-
income and middle-income countries is needed.
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5.4.3. Health System Response
WHO framework on health systems suggests that the key building blocks
of a health system are: Service Delivery, Leadership and Governance; Human
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Resources; Finances; Information management; Medical products; and

Technology and Infrastructure (WHO, 2007). Globally, health systems are
largely built around an acute, episodic model of care (Nolte et al, 2008).
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Hence, the challenge facing health policy-makers today is how to re-orient

existing systems to meet the needs of people with complex chronic health
problems (Lucas, 2006; Nolte et al, 2008).The health systems of developing
countries, particularly in sub-Saharan Africa, are ill equipped to deal with the
demands of chronic disease care and treatment (WHO, 2005). Consequently
people die at younger ages than in high income countries, and individuals and
their families struggle to cope with the impact of chronic diseases, with a
disproportionate burden on the poorest (Unwin et al, 2001; Yach et al, 2004;
WHO, 2005).
A functioning health system is critical to both the effectiveness of any
NCD public health or treatment intervention (Jamison et al, 2006; Lucas,
2006) and countries can obtain greater efficiency from their health systems by
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combining disease management for all chronic conditions in order to reduce
overlap and avoid fragmentation in the health system (WHO 2005). Such
programmes should:
 Focus on the common risk factors;

 Encompass health promotion, disease prevention, and control
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strategies;
 Emphasize population level interventions;
 Integrate across settings, such as health centres, schools, workplaces
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and communities;
 Make explicit links to other government programmes and community-
based organizations (WHO, 2005).
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Developing countries could also learn from appropriate staffing models
and draw on the experience of providing HIV services in developing countries
and NCD management in countries such as England, Sweden and the
Netherlands, where there has been a progressive increase in the role of nurses
in managing many chronic diseases, through nurse-led clinics, discharge
planning and/or case management (Nolte et al, 2008). An effective NCD
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response requires a minimum package of services, which includes at least:

targeted and specific information, education and communication on NCDs;
affordable diagnosis and treatment to prevent complications. Training of
health care professionals is essential to re-orient them to NCDs, and the
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optimal response combines general health promotion, specific prophylaxis,

early diagnosis and treatment, limitation of damage and rehabilitation (Lucas,
2006:3). Appropriate clinical guidelines on NCDs should be developed, taking
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into account the country context, cost-effectiveness and resource availability

and long term sustainability.
Again, many best practices are in existence in developing countries. For
example, the Government of Chile re-oriented its health system in response to
the 2000 survey findings on living conditions and health that showed the large
health inequalities and increasing magnitude of chronic diseases in the country
(WHO, 2005). Health objectives were identified, including targets for chronic
diseases, commitment to universal health care access, quality of care, and
financial coverage, with the private sector needing to comply with the same
regulations and guidelines of the public health system (WHO, 2005). The
Ministry of Health provided overall stewardship, and community participation
was crucial (WHO, 2005).
Management of NCDs is fundamentally different from acute care, relying
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on several features: opportunistic case finding for assessment of risk factors,
detection of early disease, and identification of high risk status; a combination
of pharmacological and psychosocial interventions, often in a stepped-care
fashion; and long-term follow-up with regular monitoring and promotion of
adherence to treatment. Primary health care plays a significant role in this
scenario. In many developing countries with shortages of primary-care
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doctors, non-physician clinicians are likely to have a leading role in preventing
and managing chronic diseases, and these personnel need appropriate training
and continuous quality assurance mechanisms. More evidence is needed about
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the cost-effectiveness of prevention and treatment strategies in primary health
care (Beaglehole et al, 2008).
Many of the conditions that cause or predispose to NCDs are potentially
avoidable. Interventions for NCDs are focussed on prevention of disease,
promotion of healthy lifestyles, early screening and appropriate treatment.
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A public health approach based on primary, secondary and tertiary
prevention is necessary for effective control of NCDs in developing countries.
This approach needs to be integrated with different levels of health care
(Primary, secondary and tertiary care) and different components of health
systems (Beaglehole et al, 2008).
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5.4.4. Socio-Cultural Factors

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Globally, social inequality, poverty, gender and inequitable access to

resources, including health care, result in a high burden of chronic diseases
among women worldwide, particularly very poor women (WHO, 2008a). This
is worsened by barriers such as user fees, lack of income, women‘s workload
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and women‘s care-giving roles when other family members are ill (WHO,
2008a). NCDS are often associated with urbanisation, industrialisation, and a
western lifestyle. Residents of informal settlements are discriminated against
in all countries around the world presented typically as the ‗cultural other‘ –
separate from and different to other urban residents (Popay et al, 2008). This is
exacerbated by limited if any access to basic services – lacking for example, a
decent income, health care, housing, education, sanitation and clear water
(UNFPA, 2007). In addition, migrants, for example, often face language and
other cultural barriers, further constraining access to NCD prevention and
treatment services (WHO 2008a). A recent South African study has pointed to
a rising burden of NCDs in rural communities and that poor people living in
urban areas are disproportionately affected (Mayosi et al, 2009). Alcohol and
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substance abuse augments this problem and expands it beyond the confines of
developing countries.
Appropriate public health action must address social and cultural issues
and inequities due to age and gender. There is global evidence that a
community‘s health is influenced by programmes and policies that often
extend far beyond the health care sector (CSDH, 2008). Social and economic
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conditions - such as poverty, social exclusion, unemployment, and poor
housing - strongly influence health. They contribute to inequities in health,
explaining why people living in poverty die sooner and get sick more often
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than those living in more privileged conditions (CSDH, 2006).
Thus, there is an urgent need globally to focus on the upstream causes of
ill-health, and addressing the ―causes of the causes‖ is probably the most
efficient way of prevention of chronic diseases (CSDH, 2008). Tackling
health‘s social and economic determinants also means reorienting efforts
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within the health sector, working with other sectors, including finance and
education, and engaging the civil society, thus adopting a ―health-in-all-
policies‖ approach (CSDH, 2008; Prince Mahidol Conference, 2009).
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5.4.5. Monitoring and Evaluation (M&E)
Few developing countries have a comprehensive M&E system, and

existing systems suffer from lack of coordination, are often paper-based and
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information generated suffers from problems of quality, completeness,

timeliness and duplication (Jamieson et al, 2006). The experience in developed
countries has shown that a good M&E system provides the foundation for
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advocacy, policy development and action (Puska, 2002; Puska et al, 2002) and
is important both for continuous monitoring of the change process and for
more comprehensive summary evaluations (Nissenen et al, 2001). A results-
based M&E system should include information on NCD disease prevalence,
trends and determinants, as well as evaluation of action or interventions. A
well functional surveillance system is crucial for M&E as it provides
information that can be used as a barometer for any intervention programme.
The WHO has suggested implementation of the STEPwise surveillance

system. This system can even be used even in a resource limited environment
and can be scaled up based on availability of resources. The objectives of this
STEPwise surveillance system are to:
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 Evaluate health facility data on NCDs
 Identify the performance status of health facilities in these disease
areas.
 Develop an NCD intervention strategy for health districts.
 Implement the intervention plan.
 Set up a surveillance site for continuous monitoring and evaluation
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of NCDs.
The system has been introduced in the Gauteng Province, South Africa
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and initial success has been demonstrated in identifying high burden areas in
the province (Gauteng Department of Health, 2008).
CONCLUSION
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NCDs and their complications cause human suffering and premature
deaths, and have a significant impact on the health systems and the economy
of a country. The need for the comprehensive management of NCDs is
undisputed. Public health measures for effective management of NCDs would
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require a comprehensive and integrated approach. The experience in

‗developed‘ countries has shown the effectiveness of a comprehensive public
health response in reducing NCD morbidity and mortality. Such a response
includes inter alia: an enabling policy environment supportive of NCD
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prevention and control; individual and population level action to reduce the
level of exposure to the common risk factors for NCDs (e.g. tobacco
consumption); a health system response that ensures that prevention and
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appropriate health services are prioritised, socio-cultural response, including

action to address social attitudes and inequities; and surveillance, monitoring
and evaluation to provide the foundation for advocacy, policy development
and action.
An appropriate response also includes inter-sectoral action at health
facility and local level. The preventive and promotive aspects include personal
and behavioural interventions; education to encourage behavioural
modification; while curative and rehabilitative services focus on individuals
who are already diagnosed, to prevent complications. However, all these need
to be incorporated into an overall health systems strengthening framework,
with particular attention paid to primary health care delivery mechanisms.
Evidence based health care is necessary to determine the cost-
effectiveness of interventions particularly in resource poor setting to optimise
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utilisation of available resources. Surveillance, monitoring and evaluation are
critical to collect accurate information on disease prevalence, trends and
determinants, as well as evaluation of action or interventions to determine their
success and/or to make recommendations for improvement.
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ACKNOWLEDGMENT
Special thanks to Professor Nancy Phaswana-Mafuya and Mr Dimitri
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Tassiopoulos helpful comments made on earlier drafts of the chapter. The
views presented in this article are those of the authors.
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Chapter 6
IMPLICATIONS OF CHRONIC
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ON HEALTH SYSTEMS
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Kebogile Mokwena
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ABSTRACT
Background: Because chronic NCDs impact on health systems
infrastructure and health service management, they require an approach
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that accommodates the whole spectrum of prevention, treatment and long

term care. The structure and function of health systems need to re-focus
to deal with chronic NCDs.
Objectives:
 To identify the impact of chronic NCDs on health systems.
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 To identify criteria for quality of care for NCDs

 To develop country guidelines to respond to the scourge of NCDs
Methods: A systematic review of articles, reports and books on
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health systems, which were published between 1997 and June 2009, was
conducted.
Key Results: The strategies to deal with chronic NCDs include
human resource development, health systems overhaul which includes

Department of Social and Behavioural Health Sciences, School of Public Health, Medunsa
Campus, University of Limpopo, Pretoria . P.O. Box 77499, Tel: 012 6585964, Fax: 012
5600172, Kebogile_mokwena@embanet.com, kmokwena@hotmail.com.
130 Kebogile Mokwena
prevention at all levels of health care, and increased accessibility to

quality health care.
Conclusions: Responsive strategies for preventing and managing
NCDs require an overhaul of health systems.
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Keywords: responsive systems, health resources, health access, quality
care
6.1. INTRODUCTION
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The global increase in the prevalence of non-communicable diseases
(henceforth referred to as NCDs), with the resultant burden of disease, has
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been well documented. This increase, which continues unabated, highlights the
need for a change in strategies if the phenomenon is to be prevented and
managed. Heart disease, stroke, cancer and metabolic disorders are emerging
as new silent killers in Africa and other developing regions (African health
Monitor, 2008). The resources needed for their prevention and management
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pose a challenge to health systems throughout the world. However, the
challenges are profound for developing countries because not only is there a
massive increase in the prevalence of NCDs, and the resultant morbidity, but
they are now responsible for most premature deaths in these countries. Both
the prevention of these deaths and the management of morbidity identify the
need to strategise health services to respond to the challenge and thus fulfil
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their mandates.
NCDs have their unique set of challenges because although they can be
prevented, the increase in their prevalence does not reflect that. They also have
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an insidious onset, are chronic in nature and therefore require extended care
and management, with related costs. Although they require clinical skills, they
also require other non-clinical skills like epidemiology, health promotion,
financial planning and health management. The effective management of
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NCDs require public health skills and resources, without which the war against
them is likely to fail. Because of the behavioural component in their
prevention and management, they also require strategies to empower the
patients, to enable him to perform much of the long-term care and not depend
entirely on health professionals. This group of diseases therefore requires
health systems to strategise and respond with a long-term prevention and
management view.
Implications of Chronic Non-Communicable Diseases … 131
The ability of a country to respond to health challenges of its citizens is

determined by the effectiveness of its response, both in resources and
processes, for the prevention and management of a disease phenomenon. In
the context of NCDs, the failure or ineffectiveness of health systems in many
countries to prevent this group of diseases from occurring, is an indication of
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lack of readiness and the need to focus on responsive health systems, hence
this chapter, which focuses on how health systems are impacted upon by
NCDs.
This chapter uses literature review to:
I. identify the impact of chronic non-communicable diseases on health
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systems,
II. identify criteria or pointers for quality of care for non-communicable
diseases, and
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III. to develop country guidelines to respond to the scourge of non-
communicable diseases
6.2. METHODOLOGY
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Information for this chapter was taken from scientific articles, reports,
discussion documents and books which were published between 1998 and
June 2009. A systematic review of thirty four (34) documents was conducted
from Pubmed, Embase and Medline databases, using the following key words:
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non-communicable diseases, chronic disease, surveillance, health resources,

health access, responsive health systems, NCD management, prevention,
treatment, costs, developing, developed, cancer, diabetes, obesity, heart
disease, hypertension, diabetes, data collection systems, surveillance systems,
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demographic health surveys, burden of disease, morbidity, mortality,

implementation, and monitoring and evaluation. Other data search engines
included Science Direct, WHO Library and Information Networks for
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Knowledge Database (WHOLIS) and Google scholar.
6.3. RESULTS
The results highlighted the need to acknowledge NCDs as a challenge not
only to the health of citizens, but also that they are on the increase and impact
negatively on health access and health resources. They thus need to be given
the attention they deserve, both in allocating resources and developing a long
term strategic plan for addressing this health and social problem.
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6.3.1. The Impact of NCDs on Health Systems
It is obvious that the increase in the prevalence of NCDs will place

demands on health systems, which are expected to adjust their resources and
processes to respond in a meaningful way. Several initiatives have been put in
place in an attempt to raise awareness regarding the need to plan for an
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efficient response to the increasing burden of non-communicable diseases.
Examples of such initiatives include the Global Forum on Non-communicable
Disease Prevention and Control in 2002, and the Report of the Global Survey
on the Progress in National Chronic Diseases Prevention and Control in 2007.
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Furthermore, the World Health Organisation has developed guidelines on the
integrated chronic disease prevention and control, in which action plans to
prevent, manage and control chronic diseases are identified. Below are
common NCDs and their impact on health systems.
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Metabolic Syndrome
Recently, worldwide increase in the cases of metabolic syndrome has been
reported, with a sharp increase in the prevalence in many developing
countries. This puts a strain on already struggling country health systems,
many of which have been slow in responding to communicable diseases. The
burden of metabolic syndrome is particularly heavy because of its chronic
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nature and its tendency to complications, which require expensive drug

therapy. This group therefore results in clogging of the health systems and
institutions, making it difficult to respond logically but by just treating the
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large number of patients as they flock to treatment centres with patterns and
numbers similar to infectious diseases. The affected health systems need to
respond to this challenging impact.
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Cardio-Vascular Diseases
The prevalence of cardio-vascular diseases like heart failure and strokes is
high, resulting in huge numbers of deaths and many others requiring chronic
medical treatment over years. Often health systems are overwhelmed and
resort to providing drug treatment without prevention strategies as life style
changes and treatment compliance strategies.
Mental Health Disorders

The massive disintegration of social support structures results in
increasing prevalence of mental health disorders. The treatment thereof is
costly and prolonged and health systems need to take this into account. The
levels of diagnosis is also crucial, the role of psychiatric nurses need to be
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extended outside of tertiary so that they can play a role in the community. To
complicate this, the use of alcohol and other drugs is also increasing, and
studies have shown that smoking seems to be increasing in developing
countries where smoking control legislation is lax or not adequately enforced.
The prevalence of hypertension is a proxy to stress levels, among others.
These high stress levels not only impact on the physical but also mental health.
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The burden of mental disorders in developing countries is reported to be on the
increase, including the problem drug abuse. However, in most cases, these
disorders are only properly diagnosed and treated at higher levels of care.
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There is a need to set systems for diagnoses and treatment at primary health
care levels but what is available for most countries is drug addiction
rehabilitation, which is prolonged, requires specialised services, is expensive
and not always successful.
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Cancers
Many cancers can be prevented by adopting a healthy lifestyle of physical
activity and diet. On the other hand, the prognosis for many cancers is also
better if they are detected and treated early. Some cancers are also linked to
environmental pollutants. The implications of cancers on health systems are
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the following:
1. It requires a strong component of health promotion and disease

prevention.
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2. It should have a viable screening program that will enable early

detection of cancers.
3. It should have a strong component of environmental diagnosis
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because there has been links of development of some cancers to the

environment.
4. It should have cancer management processes, including appropriate
diagnostic and treatment technologies.
Global efforts to address the challenges of NCDs have been led by the
World Health Organization, but it is clear that this international body can only
advise and provide strategic guidelines, and that it is up to individual countries
to develop their health systems to respond to their specific health needs. The
efforts to respond to health needs are to a large extent dependent on the
availability and use of resources, which vary across countries. However, the
challenges relating to NCDs in developing countries are similar.
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6.3.2. The Double Impact of Acute Infectious and Chronic Non-
communicable Diseases
Although historically, the burden of disease in developed countries was

known to be characterised by chronic lifestyle diseases, and in developing
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ones by acute infectious diseases, developing countries are now experiencing
the double impact of both infectious and non-communicable chronic diseases.
This occurs while there are concerns that health systems in developing
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countries are reported to be in a state of collapse (Global Health Watch, 2006)
and several reports indicating that health systems in many developing
countries are fragmented and lack a sense of vision, explaining why they fail
to respond to the growing challenge of current diseases, including non-
communicable diseases.
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The African Health Monitor (2008) identifies non-communicable diseases
as Africa‘s new silent killers. This group of diseases has also been identified as
the leading causes of death worldwide, and are responsible for significant rates
of mortality and morbidity: up to 60% of all deaths and up to 80% in low and
middle-income countries (Habib and Saha, 2008). The irony of the situation is
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that not only is the impact of NCDs felt much more in developing countries,
but such countries are the most ill-prepared and ill-equipped to deal with this
phenomenon. The increase in the burden of non-communicable diseases is also
disproportionately experienced between developed and developing world. It is
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estimated that between 2000 and 2020 cases of cancer is predicted to increase
by 29% in developed countries, but as much as 73% in developing countries
(Habib and Saha, 2008). There is therefore indications that disease progression
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for NCDs may be complicated by other social factors, and that health systems
need to acknowledge and respond to these realities.
Reports of early onset of non-communicable diseases has also been
reported in some developing regions of the world, e.g. in South Asia, it has
been reported that up to 52% of cardiovascular deaths occur among people
younger than 70 years, compared to 22% in developed countries (Sekhar et al,
2008). The report of the Sixtieth World Health Assembly, 2007, highlighted
the concern that in 2005, NCDs caused an estimated 35 million deaths, which
constituted 60% of all deaths globally, and that 80% of these occurred in low
and middle-income countries. The inadequate awareness of the multi-sectoral
approach and appropriate action to reverse the trend is lacking, resulting in the
increase in the trend. An example of regional differences is NCD-related
mortality ranges between 47.2% in South & South-West Asia, compared to
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80.8% in North and Central Asia (Sen, 2001)
6.3.3. Components of a Health System
The health status of any country is determined by the nature and
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functionality of its health system. Health systems are a combination of
facilities (buildings and equipments), access to such facilities (referral
systems, level of care and ability to pay for services), institutions (hospitals,
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clinics, community health centres) and people (health practitioners, service
consumers and policy makers) interacting during the provision of health care
for a group of people.
By expectation, health systems are supposed to respond to health care
needs of the community they serve, and because the emergence of NCD poses
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such a challenge to the health of huge numbers of people in developing
counties, health care systems need to be assessed in relation to their ability to
respond to NCDs, among others. To enable a health system to respond as
expected often needs modification or manipulation of any or a combination of
the four components.
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Although all health systems have all the above components, there are vast
country differences in the extent to which each component has been developed
and functions. The efficiency of a health system is determined by both the
strength of each component and the quality of interactions between the four
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components. Factors that impact any of the four components, any combination
or their interaction with each other will have a ripple effect on the whole
function of health care services.
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6.3.4. The State of Health Systems in Developing Countries
Although it is acknowledged that not all developing countries are in the

same stage of development, several challenges characterise the state of health
systems in developing countries. According to the Global Health Watch, 2006,
many health care systems in low-income countries are functioning so poorly
that they are in a state of collapse. The following are characteristics of health
systems in developing countries:
Inadequate Numbers of Personnel

The inadequate number of health professionals in developing countries
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has been well documented. In Africa, human resources for health has been
described as a crisis (Samba, 2007). Mokwena et al, 2007, identified the need
to develop ways of increasing the number of health personnel. The training
and distribution of adequate numbers of professionals for the African continent
and other developing regions of the world remains a challenge.
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Source: developed from Shortell and Kaluzny (1997) in Essentials of Health Care
Management.
Diagram 1. Components of a health system.
The situation is worsened by the low remuneration and poor working

conditions that health workers in developing countries are subjected to, which
results in them migrating to richer western countries, the phenomenon of
―brain drain‖. In response, western countries often take advantage of the

situation by active and aggressive recruitment of personnel from developing
countries, thus saving themselves the high costs of training. The situation then
results in poorer developing countries ―subsidising‖ training costs for richer
countries. They, in the meantime remain unable to meet human resource needs
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of their regions and countries because they can‘t retain the few professionals
that they train.
A strategy is therefore needed that will increase the number of trained
personnel and then retain those that they employ. On the other hand, as
conditions continue, the personnel need upgrading of their skills to enable
them to deal with the scourge of NCDs.
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Fragmented Health Systems
Fragmentation is a feature of many health systems in developing
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countries. Fragmentation means that the players in the delivery of health
services play their roles independently, and that there is little or no
coordination between them. Fragmentation is expensive and is counter-
productive for service delivery in developing countries, where cutting costs is
a necessity and a requirement. Fragmented systems are more expensive
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because there is often duplication of services, which requires infrastructure for
every element. On the other hand coordinated systems are not only more
efficient, but also cost-effective.
Fragmented services also results in gaps in service delivery, which impact
negatively on treatment outcomes. Well coordinated systems can identify gaps
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because there is a thread running through all elements of the system, and the
various role players know about the activities of others, hence are apt to
identify duplication or gaps in the system.
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Poorly Resourced Services

Each of the four components of health systems identified above require
financial resources, and the inadequate financing that characterises health
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services and systems in developing countries has been adequately documented.

Resources are not only needed for the development of infrastructure for NCDs
but also prevention, diagnosis, treatment and long term management. Poorly
resources health systems are therefore likely to fail in their operations and thus
compromise service delivery. As in all other areas, poor resources are
associated with poor outcomes, providing partial explanation of the non-
communicable diseases situation in developing countries.
Poor Access to Health Services

Poor access to health services emanate from the following:
I. Lack of information. The lowest level of health care service is

information about health, including where people can go for what
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services. The feature of poorly resourced areas is that this component
is often ignored, focussing on people who are sick and often require
life-saving procedures
II. Unavailability of services, e.g. few or no health facilities, i.e. clinics,
hospital, community health centres. The availability is also
determined by distance to health facilities, as well as the ability of
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health consumers to reach these centres.
III. Unfavourable ratio of personnel to patient, which results in too many
patients attempting to access health services and often failing because
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of the numbers. This delays the process of seeking help and
contributes to poor health seeking behaviour.
IV. Inappropriate levels of health care provision, i.e. unavailability of
services at lower levels of health care (primary and community),
resulting in patients having to wait until they are seriously sick before
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they can be attended to. Efficient access to screening, primary,
secondary and tertiary health care is an important element of access to
health care.
V. Payment for health services does also deny access to health services.
Health systems in which access is determined by socio-economical
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status of an individual, often work against the principle of equity. In

such systems, health services are often characterise by poorly run
public service left for the poor. Often poor patients fail to access
health services because of financial reasons, while private health care
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costs often spirals higher, making it even more difficult to access.

This creates a situation in which costs are barriers to the prevention,
early detection and treatment of NCDs.
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6.3.5. The Concept of a Responsive Health System
Health care is a basic right which governments are expected to provide for
all its citizens. For the majority of people in most countries of the world, and
more so in developing countries, the enormous costs required to provide health
care can only be met by governments. The government is expected to provide
for the vulnerable and those who cannot provide for themselves, hence their
position to respond to the needs of its citizens. Because health systems are
social institutions, a responsive health system needs to be secured by
government, because it has the authority to enforce public accountability.
A responsive health system is one that is able to respond to health
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challenges in terms of access, equity and in a cost-effective way. Several
factors influence the delivery of health care services, including finances, health
informatics, infrastructure for diagnosis and treatment, the socio-cultural
factors of the people that interact with the system, and the demographics of
health care consumers (Shortell and Kaluzny, 1997). The existence and
interaction of these factors determine the responsiveness of a health system to
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the health needs of its users.
A responsive health system is able to identify challenges in their early
stages, develop prevention strategies and put up infrastructure to deal with the
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health phenomenon. In the context of NCDs, a responsive health system would
be able to identify the risk factors, develop prevention strategies, put up
infrastructure for prevention, treatment and long term care of this group of
diseases. A responsive health system would have policies that relate to the
management of NCDs and have a clearly articulated strategy which has been
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tailor-made for the specific situation.
A responsive health system is one that integrates all components of
common elements for NCDs, e.g. promotion of physical activity and low-fat
diet would benefit cardiovascular, metabolic disorder and cancer prevention
and treatment programs. A responsive health system is also one that keeps
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track of disease statistics for purposes of planning and resource allocation.

According to the Global Watch discussion document on health systems,
2006, key elements of a health systems development plan includes human
resource planning (including ensuring adequate numbers and skills for the
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profile of diseases in that country), resource generation, strengthening health

sector management and managing comprehensive health systems
development.
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6.3.6. Characteristics of a Responsive Health System
1. Policies that are Well Crafted and Can be Implemented

Healthy public policy is the cornerstone of health service delivery
(Metcalfe and Higgins, 2009). However, often such policies are lacking
(Leowski and Krishnan, 2009) or if existent, are only on paper. This works
against service delivery because health policies play a vital role in increasing
to access health services health (Frenk, 2009 and Alikhani et al, 2009). Not
only is it essential to have national policies for health, but also policies that are
specific to NCD, seeing that they are such a significant phenomenon and
require specific legislations. Such policies should include medical insurance,
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e.g. the need for medical insurance to cover, not only treatment but also
screening and prevention interventions.
2. Efficient Use of Health Resources

It is commonly accepted that the wealthier the country, the more it can
―afford‖ health services and the more favourable the health outcomes.
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However, this is not always so, examples being Palestine with an efficient
health system despite the political challenges. Even in countries with limited
resources, specific plans can be developed to respond to training, retention and
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remuneration challenges. Efficient use of resources includes clear referral
systems, which ensures optimal utilisation of the health system optimally. This
promotes positive treatment seeking behaviour because patients will be eager
to go to an organised system.
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3. Quality of Care for Non-communicable Diseases
Quality of care for NCDs consists of screening, prevention, and
comprehensive management, which is not limited to drug therapy, but also
other aspects of health care, including patient education that enables self
management. Quality care should also be implemented at lower levels of care,
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otherwise it becomes more expensive, less accessible and less effective.

Quality of care for non-communicable diseases is multidimensional, and
covers four areas:
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a) Availability of services
 Different levels of prevention: primary, secondary and tertiary,
 Protocols relating to treatment and management of chronic
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diseases
 access in terms of availability of services and affordability
b) Ability to meet minimum standards of care
 Relevant human resources with necessary skills and knowledge
 Drug availability
 Technology for treatment and diagnosis
c) Self care/patient empowerment
 Health literacy and understanding of health conditions

 Knowledge and skills for prevention of disease and/or
complications thereof
 Self-care skills
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4. Solid and Strong Primary Health Care Services
Over the years, Primary health care services have received a declining
attention, much to the detriment of affording quality health care at the most
appropriate level and an affordable cost. The 2008 World Health Report
identified the need to develop, strengthen and utilise Primary Health Care
―now more than ever‖. The failure to utilise the primary health care services
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has resulted in most of NCD cases being picked up at secondary and tertiary
levels of care, when the patients are already sick, often with complications that
could have been prevented. The practise and treatment protocols at these
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higher levels are congruent with second and even third line of drug therapy,
resulting in patients not benefiting from a progressive treatment approach.
The costs of attending to a patient increases with the level of care, i.e. it is
much more expensive to attend to any patient at secondary or tertiary care
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level, compared to primary health level. With the increase in the number of
patients with non-communicable diseases and the legitimate expectations of
people globally that the health systems meet their health care needs, the 2008
World Health Report argues that primary health care has the potential and
ability to respond better to the identified needs by increasing access to health
care at a faster pace and earlier in disease progression process. The main
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advantage of primary health care is accessibility to more people at a reduced

cost. However, this level of health care needs to be strengthened with
appropriate resources if it is to respond appropriately to health needs of NCD,
so that most are appropriately attended to at that level, reducing the need for
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care at a higher level.
Prevention Services
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Because most NCDs can be prevented, health systems need to use this to
their advantage by strengthening this component of health service. Effective
prevention services are not only cost-saving measures, but also decrease
morbidity that compromises quality of life and causes premature mortality.
Because the provision of prevention services is not limited to clinical
professions, stakeholders from constituencies external to health services can be
recruited to strengthen the services. Examples of stakeholders are schools and
workplaces who can cooperate with the health sector to use health promotion
strategies to promote health and prevent the development of NCDs. A

significant strategy for this prevention is the increase of health literacy across
all groups of people.
Treatment Services
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Historically, health systems are expected to provide treatment services to
the community, and this remains a significant role. Treatment services should
be comprehensive for all age groups and ensure access to all levels of care,
from community to tertiary levels. Treatment policies and protocols should
support the availability of drugs to match the extent of the problem, in a cost
effectiveness way. The scourge of HIV has made countries like Brazil to
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develop a different strategy for accessing drugs in a cost-effective way. The
same should be done for NCDs. Treatment should include patient education
and community empowerment.
Human Resource Development
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A responsive health system is one that implements a plan for human
resource development, which is continuously evaluated to match the needs of
the country. A human resource development plan assesses the needs of the
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country for purposes of training, so that the trained people develop skills that
match the needs. Such a development requires consideration for both quantity
and quality of training. Training programs need to be structured according to
health needs. The massive training of manpower at different levels, which
followed the scourge of HIV and AIDS, is an example of what needs to be
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done even for non-communicable diseases, i.e. to train different categories of

health workers and re-skill those already trained, to equip them with the skills
necessary to respond to non-communicable diseases.
The need for training and distribution of health professionals have been
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well documented, and remain a challenge for developing countries. The

training of the main health professionals, e.g. nurses, doctors, physiotherapists
etc, require significant investment and the inability of many developing
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countries to retain these trainees by acceptable remuneration packages

continuously work against them because the trained professionals are often
recruited to the western world, where they are offered much higher salaries.
Developing countries then need to continuously train. This results in such
countries continuously lacking experienced professionals. Perhaps they need
to calculate the cost effectiveness of continuing with this trend and rather pay
salaries that are likely retain professionals.
Training for responding to non-communicable diseases should also

include training for other non-clinical categories, e.g. health promoters,
epidemiologists, biostatisticians and health care managers which needs
innovative thinking and planning, such as the online program offered in South
Africa, which trains post-graduate public health professionals for local
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(continental) needs, and African and other developing regions would do well
to duplicate such programs at various locations(Mokwena et al ,2007)
In particular, health promotion strategies should be enhanced because they
are able to reach wider audiences. Training at schools, e.g. captive audience
like teachers and learners need to be utilised for effective prevention and
treatment of NCDs. All this requires the health care system to plan
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accordingly.
Access and Availability of Drugs
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Developing countries need to have long-term plans for access to essential
drugs for the treatment of chronic non-communicable diseases. Because
development is intrinsically linked to health, developing countries need to
develop strategies to access drugs to enable them to meet the needs of their
citizens in a cost-effective and sustainable way. The increase in the number of
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people with NCDs increases the challenge of acquiring needed drugs
especially in the face of competing infectious diseases like HIV and AIDS.
First line drugs are also less expensive than subsequent line drugs and
even in the case where drugs are needed, it will be cost effective to keep
patients on first line drugs for as long as possible.
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Surveillance
The saying that ―you can‘t manage what you can‘t measure‖ is certainly
true for non-communicable diseases. A health system that is capable of
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managing this group of diseases is one that has invested in an efficient

surveillance system. If disease surveillance system is not functional, it will be
difficult, almost impossible, to plan for and have the capacity to deal
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sufficiently with NCDs.

The value of surveillance, as a tool for managing health problems, is well
documented and includes the availability of reliable statistics for NCDs, upon
which lies crucial information for planning and logistical arrangements to
enable efficient and informed decision-making.
The development of a surveillance system is useful for the following:
 Strengthen public health surveillance services by developing protocols

and training staff
 Identifying cases for surveillance and a comprehensive list of
variables
 Putting together a system which includes data collectors
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 Developing mechanisms of utilizing the data locally
 Identifying decision makers
 Monitoring and evaluation processes
 Training professionals to utilize data for decision making and program
improvement
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6.3.4. Country Guidelines for Management of to Non-
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Communicable Diseases on Health Systems
There is a need for low and middle-income countries to acknowledge the

seriousness of NCD and to develop a set of coordinating processes to avail
medicines for high-risk populations (Sixtieth World Health Assembly, 2007).
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The development of country guidelines is useful for international collaboration
efforts, because such guidelines can be used to assess progress towards a
responsive health system. Shortcomings can be identified and specific actions
implemented towards the ideal.
Literature and studies of best practices resulted in the following guidelines
for countries to enable them to respond to NCDs
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1. Improve Efficiency/Develop Leadership

The problems identified under the State of health systems in developing
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countries above, reflect the challenges of governance and management in

many developing countries. While governments are not to blame for the
changing lifestyles of their citizens, they are expected to provide leadership in
addressing the resultant health consequences and to provide prevention and
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management programs.
Leadership skills are integral to public health services delivery and to
change the public health landscape for the better (DeBuono, 2007). However,
it is the responsibility of public health role players to develop such leadership.
Effective leadership should be comprehensive to include technical knowledge,
innovative thinking, social skills and the vision for social justice. This calls for
conceited efforts to develop and implement a ―curriculum‖ in public health
practice relating to non-communicable diseases. The challenges presented by

non-communicable diseases will be with us for some time and will need the
kind of leadership that will lead and guide the various practitioners.
Public health leadership will provide the necessary strategy to improve
efficiency of the health system by identifying and addressing specific
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challenges as they play out in the prevention and management of non-
communicable diseases. In the face of limited resources for all services,
including health services, developing countries, with their limited resources,
can hardly accommodate and afford inefficiency, which is expensive. A
fragmented and inefficient system not only fails to deliver services, but also
wastes the limited resources. By investing in improving efficiency, developing
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leadership in all segments of the health care system and putting in place
monitoring and evaluation strategies, limited resources can be spread to
achieve much.
2. Develop and Implement Policy
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The identified increasing prevalence of non-communicable diseases
implies that health systems in developing countries need to work on very
specific strategies to curb the scourge. The development of NCD-specific
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policy assists health workers to follow standardised guidelines and process,
and enables logical review of health outcomes.
Policy should be comprehensive to cover treatment guidelines issues but
also other aspects of the management of NCDs, like access, financing and drug
policies. Treatment protocols which have been informed by research, which
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will also help the monitoring and evaluation process because the treatment
outcomes will be based on a known process, making it feasible to modify
processes to achieve a pre-identified and predetermined outcome
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3. Develop Surveillance Programs, Conduct Health Research and Share

Information
Health research should not be considered, as is still the case in many
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developing countries, as a separate academic activity, but, on the contrary,

health research should be an integral element of health service delivery. It is
well known that the high occurrence of obesity and diabetes took many
country health systems by surprise because appropriate research, which
identifies trends and risk factors, had not been and in some cases, is still not
being conducted. Health research must be adequately funded and governments
in developing countries must invest finances, facilities and time to health
research. This research will inform country health systems about disease hot
spots and where to put more resources. Research will also inform health
services regarding specific contributory country or group risk factors , which
also need to be taken into account as an integral part of the management of
some NCD, e.g. Tull et al, 2007, have conducted studies which link
internalised racism to increased blood sugar levels among blacks in
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Zimbabwe, which does not necessarily apply to other communities. In this
case, this research implies that the element of internalised racism be taken into
account in the diabetic management of such patients. Health research will
inform the system about other elements of health care, e.g. policy, access to
treatment, health seeking behaviour, barriers to adherence etc.
Health research also includes the investigation of which routine data is
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usable, and to ensure accurate data collection. The data collected should also
be used to develop policy, plan services and improve access. Although the
amount of routine data collected at health facilities counts, what is even more
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important is the purpose for which the data is collected and what it is used for.
Regular visits regarding the collection of data and its use should be made. (see
chapter 11 for details of research agenda)
4. Increase Universal Access to Health Services Related to Prevention,

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Treatment and Management of NCDs
Access to basic health care still remains a challenge for many people in
developing countries, making such health systems to be declared
unresponsive. Moreover, stress-related health conditions are on the increase,
with heart conditions, stroke and mental health challenges being more
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common. It is also regretful that mental health seems to get attention mostly in
tertiary public facilities and almost none at primary health care level.
Increasing access to health care is to be done by expanding comprehensive
services to all people, including those marginalised by poverty, and residing in
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areas with limited access to health services. This access should include all
levels of care (primary, secondary and tertiary). Efficient access at lower
primary care levels helps the system by preventing clogging of the health
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system at secondary and tertiary levels. The universal access therefore

supports the strengthening of primary health care facilities.
In countries with a shortage of healthcare workers, universal access to
treatment can be accomplished by involving community based health workers
Kruger, 2006). This is group of a wide variety of workers who have been in
existence for years, and have been trained in limited but very specific skills,
e.g. briefly trained primary health workers, variously named volunteers, health
promoters and village health workers. The different names reflect the task
these workers perform, and they need to be. They need to have clear scope of
practise and supervision protocols and be linked to health services in their
communities.
As early as 1978, community health workers were recognised as a
worthwhile group for international health organizations to focus support on
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because they provide a critical interface between the patient, the community
and the health sector. Community-based approaches to health care delivery,
with community health workers in the foreground, have been very successful
in resource-limited settings where they have been used to integrate effective
distribution of health care. Community health workers have the potential to
serve as a cost-effective means of tracking individual health, disseminating
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health information and providing counselling and care and in the past few
years they have successfully relieved the burden of epidemics such as
HIV/AIDS and TB on already overburdened health clinics.
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Lessons from developed countries, have shown that community based
interventions for non-communicable diseases were effective, thus a need to
develop and such for developing countries (Nissinen et al, 2001). However,
this group of workers have not always benefited from both financially and
emotionally support and in the application of their duties, they have lacked
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even basic health resources and basic skills and knowledge needed to
effectively work in what is considered the most severe and challenging of
health settings. The advantage of using CHW is that they can support
community based programs, which are essential for program sustainability.
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5. Develop Culture-Sensitive Interventions

Social and health researchers continue to identify the link between culture
and health outcomes at all levels of interventions, i.e. at initiation, promotion,
uptake and retention. The acknowledgement of the cultural impact on health
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and the integration of cultural competencies in health interventions can go a

long way to improve outcomes of health interventions. When health care
providers are insensitive to cultural differences, the quality of health care is
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compromised, which may explain why often prevention strategies do not yield
expected outcomes (Anderson et al (2003). This poses a challenge to
developers of health programs to acknowledge that culture has a significant
influence on behaviour and effective behaviour change interventions are, by
design, bound to be culture-sensitive. The research agenda for NCDs should
inform the areas related to culture that need to be studied, as well as their
implications on health outcomes.
Warner et al (2006) state that cultural context should be considered at 3

levels, the individual, the family and the community. This is especially
relevant for the management of NCDs because of their chronic nature, and that
social and family support may be a determinant of treatment compliance. The
approach is also in line with the public health ecological approach to
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behaviour change, which holds that for behaviour change to take place, all
operational levels of an identified behaviour need to be targeted.
6. Provide Comprehensive Screening Services

Screening is a useful health provision activity that not only saves money
but also prevents complications by addressing health issues at an early stage,
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thereby optimising better prognosis. Many developing countries do not make
maximal use of screening services, which results in more expensive
interventions when the disease entities are far advanced. It is known that non-
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communicable diseases develop over a long period and the sooner they are
identified while in the earlier stages of development, the more favourable the
treatment and management outcome. The country health services should also
take a cue from this, and increase both screening and prevention services for
non-communicable diseases.
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Although, in itself, screening is less expensive than treating chronic non-
communicable diseases at a later stage, there is a need to invest in efficient
screening tools and procedures, to make it worthwhile. Screening facilities,
which include procedures and/or equipment for the test itself, human
resources, and clear guidelines and skills on the conduction of the test, are all
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essential elements of a valid screening procedure. The extent to which a

screening test is rendered valid is its ability to distinguish between those who
have a disease and those who do not. For a screening test to be valid, both its
sensitivity (its ability to correctly identify those that have the disease) and its
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specificity (its ability of to correctly identify those that don‘t have the disease)
have to be high.
Useful screening programs often use two stage screening, in which the
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simplest, less expensive, less invasive and less uncomfortable tests (which
often means less sensitive) are carried out first and those who are picked up as
positive at this level are then referred for a more invasive and more expensive
test (which is often more sensitive). For a health system to utilise the benefits
of screening, it has to plan for all these eventualities.
7. Develop Efficient Prevention Services and Health Promotion

Environments
Many non-communicable diseases, such as obesity and the resultant
diabetes, some cancers and heart diseases, can be prevented because they are
linked to life style and/or environment factors. Health insurers take advantage
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of this by encouraging members to vaccinate for vaccine preventable disease
because they know that although they pay for the costs of the vaccination, it is
much cheaper than what they will pay later on to treat the disease and/or its
complications. Prevention enables health systems to pay for health rather than
pay for the disease, and the progression of non-communicable diseases is such
that it is cheaper to pay earlier than later.
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There is also a need to develop prevention programs across the whole
spectrum of preventable non-communicable diseases and at all levels of health
care services. This means that at every level (primary, secondary and tertiary)
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patients should not only get drug treatment, but a planned logical program of
prevention, be it prevention of the disease itself, or the prevention of related
complications.
Much can be done to develop health promoting environments. Examples
can be promotion of fruit and vegetables, walking pathways, discourage
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smoking etc. These interventions are to be integrated into prevention and
management of NCDs.
One of the key characteristics of an efficient health system is effective and
regular communication with all its stakeholders, which is a feature that needs
to be integrated in health systems in developing countries. Acknowledging that
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communication has financial implications, lack thereof has even more and
serious financial and quality of life implications. The development of a
communication system is vital and should be tailor-made to the local situation.
Various media types can be effectively used to convey health –related
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messages to the public, and the appropriateness of each is dependent on the

profile and access of the target group. However, patient-specific information is
a must for every patient attending a health facility, whether for screening or
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treatment at any level. Information for people who are at risk of, or have
developed any of the non-communicable diseases, should be comprehensive
and include how the disease developed, the treatment and prevention of
complications. Such a patient should be adequately informed because
informed patients are more likely to adhere to treatment of disease prevention
activities.
8. Improve Effective Treatment Services for NCDs

Service provision is improved by training of personnel, including clinical
and public health personnel, investing in technology for diagnosis and
treatment, and developing structural facilities for prevention, treatment and
management services.
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9. Strengthen Collaboration
Global programs and collaborations across countries have not only helped
to support developing countries, but also to build national capacities. The need
for collaboration in dealing with non-communicable diseases is essential for
success. The collaboration is needed both within and across countries. Great
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strides have been achieved by collaboration in other health spheres, and non-
communicable diseases is not different.
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10. Improved Financing and Tailor-Made Financing Strategies
The 2007 World Health Report identifies inadequate investment in public
health as one of the threats to public health security. This threat results from a
false sense of security in the absence of acute infectious disease. However,
because in developing countries a significant burden of disease still emanates
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from infectious diseases, the need for investment in health becomes even
greater and more urgent to enable the systems to cope with this double burden.
Health services is one of the key demands for country expenditure and if
well planned, health care systems can lay a solid foundation that can enable a
country and its citizens to prevent and manage NCDs. In the long run, the
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investment will be cost-effective for the management of NCD, and will ensure
a healthier population.
11. Human Resource Development

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The inadequate number of health professionals in Africa and other

developing regions of the world have been documented (Mokwena et al,
2007), which puts pressure on countries for more training of more
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professionals across the wide variety of categories. However, the increasing

prevalence of chronic non-communicable diseases not only requires an
increase in numbers but also for specific public health skills. Non-
communicable diseases not only need clinical skills but also management and
public health skills. In particular, countries need to train health system
managers that understand all components of health management, as well as
social and behavioural health scientists who can make community and societal
diagnosis and develop health interventions.
Training also requires regular continuous professional development

programs, which will skill the professionals with the required skills. Training
and utilization of community health workers should also be considered to
address non-communicable diseases, because there is a considerable body of
international evidence that show that these categories of health workers have
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been found to play a vital role in improving the quality and outreach of health
services (Friedman, 2002). In particular, they can be integrated into the health
system so that they play a role in primary health care.
CONCLUSION
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Efforts to curb the scourge of NCDs in developing countries can be
enhanced by careful planning by all stakeholders, including global and
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regional collaborators, but especially governments who are responsible for
providing health care services to all citizens. With the global sharing of
research and practice information, it has become easier to lean from other
countries and regions, and implement programs emerged as examples of best
practice for the prevention, treatment and management of NCDs. If prevention
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strategies are adequately developed and implemented, the numbers of new
cases of NCDs can be decreased and resources can then be channelled into
other elements of NCD management. Health advocacy needs to be utilised to
get political support for effective prevention and management of NCDs.
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RECOMMENDATIONS
It is recommended that developing countries acknowledge the serious
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impact of NCDs on the morbidity and mortality of their citizens. An essential

factor in the response to curbing the scourge of NCDs is an intentional
program of identifying social and cultural factors that contribute to or are
frustrating efforts to respond to this scourge. However, a critical
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recommendation is an overhaul of health systems to make it responsive to this

emerging challenge.
ACKNOWLEDGMENT
The School of Public Health, Medunsa Campus, is acknowledged for
supporting this work in kind.
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Beaglehole R and Dal Poz M. (2003) Public Health workforce: challenges and
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Beaglehole R, Sanders D, and Dal Poz M. (2003). The Public Health
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S16
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Chapter 7
MEDICINES FOR CHRONIC
N
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Andy Gray and Fatima Suleman
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ABSTRACT
Access to uninterrupted supplies of suitably selected, affordable
essential medicines are critical to the management of chronic, non-
communicable diseases. Selection of these medicines requires
consideration of evidence of efficacy and safety by multi-disciplinary
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teams, with due consideration of the potential impact of conflicts of

interest. Ensuring access to these medicines at all levels of the healthcare
system requires close attention to financing options, but also to each of
the steps in the logistic process – procurement and distribution. Ensuring
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that prescribers adhere to well-designed standard treatment guidelines,

and that patients adhere to and persist with treatment also requires close
attention. The available evidence points to poor availability of medicines
for chronic, non-communicable diseases in developing countries, but also
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to sub-optimal patient adherence in all settings.
Keywords: medicines selection, procurement, distribution use; patient

adherence

Telephone: +27-31-260-4334, Fax: +27-31-260-4334, Email: graya1@ukzn.ac.za.

Tel: +27-31-260-7358, Fax: +27-31-260-7792, Email: sulemanf@ukzn.ac.za.
156 Andy Gray and Fatima Suleman
7.1. INTRODUCTION
While much of the attention in relation to chronic non-communicable
diseases is correctly focused on prevention by means of lifestyle changes, the
treatment of such conditions relies largely on the use of medicines (Miranda et
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al, 2008). Unlike in acute, infectious diseases, treatment does not effect a cure,
but may still be life-saving (as in type 1 diabetes mellitus) or may prevent the
development of the clinical sequelae of a condition (such as hypertension). In
some cases (such as asthma), acute exacerbations may require immediate
access to medicines, while long-term maintenance therapy is also indicated.
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Overall, though, the management of chronic, non-communicable diseases
poses very different challenges to the health systems of developing countries
that may, in the past, have been geared to dealing predominantly with acute
diseases (Beaglehole et al, 2008).
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Quick at al. (1997: 15) have stated that ―[r]egardless of the setting, or the
indication for use, the management of medicines in a health system can be
viewed as a cycle‖. This cycle starts with selection of the medicines to be
used, is followed by the steps needed to procure and distribute those
medicines, and ends with their use by patients. Consideration of the outcomes
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that result from such use may result in changes to the selection made, or to the
ways in which the logistics aspects are arranged. The medicines management
cycle is particularly useful as a way of viewing issues related to medicines for
chronic, non-communicable diseases. Since such medicines are to be used for
protracted periods of time, and in most cases life-long, in conditions that are
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often ―silent‖ (in that there are few if any obvious symptoms experienced by
the patient, except during acute exacerbations or when related to the long-term
sequelae of the condition), issues related to uncomfortable adverse effects and
ease of use can have a major impact on patient adherence to treatment. As with
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all medicines, selection has to be based on demonstrated efficacy and

appropriate safety. These are the first considerations in any assessment of
efficacy. However, the difference between efficacy (as demonstrated in
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clinical trials) and effectiveness (as demonstrated in real-world application)

can be considerable in such conditions. The logistics steps – procurement and
distribution (and their financing) – also have a major impact on access to life-
long medication, and any improvements or interventions made to ease access
have to be sustained in order to make a difference in disease outcomes.
This chapter uses the medicines management cycle to examine issues
particular to medicines for chronic, non-communicable diseases in developing
countries. It does so by focusing on four conditions: hypertension, diabetes
Medicines for Chronic Non-Communicable Diseases 157
mellitus, asthma and chronic obstructive pulmonary disease. While these are
all highly prevalent conditions, other chronic diseases, including cancer, are
responsible for an increasing burden of disease in developing countries
(Kanavos, 2006).
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7.2. SELECTION OF MEDICINES
Miranda et al (2008) have pointed to the many challenges facing low- and
middle-income countries in managing chronic, non-communicable diseases,
and have proposed that ―clear evidence of cost-effectiveness of interventions
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that are feasible to implement at individual and societal levels is likely to be
culture specific and require nationally relevant evidence to be credible to
policy makers‖. While this may be more easily understood in relation to
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primary prevention interventions, such as lifestyle or dietary changes, the
challenge is relation to medicines selection is as acute. While primary chronic,
non-communicable diseases are spared the problem of microbial resistance
that complicates the selection of medicines for infectious diseases, assessment
of the cost-effectiveness of competing choices of medicines requires local data
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on costs that may not always be readily available. Instead, those charged with
the selection of medicines to be provided or reimbursed in a health system
have to rely on evidence of efficacy and safety only, most of which has been
provided by clinical trials conducted in developed country settings.
Considerations of affordability and value-for-money are then reduced to
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simple comparisons of acquisition costs. Such cost-minimization assessments

should only be done if the efficacy and safety of the medicines being
considered are equal. This assumption may be met in relation to choices within
narrow pharmacological groups (for example, when choosing between
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angiotensin-converting enzyme inhibitors or dihydropyridine calcium channel

antagonists), but will not be satisfied when comparing very different groups
(for example, when faced with a choice between beta-adrenergic antagonists
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and thiazide diuretics for hypertension).

Medicines selection should be performed by structures with the necessary
expertise, as well as with due regard to the considerable potential for conflicts
of interest that may cloud decisions taken by individual and committees. In
2001, staff of the Department of Management of Non-communicable Diseases
of the World Health Organization outlined the following key strategies ―to
improve clinical care and outcomes for chronic conditions‖ (Epping-Jordan et
al, 2001):
 ―Develop health policies and legislation to support comprehensive

care
 Reorganise healthcare finance to facilitate and support evidence based
care
 Coordinate care across conditions, healthcare providers, and settings
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 Enhance flow of knowledge and information between patients and
providers and across providers
 Develop evidence based treatment plans and support their provision in
various settings
 Educate and support patients to manage their own conditions as much
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as possible
 Help patients to adhere to treatment through effective and widely
available interventions

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Link health care to other resources in the community
 Monitor and evaluate the quality of services and outcomes‖.
Evidence-based treatment plans are the basis for the rational selection of
medicines. Based on the available evidence, Laing et al (2001) recommended
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that developing countries apply the following techniques in order to promote
the rational use of medicines:
 ―Establish procedures for developing, disseminating, utilizing and

revising national (or hospital-specific) standard treatment guidelines
 Establish procedures for developing and revising an essential drug list
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(or hospital formulary) based on treatments of choice

 Require hospitals to establish representative Pharmacy and
Therapeutics Committees with defined responsibilities for monitoring
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and promoting quality use of medicines‖.

The extent to which these principles have been applied in developing
countries varies. While the Essential Medicines concept has been widely
accepted, the extent to which local essential medicines lists and standard
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treatment guidelines are explicitly based on a careful consideration of

available and applicable evidence is unknown (World Health Organization,
2004: 65). Many such committees operate outside of the public gaze and rarely
provide documentation on the basis for their decisions. In some developing
countries, where the capacity to undertake such reviews is lacking, the World
Health Organization‘s Model Essential Medicines List is used directly to
inform procurement.
National selection decisions can also be influenced by respected national

structures in developed countries or by international groups dedicated to a
particular disease. These organisations may, however, receive at least some of
their funding from pharmaceutical manufacturers. The extent to which this
potential conflict of interest is disclosed and managed may also vary.
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While the impact of donor programmes, funding vertical programmes
such as those for the management of tuberculosis, malaria and HIV/AIDS, has
been responsible for a marked increase in the number of patients being treated
for these infectious diseases, the impact on programmes responsible for the
management of chronic, non-communicable diseases has been as marked but
less obvious, and perhaps less positive. The internal ―brain drain‖ created by
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such donor-funded, vertical programmes has impacted negatively on the
ability of many developing countries to attract and retain suitably qualified and
experienced professional staff in other areas. The quality of selection,
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procurement, distribution and use of medicines processes has often suffered as
a result.
7.2.1. Hypertension
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Globally, the management of hypertension has traditionally been
underpinned by the decisions of the American Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
(JNC). The 7th edition of their guidelines was published in 2003 (National
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Heart, Lung, and Blood Institute, 2003). This report was prefaced with a series
of financial disclosures, and concluded with a description of how evidence had
been used to develop the treatment guidelines. The year before, the single
largest randomised clinical trial of hypertension treatment had been reported
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(ALLHAT, 2002). In 2003, the joint World Health Organization/International

Society of Hypertension (WHO-ISH) guidelines for the management of
hypertension were also updated (Whitworth and World Health Organization,
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International Society of Hypertension Writing Group, 2003).

The WHO-ISH document summarised the evidence as follows: ―Lifestyle
modification is recommended for all individuals. There is evidence that
specific agents have benefits for patients with particular compelling
indications, and that monotherapy is inadequate for the majority of patients.
For patients without a compelling indication for a particular drug class, on the
basis of comparative trial data, availability, and cost, a low dose of diuretic
should be considered for initiation of therapy.
Table 1. Antihypertensive medicines listed in the 16th WHO Model

Essential Medicines List (accessible at
http://www.who.int/entity/selection_medicines/committees/exper
t/17/sixteenth_adult_list_en.pdf)
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Medicine Dosage form (and notes)
Core list
� amlodipine Tablet: 5 mg.
� atenolol Tablet: 50 mg; 100 mg.
� enalapril Tablet: 2.5 mg; 5 mg.
hydralazine* Powder for injection: 20 mg
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(hydrochloride) in ampoule. Tablet: 25
mg; 50 mg (hydrochloride).
* Hydralazine is listed for use in the
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acute management of severe pregnancy-
induced hypertension only. Its use in the
treatment of essential hypertension is not
recommended in view of the availability
of more evidence of efficacy and safety
of other medicines.
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� hydrochlorothiazide Oral liquid: 50 mg/5 ml.
Solid oral dosage form: 12.5 mg, 25 mg.
methyldopa* Tablet: 250 mg.
* Methyldopa is listed for use in the
management of pregnancy-induced
hypertension only. Its use in the treatment
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of essential hypertension is not

recommended in view of the availability
of more evidence of efficacy and safety
of other medicines.
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Complementary list
sodium nitroprusside Powder for infusion: 50 mg in ampoule.
Source: Note from the original document (World Health Organization, 2009): ―The square
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box symbol () is primarily intended to indicate similar clinical performance within a
pharmacological class. The listed medicine should be the example of the class for
which there is the best evidence for effectiveness and safety. In some cases, this may
be the first medicine that is licensed for marketing; in other instances, subsequently
licensed compounds may be safer or more effective. Where there is no difference in
terms of efficacy and safety data, the listed medicine should be the one that is
generally available at the lowest price, based on international drug price information
sources.‖
In most places a thiazide diuretic is the cheapest option and thus most cost
effective, but for compelling indications where other classes provide additional
benefits, even if more expensive, they may be more cost effective. In high-risk
patients who attain large benefits from treatment, expensive drugs may be cost
effective, but in low-risk patients treatment may not be cost-effective unless
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the drugs are cheap‖.
That approach is also reflected in the range of antihypertensive medicines
included in the 16th WHO Model List of Essential Medicines, published in
March 2009 (World Health Organization, 2009). Section 12.3 of the document
lists core medicines (―a list of minimum medicine needs for a basic health-care
system, listing the most efficacious, safe and cost-effective medicines for
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priority conditions) and complementary medicines (―essential medicines for
priority diseases, for which specialized diagnostic or monitoring facilities,
and/or specialist medical care, and/or specialist training are needed. In case of
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doubt medicines may also be listed as complementary on the basis of
consistent higher costs or less attractive cost-effectiveness in a variety of
settings‖), as shown in the table below. This list may, at first glance, appear
short. However, it provides national selection bodies in all countries with the
basic elements from which to select the most affordable example from each of
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the pharmacological classes needed to treat individual patients, including those
with concomitant diseases. Finding evidence of efficacy and/or safety that has
specifically been generated in developing countries, and which gives an
indication of real-world effectiveness in such settings, is, however, difficult.
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7.2.2. Diabetes Mellitus
The potential problem of commercial influence on guideline development

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is well illustrated by the documents issued by the International Diabetes

Federation (IDF). On its web site (http://www.idf.org/idf-task-force-clinical-
practice-guidelines), the Federation noted that there had been a ―proliferation
of clinical and other guidelines in the early 1990s‖ and that ―the content,
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background and structure of these publications varied greatly‖. It also

complained that ―many of the guidelines were directed at highly resourced
clinical care, and did not address the needs of most people with diabetes in the
world‖. An IDF Global Guideline for Type 2 Diabetes was published in 2005
(IDF Clinical Guidelines Task Force, 2005). The document included the
following disclosure: ―This activity was supported by unrestricted educational
grants from: Eli Lilly, GlaxoSmithKline, Merck Inc (MSD), Merck Santé,
Novo Nordisk, Pfizer Inc, Roche Diagnostics, Sanofi–Aventis, Takeda. These

companies did not take part in the development of the guideline. However,
these and other commercial organizations on IDF‘s communications list were
invited to provide comments on draft versions of the guideline.‖ It also
thanked a staff member of Eli Lilly for ―providing organizational support for
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the meeting of the Guidelines Group‖. While some may be comforted by the
―unrestricted educational grant‖ status of the funding, others may baulk at the
close involvement in the organisation of the process and the opportunity to
provide comment on drafts of the guideline.
The guideline provided for three levels of care:
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 Standard care – ―Evidence-based care, cost-effective in most nations
with a well developed service base and with health-care funding
systems consuming a significant part of their national wealth.‖
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 Minimal care – ―Care that seeks to achieve the major objectives of
diabetes management, but is provided in health-care settings with very
limited resources – drugs, personnel, technologies and procedures.‖
 Comprehensive care – ―Care with some evidence-base that is
provided in health-care settings with considerable resources.‖
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In terms of ―standard care‖, the following points were made in relation to
the choice of oral agents:
 ―Begin with metformin unless evidence or risk of renal impairment,

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titrating the dose over early weeks to minimize discontinuation due to

gastro-intestinal intolerance.‖
 ―Use sulfonylureas when metformin fails to control glucose
concentrations to target levels, or as a first-line option in the person
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who is not overweight.‖

 ―Use a PPAR-γ agonist (thiazolidinedione) when glucose
concentrations are not controlled to target levels, adding it:
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o to metformin as an alternative to a sulfonylurea, or

o to a sulfonylurea where metformin is not tolerated, or
o to the combination of metformin and a sulfonylurea.
Be alert to the contra-indication of cardiac failure, and warn the person

with diabetes of the possibility of development of significant oedema.‖
 ―Use α-glucosidase inhibitors as a further option. They may also have

a role in some people intolerant of other therapies.‖
For ―minimal care‖ the guidelines noted that:
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 ―Metformin and a generic sulfonylurea should be the basis of oral
glucose-lowering therapy. Where the costs of thiazolidinedione
therapy are lower than those of basic insulin therapy, use of these
drugs may be considered before transfer to insulin.
 Where renal function tests are not routinely available for people on
metformin, such tests are nevertheless required where the likelihood
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of renal impairment is high.‖
Thus, while the impression is created that ―standard care‖ (which might be
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interpreted as the ―standard of care‖) should provide access to a wide range of
the oral antidiabetic agents, the absolute minimum seems to more closely
match the narrow range of medicines for the management of diabetes mellitus
(types 1 and 2) that were included in section 18.5 of the 16th WHO Model List
of Essential Medicines, published in March 2009 (World Health Organization,
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2009), as shown in the table below.
Table 2. Antidiabetic medicines listed in the 16th WHO Model Essential

Medicines List
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Core list
glibenclamide. Tablet: 2.5 mg; 5 mg
insulin injection (soluble) Injection: 40 IU/ml in 10ml vial; 100
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IU/ml in 10ml vial.

intermediate-acting insulin Injection: 40 IU/ml in 10ml vial; 100
IU/ml in 10ml vial (as compound insulin
zinc suspension or isophane insulin).
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metformin Tablet: 500 mg (hydrochloride).

Complementary List [c]
metformin Tablet: 500 mg (hydrochloride).
Source: Note from the original document (World Health Organization, 2009): ―Where
the [c] symbol is placed next to the complementary list it signifies that the
medicine(s) require(s) specialist diagnostic or monitoring facilities, and/or
specialist medical care, and/or specialist training for their use in children.‖
Unlike in hypertension, where the vast majority of patients will be adults,

the selection of medicines for type 1 diabetes mellitus in particular must take
account of the needs of children. The WHO Model EML has accommodated
the growing threat of type 2 diabetes in the young, while noting that safe use in
this age group requires additional resources. This explains why metformin (a
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standard first-line choice in adults) is included in both the core and
complementary lists.
7.2.3. Asthma and Chronic Obstructive Pulmonary Disease
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Global guidelines for the management of asthma have been issued by the
Global Initiative for Asthma, for both adults and children (GINA, 2008; GINA
2009). As with the diabetes guidelines, both these documents list a series of
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pharmaceutical manufacturers as having supported the guideline development
process by means of unrestricted education grants.
The adult GINA guidelines (GINA, 2008: 3) noted that ―[f]urther studies
of the … cost-effectiveness of treatment are needed in both developed and
developing countries‖. While including newer agents (such as the leukotriene
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antagonists and long-acting beta-agonists), the 2008 GINA guidelines did
provide some support for the choices evident in section 25.1 of the 16th WHO
Model List of Essential Medicines, published in March 2009 (World Health
Organization, 2009), shown in the table below. Specifically, it noted that
―[t]he role of theophylline in treating exacerbations remains controversial‖.
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Theophylline no longer appears on the WHO Model EML, though it has been
widely used in many countries (GINA, 2008: 35). A similar sentiment was
expressed in the 2009 GINA guidelines for children aged 5 and younger
(GINA, 2009: 7).
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In addition, the WHO Model EML included prednisolone (with a square

box symbol) as oral liquid (5 mg/ml – for use in children, but with the [c]
symbol) and tablet (5 mg; 25 mg), under section 3 (Antiallergics and
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medicines used in anaphylaxis).

The 2008 GINA guideline also noted that ―[s]hort-acting 2-agonists are
appropriate for use in the few patients who are unable to use inhaled
medication. However, their use is associated with a higher prevalence of
adverse effects‖ (GINA, 2008: 35). This was echoed in the 2009 GINA
paediatric guidelines (GINA, 2009: 8). This document was perhaps less
supportive of other oral medication used in children, finding some evidence
for the leukotriene modifiers, but none for the cromones (GINA, 2009: 7).
Table 3. Asthma medicines listed in the 16th WHO Model Essential

Medicines List

Core list
 beclometasone.
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Inhalation (aerosol): 50 micrograms (dipropionate) per
dose; 100 micrograms (dipropionate) per dose (as CFC
free forms).
 budesonide [c] Inhalation (aerosol): 100 micrograms per dose; 200
micrograms per dose.
epinephrine (adrenaline) Injection: 1 mg (as hydrochloride or hydrogen tartrate) in
1‐ml ampoule.
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ipratropium bromide Inhalation (aerosol): 20 micrograms/metered dose
 salbutamol* Inhalation (aerosol): 100 micrograms (as sulfate) per dose.
Injection: 50 micrograms (as sulfate)/ml in 5‐ml ampoule.
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Metered dose inhaler (aerosol): 100 micrograms (as
sulfate) per dose.
Oral liquid: 2 mg/5 ml.
Respirator solution for use in nebulizers: 5 mg (as
sulfate)/ml.
Tablet: 2 mg; 4 mg (as sulfate).
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* Oral salbutamol treatment should only be considered
when inhaled asthma therapy is not feasible.
Source: Notes from the original document (World Health Organization, 2009): ―The square
box symbol () is primarily intended to indicate similar clinical performance within a
pharmacological class. The listed medicine should be the example of the class for
which there is the best evidence for effectiveness and safety. In some cases, this may
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be the first medicine that is licensed for marketing; in other instances, subsequently
licensed compounds may be safer or more effective. Where there is no difference in
terms of efficacy and safety data, the listed medicine should be the one that is
generally available at the lowest price, based on international drug price information
sources.‖ ―Where the [c] symbol is placed next to an individual medicine or strength of
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medicine it signifies that there is a specific indication for restricting its use to
children.‖
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The problem of finding an affordable spacer device for children,

appropriate to their age group, remains intractable in many settings. The 2009
GINA guidelines suggested that the preferred inhaler device for children aged
younger than 4 years was a pressurized metered-dose inhaler plus a dedicated
spacer with a facemask, while for children aged 4 to 5 years, the same inhaler
could be used with a dedicated spacer with a mouthpiece. While dedicated
spacer devices are available, they may not be affordable or accessible to many
carers in developing countries. Although caution was urged due to the low
number of randomized trials that could be used, a Cochrane Review found no

statistically significant difference in outcomes when metered-dose inhalers
were used for delivering rapid-acting inhaled -2 agonists with home-made or
commercial spacers in children with acute exacerbations of wheezing or
asthma (Rodriguez-Martinez et al, 2008).
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The Global Initiative for Chronic Obstructive Lung Disease published
guidelines for the management of this condition in 2008 (GOLD, 2008). As
with the GINA guidelines, the development of this document was made
possible with ―unrestricted educational grants‖ from pharmaceutical
manufacturers active in this market. In general, the evidence summarised in
this report would appear to support the non-listing of the methylxanthines
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(such as theophylline) in the WHO Model EML. However, the major
difference would be the lack of a long-acting anticholinergic inhaler
(tiotropium) and the long-acting 2-agonists (salmeterol and formoterol) on
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the WHO list.
7.3. PROCUREMENT AND DISTRIBUTION OF MEDICINES

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One of the key components of any national medicines policy is to outline
the supply system to be followed in a country Efficient procurement and
distribution are enabled by clear selection. As the WHO guide states:
―Essential drugs, which are selected on the basis of safe and cost-effective
clinical guidelines, give better quality of care and better value for money. The
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procurement of fewer items in larger quantities results in more price

competition and economies of scale. Quality assurance, procurement, storage,
distribution and dispensing are all easier with a reduced number of drugs.
Training of health workers and drug information in general can be more
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focused, and prescribers gain more experience with fewer drugs and are more
likely to recognize drug interactions and adverse reactions‖ (Hodgkin et al,
2001: 6).. Elements that need to be addressed in any national medicines policy,
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and which will have an impact on the procurement and distribution of

medicines for non-communicable diseases include choices around the
appropriate mix of public and private involvement in supply and distribution
systems, a clear commitment to good pharmaceutical procurement practices,
the publication of price information, steps to ensure supply in acute
emergencies, systems for inventory control and the prevention of theft and
waste, and finally, appropriate measures for the disposal of unwanted or

expired medicines (Hodgkin et al, 2001: 8).
Ensuring that the correct medicines are available at the right cost in the
right amounts requires that skilled personnel are involved in these
deliberations and that there is a good information system and adequate
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financing available. A major challenge to ensuring adequate management of
chronic, non-communicable diseases is, as was noted by Epping-Jordan et al
(2001), the ability to ―[r]eorganise healthcare finance to facilitate and support
evidence based care‖. This is particularly true in relation to medicines for
these conditions. Where public sector facilities are unable to provide access to
medicines at a price, patients and carers can afford or are frequently out of
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stock of such medicines, and where out-of-pocket purchases of medicine are
common, then sustained access to chronic treatment may be compromised. In
developing countries, access to medicines can be interrupted due to poor
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forecasting by health care facilities, or the procurement agency, or by the costs
relating to accessing treatment from facilities that patients have to incur (such
as transport costs, loss of earnings, costs incurred by accompanying family
members or carers).
Disconcerting evidence of the lack of access to 32 selected essential
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medicines for chronic diseases was provided in a survey conducted in 6 low-
and middle-income countries (Mendis et al, 2007). The list chosen could also
form the basis of a key list for monitoring purposes (see Box 1). This survey,
conducted in Brazil (Rio Grande do Sul state), Pakistan, Sri Lanka,
Bangladesh, Malawi and Nepal, showed that less than 8% of the 32 medicines
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were available in all countries except two (Brazil, 30%; Sri Lanka, 28%). The
potential effect of price on accessibility was striking. For example, it was
shown that the cost of innovator products (branded products sold by the initial
patent–holder) was three times that of generic medicines in the Malawian and
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Sri Lankan private sectors. The cost of a one-month course of intermediate-

acting insulin ranged from 2.8 days‘ average wages for the lowest-paid
government worker in Brazil to 19.6 in Malawi. Similarly, a month of
combination treatment for coronary heart disease cost from 1.5 days‘ wages in
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Sri Lanka to 18.4 days‘ wages in Malawi. The extent to which these prices
would constitute a real barrier to care would vary considerably depending on
how healthcare (and medicines in particular) was financed. The different
forms of financing medicines access were also highlighted in this paper: ―In
the public sector in Bangladesh, Brazil, Malawi, Pakistan and state hospitals in
Sri Lanka, medicines are generally provided free of charge. In Sri Lanka,
patients must pay at public pharmacies. In Malawi, patients are required to pay
for some medicines that are not on the national essential medicine list and are
therefore not supplied through the Central Medical Store, however these are
rarely available.‖ Similarly, it was noted that ―[i]n Nepal‘s public sector,
government-supplied medicines are free, but because they are often not
available public facilities obtain medicines from other sources (e.g.
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community drug treatment programmes) and then sell them to patients.‖
Financing ongoing access to a medicine, albeit a life-saving or live-prolonging
medicine, that costs more than half a month‘s earnings for a basic government
worker is simply not feasible. Pre-payment schemes, through general taxation
or ear-marked social security taxes, are needed but all too often absent or
inefficient in such settings.
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Access to medicines is not sufficient though to ensure that care will be
appropriate. Beran and colleagues (2008) have pointed to the need for access
to diagnostic tools, the presence of trained healthcare workers with the ability
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to interpret laboratory data and a referral pathway in relation to diabetes care.
While that is true, the effects of medicine prices (and the effects on these of
monopoly practices related to patent protection) cannot be ignored.
A more in-depth assessment of barriers to treatment for chronic disease
was provided by a household survey performed in the Agincourt district of
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Mpumalanga province, South Africa (Goudge et al, 2009). In this study, data
were obtained from 1446 individuals, and then 30 households were followed
up for 10 months. In the initial survey, although 74% of reported health
problems were described as ―chronic‖, almost half (48%) had no treatment
action taken in the previous month. Equally, although 34 cases of chronic
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conditions were identified in the 30 households, only 35% were receiving

regular treatment. This needs to be understood in the context of post-apartheid
South Africa having made access to primary health care services (including
medicines) free at the point of care. Despite this policy, reasons for not
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accessing care included interrupted medicine supplies at the clinics and also
―insufficient clinical services at the clinic level necessitating referral‖. While
the authors noted that ―[p]oor provider-patient interaction led to inadequate
understanding of illness, inappropriate treatment action, ‗healer shopping‘, and
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at times a break down in cooperation, with the patient ‗giving up‘ on the
public health system‖, they also found instances of ―productive patient-
provider interactions‖, which ―not only facilitated appropriate treatment action
but enabled patients to justify their need for financial assistance to family and
neighbours, and so access care‖. Examples of the experiences of patients from
this survey site are shown in Box 2.
Box 1. 32 key medicines for chronic, non-communicable diseases
Cardiovascular disease
Aspirin 100mg
Atenolol 50 mg
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Benzathine benzylpenicillin 2.4M IUs
Captopril 25 mg
Enalapril 10 mg
Erythromycin 250 mg
Furosemide 40 mg
Hydrochlorothiazide 25 mg
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Isosorbide dinitrate 5 mg
Losartan 50 mg
Lovastatin 20 mg
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Methyldopa 250 mg, 500 mg
Nifedipine (sustained release) 20 mg
Phenoxymethyl penicillin 250 mg
Propranolol hydrochloride 40 mg
Spironolactone 25 mg
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Streptokinase 1 500 000 IU
Chronic respiratory disease
Aminophylline 100 mg
Beclometasone inhaler 0.05 mg/dose
Ipratropium bromide 20 μg/dose
Prednisolone 5 mg 25 mg
Salbutamol inhaler 0.1 mg/dose
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Diabetes
Glibenclamide 5 mg
Insulin isophane 100 IU/ml
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Insulin soluble 40 IU/ml A

Insulin soluble 100 IU/ml
Insulin zinc suspension 40 IU/ml
Insulin zinc suspension 100 IU/ml
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Metformin 500 mg
Palliative cancer care
Codeine 30 mg
Morphine sulfate 30 mg
Glaucoma
Timolol eye drops
Source: Mendis et al (2007) Note: Benzathine benzylpenicillin and erythromycin
were included for patients with rheumatic fever.
Box 2. Patients’ experiences with interrupted medicine supplies
―Respondents complained that public clinics repeatedly ran out of drugs.

For a highly vulnerable household such as Elphas‘s (Case HV12), the regular
stock outs at his closest clinic led to ‗shopping around‘, non-consultation and
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self-treatment, rather than wasting funds on transport for a fruitless trip to his
local clinic. High blood pressure patients from secure households also faced
regular drug shortages. As a result Ruth (Case S8) took a sample of her pills to
the local chemist who sold her some without a prescription, and Phosiwe (Case
S4) regularly returned to the district hospital to ensure she had the necessary
supply of pills. In comparison, Elphas (Case HV12) from a highly vulnerable
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household who had more complex symptoms and an unclear diagnosis did not
have the funds to go the chemist or to visit the hospital.‖
Source: Goudge et al (2009).
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The barriers to access to appropriate medicines for chronic, non-
communicable diseases are thus not only physical (such as the distance to the
nearest clinic), and financial (consulting fees and medicine prices), but also
operational (such as access to ambulance services, clinical capacity for
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diagnosis and management, effective referral pathways) and attitudinal (those
that hinder the development of the ―therapeutic alliance‖ between patients,
carers and healthcare workers).
However, without access to essential medicines, even the most committed
and well-trained first-level healthcare workers cannot easily provide
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meaningful care to patients diagnosed with chronic, non-communicable

diseases.
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7.4. USE OF MEDICINES

A key intervention in relation to the care of children was the development
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of the Integrated Management of Childhood Illness (IMCI) approach by the

World Health Organization and UNICEF (http://www.who.int/child_
adolescent_ health/topics/prevention_care/child/imci/en/index.html). A similar
process is underway, entitled Integrated Management of Adolescent and Adult
Illness (IMAI) (http://www.who.int/3by5/ publications/ documents/imai/en/).
One of the first products has been a booklet on ―General Principles of Good
Chronic Care‖ (World Health Organization, 2004b). The principles are
presented in Box 3.
Box 3. General Principles of Good Chronic Care
1. Develop a treatment partnership with your patient.

2. Focus on your patient‘s concerns and priorities.
3. Use the 5 A‘s: Assess, Advise, Agree, Assist and Arrange.
4. Support patient self-management.
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5. Organize proactive follow-up.
6. Involve ―expert patients,‖ peer educators and support staff in your health
facility.
7. Link the patient to community-based resources and support.
8. Use written information—registers, Treatment Plan, treatment cards and
written information for patients—to document, monitor and remind.
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9. Work as a clinical team.
10. Assure continuity of care.
Source: World Health Organization (2004b).
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It has long been recognised that patients‘ adherence to treatment
instructions is less than acceptable, but also that the interventions needed to
improve adherence are complex and multi-faceted (Haynes et al, 2008). This
Cochrane Review concluded that: ―Almost all of the interventions that were
effective for long-term care were complex, including combinations of more
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convenient care, information, reminders, self-monitoring, reinforcement,
counselling, family therapy, psychological therapy, crisis intervention, manual
telephone follow-up, and supportive care. Even the most effective
interventions did not lead to large improvements in adherence and treatment
outcomes.‖ Other Cochrane Reviews have looked at adherence specifically in
relation to hypertension (Schroeder et al, 2004), type 2 diabetes mellitus
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(Vermeire et al, 2005) and asthma (Toelle and Ram, 2004). As expected, the
vast majority of the studies included in these reviews were conducted in
developed countries. Their applicability in developing countries settings may
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thus be questioned.
Much effort has been expended on the terminology of adherence. Haynes
et al (2008) wrote that ―adherence can be defined as the extent to which
patients follow the instructions they are given for prescribed treatments. …
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The term, adherence, is intended to be non-judgmental, a statement of fact

rather than of blame of the patient, prescriber, or treatment. Adherence is not
the same as ―concordance‖, which includes a consensual agreement about
treatment taking established between patient and practitioner. Many reasons
exist for non-adherence to medical regimens, including (but not restricted to)
problems with the regimen (such as adverse effects), poor instructions, poor
provider-patient relationship, poor memory, and patients‘ disagreement with
the need for treatment or inability to pay for it.‖ In terms of chronic treatment,
another term used has been ―persistence‖. A review of methods to assess
persistence using automated databases found that the terminology, definitions,
and methods to determine adherence and persistence differed greatly in the
published literature (Andrade et al, 2006). However defined, ensuring that
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patients adhere to treatment instructions over time, and timeously refill
prescriptions so as to ensure uninterrupted, persistent use of their medicines, is
a challenge in all settings. Where there are substantial funding barriers to
overcome, this problem would be expected to pose even greater challenges.
Another aspect that requires monitoring is adherence to treatment
protocols by prescribers. A survey conducted in the North West province of
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South Africa found that less than optimal adherence to guidelines for
hypertension, diabetes, asthma and epilepsy. It also found that less than 50%
of patients were ―controlled‖. Surveys such as these are time-consuming and
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expensive to perform. An alternative, in which supply data from central
pharmaceutical stores is used to assess adherence to guidelines, was shown to
be effective in relation to medicines for hypertension (Pillay et al, 2009).
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7.5. RESEARCH NEEDS
The lack of reliable data on the overall burden and causes of disease in
developing countries is a cause for concern. This lack of data needs to be
addressed so that the priority given to different health interventions within a
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population will take into account the relative burden of diseases. A major
challenge is to do this within the available resources, both local and from
external agencies. Longitudinal studies of representative communities provide
one approach to filling the data gap. In addition, the modification of behavioral
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risks will be dependent on understanding and integrating cultural aspects into

lifestyle changes.
Another major unmet research need is to provide the data necessary to
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improve the efficiency and effectiveness of scarce resources. There is limited

systematic evidence available on the quality of the care provided for patients
with non-communicable diseases in developing countries. The application of
health services research methods is crucial if resources that are currently
committed to the treatment of these conditions are to be used in the most
efficient and effective way possible.
Rational selection requires access to relevant data on the comparative
efficacy and safety of medicines, preferably generated in populations
substantially similar to those for which the selection decisions are being made.
Randomized head-to-head comparative trials of medicines for chronic, non-
communicable diseases are rare enough, but even fewer have been conducted
in developing country settings.
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7.6. PUBLIC HEALTH IMPLICATIONS
AND HEALTH SYSTEM NEEDS
Health systems in developing countries are facing major challenges as a
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result of growing epidemiological diversity, which is a consequence of rapid
economic development and declining fertility. The infectious and parasitic
diseases of childhood that have always been a problem must now compete for
scarce resources with chronic diseases among adults, as well as adolescents.
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Jamison and Mosley (1991) argue, "Health policymakers must engage in
undertaking an epidemiological and economic analysis of the major disease
problems, evaluating the cost-effectiveness of alternative intervention
strategies; designing health care delivery systems; and, choosing what
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governments can do through persuasion, taxation, regulation, and provision of
services". Most developing countries lack information about most major
diseases among adults and adolescents, resulting in a poor capacity for
epidemiological and economic analyses, health technology assessment, and
environmental monitoring and control. There is a critical need for national and
international investment in capacity building and essential national health
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research in order to inform rational health policies.

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CONCLUSION
As chronic non-communicable diseases become a more prevalent and
widespread problem in developing countries, governments will need to adopt
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strategies that are evidence-based to assist with managing these conditions.

Prevention strategies need to target the young age group, to reduce long term
complications and prevent further burden of the health care system. In terms of
management of these conditions, attention needs to be paid to accepting
guidelines that have been approved by authoritative and unconflicted bodies,
such as the WHO, and efforts need to be directed at addressing efficient
procurement, distribution and use of these medicines. Uninterrupted supplies
need to be maintained, and for this the appropriate training of staff at all levels
need to be undertaken. Proper information systems need to support
procurement and cost analyses. Prescribers need to be trained and encouraged
to adhere to treatment guidelines, and patients need to be educated about
adhering to therapy.
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Further attention by the international community on developing dosage
forms that are suitable to children is critical, as more and more children begin
to develop chronic non-communicable diseases. This area has been sadly
neglected, resulting in complicated dosing strategies for children, or limiting
the options available for therapy.
Finally, health and treatment literacy levels in developing countries are
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low. Communication and counselling of patients has to consider language
barriers, as well as literacy barriers. Patient aids to medication therapy need to
be developed in a standardised manner to assist with these barriers.
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ACKNOWLEDGMENT
The authors wish to acknowledge the inputs provided by anonymous
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reviewers of this chapter, as well as the contributions over time of their
colleagues involved in medicines selection, procurement, distribution and use.
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[Accessed 12 June 2009].
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Chapter 8
POPULATION AGEING: THE CHANGING
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PROFILE OF CHRONIC DISEASES IN
DEVELOPING COUNTRIES
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Sebastiana Z. Kalula and Adesola Ogunniy
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ABSTRACT
Background: Population ageing in sub-Saharan African (SSA)
countries will increase the burden of chronic diseases and disability
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which are demanding of public health services.

Objectives: To document the predominant diseases in older persons
and highlight the changing profile of risk factors for chronic diseases.
Methods: A systematic literature search of PubMed and Medline was
done for the period between January 1995 and August 2009. Three
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hundred and twenty one journal articles including 43 reviews were

accessed for relevant information.
Results: Ageing was associated with high prevalence of obesity,
hypertension, coronary heart disease, and type 2 diabetes. Hypertension
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remains a major killer and its morbidity is accentuated by poor levels of

awareness, monitoring, treatment and control. Smoking and alcohol
consumption are responsible for substantial morbidity and mortality.

+27 21 406 6211 (office), +27 21 406 6846 (fax), Email: Sebastiana.kalula@uct.ac.za.

Tel: +234 8038094173, E-mail: aogunniyi892@gmail.com.
180 Sebastiana Z. Kalula and Adesola Ogunniy
Conclusions: Chronic diseases have become major public health

problems in SSA due to ageing and increasing urbanization.
Implementation of coordinated health promotion is warranted.
Keywords: Ageing, Chronic diseases, Developing countries
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Epidemiologic transition
8.1. INTRODUCTION
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Population ageing refers to an expanding population aged 60 years and
older, relative to a shrinking younger population. The process is measured by
an upward change in a population‘s median age and an increase in the
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proportion of persons aged 60+ years. Population ageing is driven by
reductions in the birth rate and mortality, and increased longevity (United
Nations DESA, 2007). The world‘s population is ageing and Africa is not left
out of this greying revolution although her proportion of older persons (aged
60 years and older) of 5% is the lowest across all the regions. The average life
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expectancy at birth is just under 52 years in most of the countries. South
Africa, with 7.5% of the aged population in her 2009 estimates, has the highest
proportion of older persons in sub-Saharan Africa (SSA) with the exception of
Mauritius that has 10% and Lesotho with 7.6% (United Nations DESA 2009)
and it is projected that by the year 2050, their proportion will rise to 13.3%
when life expectancy at age 60 years would have increased to 19.5 years from
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16.5 years at the present time (United Nations, 2007). Women in the sub-
region have greater life expectancy than men (17 years for women, 15 years
for men) and the majority of older persons (55%) are women (United Nations
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DESA, 2007). The longevity trend is further reflected in the fact that the age
group 80 years and over that constitutes 8 per cent of the older population, is
projected to increase to 19 per cent by 2050. This is regarded as the fastest
growing segment of the older population (UN Population Division (UNDP),
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2006).
In 2009, the ethnic distribution of South Africa‘s population of age 60
years and over was blacks 63.5%, coloureds (mixed ancestry) 8.5 %,
Indians/Asians 3.8 % and whites 24.2% (Stats SA, 2009). However, the
absolute number of black elderly persons is set to increase dramatically, and
the white population to decrease proportionately, which will have implications
for future public sector care and service provision. The blacks who are in the
Population Ageing 181
majority have been disadvantaged across the life course and suffer cumulative
effects of the disadvantages in old age. They are largely poor, reliant on public
welfare (especially the old age social grant) and public services (health and
social services). In addition, many of them lack medical insurance which
provides access to private healthcare.
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Health matters concerning the older persons have not received adequate
attention from governments in many African countries because the population
is relatively young and older persons are no longer in the productive sector of
the economy. With increasing age, there is a shift in disease profile from
mainly infections, nutrition and maternal conditions to chronic and
degenerative disease and other lifestyle-related disabilities. The shift in disease
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pattern leads to a change in health needs with an increased demand for chronic
care. This chapter therefore focuses on the health and social needs of older
persons in sub-Saharan Africa (SSA) with emphasis on South Africa
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highlighting how changing environmental factors like urbanization and
lifestyle have influenced health with preponderance of non-communicable
diseases (NCDs). The issues will be presented in proper perspective by
drawing examples from the other parts of the world.
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8.2. METHODOLOGY
A systematic literature search of PubMed and Medline was done with
combinations of search terms, including ―developing countries‖, ―non-
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communicable disease‖, ―epidemiologic transition‖, ―chronic diseases

epidemiology in sub-Saharan Africa‖, ―population ageing‖, ―medical
morbidity in older persons‖, ―urbanization and diseases of older persons‖ and
―determinants of health ageing‖. PubMed and Medline were searched from
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January 1995 until August 2009 with emphasis on literature from Africa, in
the main and relevant papers from other parts of the world. Only sources in
English were accessed and these comprised 278 papers and 43 reviews. In
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addition, 14 books and reports were also consulted for additional information.
Journal articles not accessible on websites were obtained from libraries around
South Africa. Information derived from the articles were categorized into
those dealing with urbanization and changing health status, risk factors for
cardiovascular diseases, falls in the elderly, dementia, neoplastic diseases and
emerging health/social needs.
8.3. RESULTS
8.3.1. Urbanisation and the Changing Health Status of Urban
and Rural Older Populations
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Increasing urban living is a global phenomenon and this trend is most
noticeable in SSA. The proportion of urban dwellers in South Africa which
was 63% in 1990 is projected to reach 80% by the year 2015 (Kinsella, 2001).
Most of the urban growth has involved migration of blacks and the main
impetus for this is the desire to seek better life through better education
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opportunities and gainful employment. Urbanization comes with a price which
has profound effect on traditional ways of life including family dynamics.
Women are disproportionately represented in the older population in rural
areas (about 60%). These areas are typically depopulated, have stagnant
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economies, poor infrastructure, services, and are characterised by increased
vulnerability of the older population.
Rural to urban migration of able-bodied young people deprives the older
persons of the usual support in the rural communities while those that are
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resettled in urban areas are likely to suffer from stress due to disorientation
and/or alienation in the new environment with possible predisposition to
mental disorders. Violence in urban settlements in the form of rape, house-
break-in, assault and armed robberies cause physical injuries, depression,
panic disorders and post-traumatic stress disorder. The attendant socio-
economic and dietary changes have added to the health burden of older
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persons.
On the other hand, living in urban areas is associated with changes in
physical activity, adoption of new dietary patterns and possible exposure to
environmental pollution depending on the extent of industrialization.
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Diminished physical activity; decline in intake of cereal and fibre, low

vegetable and fruit intake as well as increased consumption of animal fat have
been reported. Some workers have also documented that the total cholesterol
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and low-density lipoprotein cholesterol levels are significantly higher in urban

men and women than their counterparts in rural communities (Steyn, et al.
1997, Steyn et al., 2003, Voster et al., 2005, Norman et al., 2007). Dramatic
increases in chronic diseases of lifestyle such as obesity, hypertension,
coronary heart disease, and type 2 diabetes have been reported in the black
population as a result of increasing urbanization. The other behavioural and
lifestyle changes include increased alcohol consumption and smoking,
particularly by women (Steyn, et al. 1997, Voster et al., 2005). Table 1 shows
the distribution of risk factors for chronic diseases from a population based
study of older persons in South Africa with higher prevalence rates for
hypertension, current smoking, exposure to fumes and dust and being
overweight.
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8.3.2. Implications of Population Ageing for Disease Profiles -
Chronic Diseases and the Risk Factors
Old age is characterised by a number of chronic diseases which result

from programmed cell death, senescence of the immune system,
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atherosclerosis, accumulation of genetic damage, wear and tear involving
joints and ligaments, diminished function of sense organs and chronic disease
of organs. Diseases do not know geographic boundaries. However, there are
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relative differences in the various SSA countries mainly due to disparities in
the extent of development as well as variations in socio-economic factors and
health practices.
In the SSA sub-region, there has been a change from a predominance of
infections, parasitic diseases, malnutrition and poor maternal health to an
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increased prevalence of chronic degenerative diseases and disabilities.
These countries were once described as confronting a ―double jeopardy‖ of
fighting re-emerging epidemics of communicable diseases like tuberculosis,
diarrhoeal diseases and malaria, while managing an increasing burden of non-
communicable diseases (NCDs). Indeed, the countries are now said to face a
―quadruple jeopardy‖ through the inclusion of high prevalence rates of injuries
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due to violence (vehicular accidents, stabbings, etc.) and the impact of the HIV
and AIDS epidemics (Joubert and Bradshaw, 2006). Disability, as a result of
violence-related injuries and AIDS-related morbidity, and the effects of age-
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associated degenerative diseases, constitutes a considerable "burden of

disease" for the governments. The shift in disease pattern leads to a change in
health needs with an increase in demand for chronic care.
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Thus far, only 30 per cent of adult deaths in SSA countries are caused by
NCDs, compared to 90 per cent in developed countries (WHO, 2003; Hale et
al., 2007). The sub-regional countries constitute a high mortality region, due to
underweight, unsafe water, poor sanitation, indoor smoke from solid fuels, and
unsafe sex – all leading factors contributing to the disease pattern.
Table 1. Risk factors for disease in older persons by residence in South

Africa (in percentages)
NON- URBAN
URBAN
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Risk factors Men Women Men Women
Current smoking 25.5 4.9 23.5 11.5
% living with 12.9 19.8 23.1 23.8
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smokers
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% exposed to 25.0 4.5 27.0 18.0
fumes/dust
Alcohol –weekend 1.9 1.2 0.2 2.2

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binges
Signs of alcohol 21.4 7.2 20.7 6.8

dependence
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BMI – Obesity 10.0 22.6 19.0 37.1

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– Overweight 30.8 34.7 34.1 34.4

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Physical inactivity 62.4 73.9 66.8 74.0
<600 METS
Hypertension 18.4 25.9 34.0 42.2

The countries remain youthful moreover (a median age of 18.2 years (UNPD,
2009)), and communicable diseases still constitute seven out of 10 causes of
child deaths and 60 per cent of all child deaths (WHO, 2003; Hale et al.,
2007). Hence, this disease pattern will continue to prevail for some time, but
the pattern of non-communicable disease is set to change.
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In South Africa for the year 2000, NCD and disability were found to be
responsible for 84 per cent of older person deaths; communicable diseases and
nutritional deficiencies for 13 per cent; injuries for 3 per cent; and AIDS for
0.4 per cent (Joubert and Bradshaw, 2006). In the 2001 population census, 16
per cent of older persons (13 % aged 60-69 years, 17 % aged 70-79 years, 27
% aged 80+ years) reported having a disability – most commonly sight and
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physical, followed by emotional, intellectual and communication conditions
(Joubert and Bradshaw, 2004).
Information on the important chronic diseases like hypertension, diabetes
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mellitus, hyperlipidemia, chronic respiratory diseases, mental disorders and
neoplastic diseases in the older persons are available from community-based
studies and hospital-derived data from many SSA countries namely South
Africa, Nigeria, Ghana, Burkina Faso, Senegal, Kenya, Cameroon and
Botswana. Hypertension, diabetes mellitus and hyperlipidemia predispose to
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myocardial infarction, strokes, cardiac failure and renal damage. The two
leading causes of death in persons aged 60 years or older in South Africa are
ischemic heart disease (IHD) and stroke as shown in Table 2 (Steyn et al.,
2006).
Ischaemic heart disease can be regarded as an emerging disease which was
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largely uncommon in the indigenous population with their traditional lifestyles

but it has now become a major factor in morbidity and mortality in older
persons. The changed situation can be blamed on adoption of western
lifestyles, risk-prone behaviour, diet and consequences of rapid urbanization as
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some authors have argued (Ntusi and Mayosi, 2009). Deaths from IHD in
India rose from 1.17 million in 1990 to 1.59 million in 2000 and are estimated
to reach 2.03 million in 2010 (Ghaffar et al., 2004). Eight of the ten leading
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causes of death in older men and women in South Africa are non-
communicable diseases unlike in the past when communicable diseases
predominated (Steyn et al., 2006).
Table 2. Ten leading causes of death in 60 years old and over by gender in
South Africa
Male (N = 71641) Female (N = 73474)
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Diseases Frequencies % Diseases Frequencies %
Ischemic heart 17.2 Stroke 17.7

disease
Stroke 12.2 Ischemic heart 16.0

disease
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COPD* 8.0 Hypertensive heart 9.8
disease
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Tuberculosis 6.4 Diabetes mellitus 7.3
Lower respiratory 5.1 Lower respiratory 5.3

tract infections tract infections
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Hypertensive heart 4.2 COPD* 4.4
disease
Lung cancer 4.1 Chronic kidney 2.8

disease
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Diabetes mellitus 4.0 Tuberculosis 2.7
Prostate cancer 3.1 Asthma 2.4

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Oesophageal 2.8 Breast cancer 1.9

cancer
* Chronic Obstructive Pulmonary Disease

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Source: Joubert, J.D.; and Bradshaw, D. (2006).
8.3.3. Risk Factors for Chronic Diseases
Hypertension and its complications constitute the most important health

condition causing disability and death in old age as shown in Table 3.
Hypertension accounted for 9% of total deaths and 2.4% of disability adjusted
life years in the year 2000 estimates in South Africa (Norman et al., 2007). In
South Africa, high levels of hypertension in women age 65 years and over (60
%) (Joubert and Bradshaw, 2006) are typically combined with poor levels of
awareness, monitoring, treatment and control. Data from the 2003 South
African Demographic and Health Survey (DHS) showed that a third of the
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hypertensives were controlled, half had their blood pressure measured in the
last 12 months, and a mere 12% of male and 20% of female hypertensives
were aware that their blood pressure was high. This is of great concern since
Norman and others (2007) have reported that 72% of hypertensive diseases,
50% of stroke and 42% of IHD were attributable to hypertension in adult
males and females.
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The risk factors for hypertension are increasing age, obesity and living in
urban settlements. The lifestyle and dietary changes associated with the latter
have been discussed earlier. The prevalence rates of hypertension in Pakistani
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adults were estimated to be 23% and 18% in urban and rural areas respectively
and similar rural-urban differential was also documented in Sri Lanka (World
Health Organisation, 2002; Jaffar et al., 2003). Table 3 shows the much higher
frequencies of hypertension in both men and women 65 years or older in South
Africa when compared with the frequencies in all adults aged 15 years and
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older. The frequencies are similar to findings in studies in Ghana and Burkina
Faso (Agyemang et al., 2006; Niakara et al., 2007). Increased consumption of
processed foods that are high in sodium is also contributory (Steyn et al.,
1997). However, rural communities are equally affected by this health
transition. A surveillance study comparing periods 1992-94 and 2002-05 in the
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Agincourt sub-district of rural South Africa, showed an increase of 65% in

deaths due to vascular disease (stroke, ischaemic heart disease and
hypertensive diseases) (Tollman, 2008).
The prevalence of hypertension is higher in blacks than in other racial
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groups, and this could be related to their salt-handling with the highest sodium
retention when compared with other ethnic groups (Charlton et al., 2005;
Norman et al., 2007). Important issues contributing to the morbidity of
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hypertension are poor compliance due to high cost of drugs and lack of
awareness; hence it is dubbed the silent killer disease.
Table 3: Morbidity and mortality associated with lifestyle risks in South Africa
Table 3. Morbidity and mortality associated with lifestyle risks in South
Africa
Prevalence (%)
Age Male Female DALYs (%) Deaths (%)
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Hypertension 60-69 2.4 9
80+
Diabetes 60-69 9.6 15.1 1.6 4.3

70-79 10.7 14.7
80+ 11.2 15
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Alcohol 60-69 15 5 7 7.1
70-79 11 4
80+ 11 4
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Smoking 60-69 40.9 11.6 4 8.5
70-79 35.2 6.6
80+ 24.9 3
Obesity 60-69 16 31.5 2.9 7

70-79 15.5 25.5
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80+ 8 22
Cholesterol >60 58 78.7 1.4 4.6
DALYs = Disability adjusted life years

Source: Joubert, J.D.; and Bradshaw, D. (2006).
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Diabetes Mellitus
Diabetes is an important cause of morbidity and mortality in Africa and
great variations in prevalence are noted from country to country and in some
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instances, within the same country. South Africa is in the category of countries
with high prevalence and Northern Sudan appears to have the highest rates in
African countries (Motala, 2002). The prevalence of diabetes increases with
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age in all South African ethnic groups and is twice as high in urban blacks as
in their non-urban counterparts (Bradshaw et al., 2007). Its combination with
hypertension means double trouble because of increased death risk from
ischemic heart disease and stroke as well as non-neoplastic renal disease.
Diabetes is also the leading cause of blindness and peripheral arterial disease
resulting in gangrene and amputation.
The risk factors for developing diabetes include age, positive family
history of diabetes, urbanization, obesity and physical inactivity. The best
example for this could be found in a study in Bangladesh that showed
doubling of the rate of diabetes between urban and rural areas (4% rural vs.
8% urban) and increased rates in affluent members of the community (Sayeed
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et al., 1997). Diabetes was attributed to have independently caused 14% of
IHD, 12% each of hypertensive and renal diseases and 10% of stroke in the
2000 risk estimate study in South Africa (Bradshaw et al., 2007). The
frequencies become staggering when added to those attributed to hypertension.
The hazard ratios for cardiovascular deaths and renal disease are significant in
all age-groups after 60 years (Motala, 2002). Microvascular complications of
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diabetes have been found to be associated with poor glycaemic control, long
disease duration, cigarette smoking, hypertension and dyslipidemia (Motala,
2002; Mwendwa et al., 2005).
Smoking
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In South Africa, the prevalence of smoking is generally higher in men
than in women in all age groups and the 60+ age bracket is not an exception
(Groenwald et al., 2007). Smoking is also more prevalent in the coloured
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population. In the comparative risk assessment survey of 2007, the prevalence
of smoking ranged between 24.9% and 41.8% in older men as against 3.0%
and 12.1% for women in age groups 60-69 and 80+ respectively (Groenwald
et al., 2007). A higher proportion of non-urban than urban men smoke daily
and/or use smokeless tobacco daily, while a higher proportion of urban than
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non-urban women smoke daily as shown in Table 1. Use of smokeless tobacco

is particularly high in non-urban women. Over one-fifth of all men 65+ and
over one-quarter of all women 65+ lived with smokers in their homes and
were subjected to secondary smoke inhalation (SADHS, 2003). Clausen et al.,
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(2006) reported a prevalence rate of 39% for tobacco use amongst the older
persons in Botswana.
Smoking is the second most important cause of death in the older
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population after hypertension in South Africa as shown in Table 3. It accounts

for 8.5% of deaths and 4% of disability-adjusted life years (Groenwald et al.,
2007). The associated morbidity is quite substantial, and smoking is attributed
to cause chronic obstructive airways disease, IHD, stroke as well as cancers of
the respiratory and digestive tracts. Smoking also predisposes to peripheral
arterial disease in addition to its being associated with pulmonary tuberculosis.
Both genders are at risk although the male tends to have higher risks for
developing most of the diseases (Groenwald et al., 2007).
Alcohol consumption is common among adults because drinking is a

social habit, however, with excessive drinking, as may occur in those who
binge on weekends or during social events, it becomes a major health issue.
The prevalence and severity of drinking are both higher in men than in women
(Schneider et al., 2007). A survey by Clausen and others (2006) reported a
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much higher prevalence of 34% prevalence for alcohol consumption in the
older population studied in Botswana. In the 2003 SADHS, a little less than
half of men 65+ and a fifth of women 65+ reported that they were current
consumers of alcohol. About 21% of men and 7% of women reported alcohol
dependence per the CAGE Questionnaire (Table 4). As alcohol consumption is
a sensitive issue, these figures are probably an underestimate.
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Table 4. Lifestyle and risk factor profile in South Africa
of persons 65+ (%)
Men
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Older population
Women
All ages (≥15 years
Men Women
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Hypertension (>140/90 52.0 60.4 22.9 24.6
mm/Hg)
Currently smoking daily 35.4 6.6 36.7 9.4
Alcohol dependant (per 22.6 7.0 27.6 9.9

CAGE measurement)
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Overweight 28.5 26.5 19.8 26.1
Obese 13.9 33.3 9.3 30.1

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Underweight 9.9 7.4 12.9 5.6
Source: SA Demographic and Health Survey, 1998, in Joubert and Bradshaw, 2004.
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Alcohol predisposes to the following health conditions in a dose-

dependent manner: chronic liver disease, hypertensive heart disease, IHD,
stroke, various neoplasms (liver, mouth, oesophagus, breast, and larynx),
diabetes mellitus, depression, epilepsy and dependence. On the other hand,
alcohol appears to have beneficial effects against ischaemic stroke,
hemorrhagic stroke in women who are mild to moderate consumers, type 2
diabetes mellitus and ischaemic heart disease (Schneider et al., 2007). Alcohol
also contributes significantly to inter-personal violence (39%), road traffic
accidents (14.3%), self-inflicted violence (3.7%) and 6% of other unintentional
injuries (Schneider et al., 2007). Alcohol caused 7.1% of deaths and was
responsible for the highest disability- adjusted life year of 7% in the 2000 risk
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estimates in older persons as shown in Table 3.
Obesity was once regarded as a western problem associated with affluence
and also culturally desirable for women as evidence of beauty and good health
in some societies. It has now become a worldwide problem because of
increased consumption of animal fats, high calorie diets and reduced physical
activity. Jobs have become more sedentary and increased application of
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technology in agricultural work has largely replaced manual labour of
yesteryears. Obesity is associated with living in urban settlements and studies
in migrant cohorts to industrialized countries have shown increased prevalence
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of obesity with adoption of western lifestyles. This was portrayed by a
comparative study of Ghanaians at 3 locations: urban, rural communities in
Ghana and those that immigrated to the Netherlands (Agyemang et al., 2009).
In the 2003 SADHS, 28.5% men 65+, were overweight (BMI 25-29.9 kg/m2)
and 13.9% obese (BMI > 30 kg/m2), while the corresponding figures for
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women 65+ were 26.5% and 33.3%. At the same time that a sharp increase in
underweight (BMI 18.5 kg/m2) was noted in this population, especially among
non-urban men (Joubert and Bradshaw, 2006). Slightly more urban than non-
urban older men were overweight, this difference was minimal among women
as shown in Table 1.
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The significant health risks associated with obesity in older men and
women in South Africa are: type 2 diabetes, hypertension, IHD, stroke,
osteoarthritis, colon cancer and kidney cancer (Joubert et al., 2007). In
addition, it is associated with breast and endometrial cancer in women. The
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mechanism by which obesity causes cancer is unclear, but may relate to

obesity induced hormonal changes (Calle et al., 2003). Obesity was
responsible for 7% of deaths in the year 2000 risk estimates and 2.9% of
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disability adjusted life years (Steyn et al. 2006). One factor that is paramount
in the control of obesity is the perception of thinness as evidence of disease
especially in the era of HIV/AIDS.
Dyslipidemia, evident by abnormal lipid profile with elevated total
cholesterol and other atherogenic lipid components, is commonly associated
with obesity, high intake of animal fat, poor intake of vegetables and fruits and
physical inactivity. The prevalence rates of high serum cholesterol (> 5
mmols/litre) in persons older than 60 years are 78.7% and 58.0% for female
and male respectively with a mean of 70.7% (Norman et al., 2007). In terms of
ethnic variation, the white population have the highest rate of elevated
cholesterol (97.9%) followed by the coloured (90.4%), the Asian/Indian
(85.2%) and black Africa bring up the rear with 44.9%. Dyslipidemia
predisposes to IHD and stroke, and was reported to be responsible for 4.6% of
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total deaths (Norman et al., 2007).
8.3.4. Other Chronic Diseases of the Older Persons
Osteoarthritis is common in older persons and affects the large joints
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usually. The wear and tear of daily life on the joints and trauma add to the
discomfort of the older persons. In a postal survey in the United Kingdom,
Badley and Tennant (1992) found that the rate of reporting joint problems
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increased markedly with age, from 5% in the 16-24 age brackets to 54%
amongst those aged 85 years and above. It also limited performance in the
activities of daily living. Obesity is a risk factor for the development of
osteoarthritis in the weight-bearing joints like the hip, knees and ankles. In
South Africa, obesity was attributable for 5.5% and 4% of the condition in
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female and male respectively (Joubert et al., 2007). Pain is the most common
presenting symptom followed by difficulty with walking. In a pilot study to
understand and foster the functioning and involvement of 55 ―contributive
elders‖ (SUFFICE) in Cape Town, Ferreira and others (2007) found that only
27.3% of the sampled elders aged 65 years and over rated their health as good
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and 90.9% claimed to be afflicted by chronic conditions. These included pain

syndromes, difficulty with walking, mood disorders and trouble sleeping. It is
conceivable that most of these complaints were due to osteoarthritis.
Osteoporosis and osteopenia or bone loss are other important causes of bone
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pains in older persons that could predispose them to fractures (Resnick and
Greenspan, 1989). The protective effect of abundant sunshine in the tropical
region which boosts vitamin D and bone metabolism warrants further studies,
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especially in older persons.

Falls are a major cause of disability and mortality in older persons. Both
the incidence and severity of complications relating to a fall increase steadily
after age 60. No data are available on the incidence of falls in older persons in
South Africa. A study from Umutara Province, Rwanda showed a prevalence
of recurrent falls of 23.2 per cent (Ntagungira 2005, thesis). International
studies show an incidence rate of 30-40 per cent in persons age 65 and over.
Twenty to 30 per cent of older persons who fall suffer serious injury such as
hip and other fractures, subdural haematoma and head injury (Tinetti, 1995).
Falls account for 10 percent of emergency hospital visits and 6 percent of
hospital admissions (Runge, 1993). Mortality following a fall is high in people
age 75 and over.
A significant proportion of those who survive a fall suffer significant
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morbidity with greater functional decline and increased dependence. Falls that
do not result in serious injury may still have serious psychological
consequences for an older person, who may fear falling again, which leads to
dependence and self-protective immobility (Tinetti et al., 1988; Vellas et al.,
1987). Management costs of fatal and non-fatal falls are high (Stevens et al.,
2006).
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Falls result from an interaction of multiple and diverse, sometimes
correctable intrinsic and extrinsic factors. Major risk factors for falls include:
lower extremity weakness; autonomic neuropathy; poor grip strength; gait and
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balance disorder; previous falls; functional impairment; visual deficits;
cognitive impairment, depression; polypharmacy and environmental hazards,
such as slippery or uneven walking surfaces and poor lighting (Tinetti et al.,
1995; Tromp et al., 1998).
The case below illustrates the complexities of causes of fall in an older
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person:
 An 80-year old male patient presented with recurrent falls of 4 months

duration. He had experienced 5 episodes characterized by falling
within 2-4 minutes of standing from a sitting position. He complained
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of a very brief spell of disorientation during one episode. His medical

history included background hypertension and ischaemic heart disease
for which he had coronary artery bypass graft (CABG) done 16 years
previously. He manifested features of renal failure in 2005 when his
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serum creatinine was 235umol/l. He suffered a recent myocardial

infarction in June 2008. In addition, he had been receiving treatment
for depression since March 2009 and has peripheral vascular disease
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with claudication after walking a distance of 20 metres. He mobilised

with a cane otherwise he was mainly house-bound with his wife who
suffers from dementia and 52 year-old son. He never took alcohol but
stopped smoking 40 years ago. He was not diabetic. His medications
included: Simvastatin 10mg nocte; Citalopram 30mg daily; Atenolol
50mg daily; Enalapril 10mg bid; Furosemide 40mg bid; Amlodipine
5mg daily; Allopurinol 300mg daily; Elantan 20mg bid; Isordil 5mg
sublingual PRN; Vitamin B complex tablets and paracetamol. On
examination, he was conscious and alert but pale, with normal vital
signs (Pulse: 60/min, in sinus rhythm, BP 140/70 mm Hg. with no
postural drop, respiratory rate 16/min. He had decreased leg pulses,
mitral valve regurgitation with bilateral carotid and femoral bruit.
Abdomen and chest were normal. He had osteoarthritis of the right
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hip. Nervous system examination showed mildly impaired cognition
(MMSE: 26/30) with presence of frontal release signs (pout, glabellar
tap and palmomental reflexes). His visual acuity was 9/6 L+R and
fundoscopy revealed grade 2 hypertensive changes. He had globally
brisk reflexes otherwise his motor and sensory testing was normal as
was coordination. The following results were obtained: hemoglobin:
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8.9 g/dl; mean corpuscular volume 94; white cell count: 6000/cu mm;
platelets 232; creatinine: 395 μmol/l; serum potassium 7 mmol/l;
random plasma glucose: 7 mmol/l; urine dipstick: +protein only;
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ECG: sinus rhythm, rate 56/min, left axis deviation, inferior infarct
and no arrhythmia on 48-hour cardiac monitoring. Tilt table test was
negative and carotid sinus massage was not done in view of bilateral
carotid bruits.
 Both enalapril and amlodipine were stopped while he continued his
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citalopram. He was placed on hematinics with vitamin D and calcium
supplements and he received kayexalate which brought his serum
potassium level down to 4.3 mmol/l pre discharge. He was
recommended for physiotherapy involving balancing and strength
training. He had no falls during the hospital stay.

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The recurrent falls in this patient could be adduced to any or a

combination of the following: medications (i.e., vasodilators, anti
depressant, diuretics, nitrates), anaemia, ischaemic heart disease, renal
impairment and hyperkalemia that could cause proximal muscle
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weakness and arrhythmia. Other possibilities included his use of cane

(assisted device) and other home-related environmental causes while
not overlooking possible carotid sinus hypersensitivity.
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Depression and Dementia

South Africa lacks representative data to estimate the prevalence of
dementia in the older population. However, high rates of depressive symptoms
in this population have been established in community surveys: an especially
high rate of 66 per cent in Khayelitsha, a newly settled township of Cape
Town, with a higher rate for women (44 %) than for men (25 %). The rates
were attributed to the effects of urbanisation, compounded by poverty, poor
environmental, housing and service infrastructure, and overcrowding, and to

stress in women burdened with coping and caregiving (Gillis, 1992).
Dementia is an emerging problem with population ageing and is a serious
medico-social problem because of its dehumanizing nature in the advanced
stages. The cost of care is also enormous and beyond the capacity of most
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countries in SSA. The prevalence of dementia is generally considered to be
lower in Africa and Asia when compared with the developed world (Kalaria et
al., 2008). South Africa has four main ethnic groups with varying degrees of
sophistication and ‗westernization‘. It is conceivable that the prevalence rates
could vary in the different communities and as such would be an ideal place
for investigating any interplay between nature and nurture in disease
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pathogenesis. The combination of cognitive impairment and functional
disability must be determined in the context of cultural practices and
educational attainment. Data is currently accruing from memory clinics in the
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tertiary care centres and about 75% of the patients seen were diagnosed as
having dementia. The current impression is that dementia is common and there
is growing awareness of the need to provide care for those afflicted. In the
SUFFICE study referred to earlier, 61.8% of those assessed complained of
memory impairment (Ferreira et al., 2007). In the absence of concurrent
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determination of functional impairment, it would be impossible to determine
the frequency of dementia in that cohort.
Recent studies have shown that vascular factors are important in the
development of the dementia syndrome both degenerative and the vascular
dementias (Kalaria et al., 2008). With the high prevalence of vascular factors
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in older persons i.e., hypertension, diabetes mellitus, obesity, smoking, high

cholesterol levels, one can speculate that dementia prevalence will rise in
tandem with increasing urbanization and adoption of western lifestyles. Caring
for individuals with dementia is also a matter of great concern because of the
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associated stress and vulnerability of care providers. In Africa, home-based

care rather than institutionalization is favoured but this mode of care may
change with time due to increasing urbanization and erosion of the extended
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family system that had served as buffer in most communities.

Cerebrovascular Disease (Stroke) is a major cause of acute mortality and
long-term disability in older persons. All the risk factors, apart from
haemoglobinopathy are more prevalent in this age group. Hypertension is by
far the most important risk factor with stroke risk almost doubling with each
7.5 mm Hg. increase in diastolic blood pressure (MacMahon et al., 1990).
Hypertension is more common in the black population in South Africa as is
the case with blacks in the rest of the world. Hypertension, obesity, smoking
and increased fibrinogen have been associated with increased incidence of

stroke in this population group (Vorster, 2002). Among the other risk factors,
diabetes was found to be most prevalent in the Asian population, dyslipidemia
in whites while smoking was marginally more common in the coloured people
than whites in a study by Connor and others (2005).
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The current trend is an increase in the burden of stroke because of
longevity of the population and increasing frequencies of the various risk
factors due to changing lifestyles. The ischemic type is more common than the
hemorrhagic type and has a better prognosis. However, repeat attacks or even
a single event that involves strategic areas of the brain like the thalamus,
hippocampus and angular gyrus can result in vascular dementia. The in-
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hospital care of stroke cases has improved in recent times with the introduction
of stroke unit. Data from the first multidisciplinary stroke unit in an urban
secondary level hospital in Cape Town showed a drastic reduction in mortality
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from 33% to 16% (de Villiers et al., 2009). Establishment of more stroke units
will ensure prompt and adequate management with better outcomes. More
research data will also become available to assist health planners on cost-
effective interventions.
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Neoplastic Diseases
Accumulation of damage to genes, sporadic mutations due to
environmental factors and immune senescence characteristic of old age result
in development of cancer. Cancer is responsible for more than 7 million deaths
worldwide and its incidence is increasing rapidly in developing countries
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which unfortunately are poorly equipped to manage the cases adequately

(Vorobiof and Abratt, 2007). Late presentation adds another dimension to the
difficulty of adequately managing the cases because the stage of possible
prevention would have passed in many instances. Chronic cardiovascular
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diseases and cancer have taken over from infectious diseases as the major
causes of death in older persons. Pain, sometimes intractable, is another aspect
of cancer accompaniment that affects the quality of life of the victims.
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In South Africa, cancer of the respiratory tract, prostate and the upper
gastrointestinal tract are amongst the ten leading causes of death in men (Table
2), while in women, breast cancer is a major killer followed by followed by
lung and cervical cancers (Steyn et al., 2006). Liver and colorectal cancers
also deserve mention for their lethality and occurrence in the older persons
being listed amongst the top 20 causes of death (Steyn et al., 2006). These
neoplastic disorders are likely to become bigger problems with the
pervasiveness of cancer-prone/promoting lifestyles/behaviours like smoking,
chronic alcohol ingestion, obesity and low intake of fruits and vegetables. In
addition, chronic infections with hepatitis B and human papilloma virus
increase the risk of liver and cervical cancers respectively. HIV infection
increases the risk of Kaposi‘s sarcoma. Introduction of cancer screening,
vaccination, and public enlightenment on lifestyle modifications for healthy
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habits will go a long way in reducing the scourge of cancer in older persons
which otherwise could overwhelm resources available.
8.3.5. Emerging Health and Social Care Needs
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Older persons have unmet health and social needs because of their limited
income and the additional role they play as carers in families. Older persons
provide this care with limited resources, which add to stress, depression and
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exhaustion. These ultimately predispose them to poor health and increased
disability. The latter role became accentuated with the devastating effects of
the HIV and AIDS epidemic which has left many orphans and vulnerable
groups to be cared for. In caring for the older persons and with the envisaged
increase in their population, these health needs must be taken into
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consideration. The destabilization of family dynamics resulting from rural-
urban migration brings social care to the forefront of new health needs.
Support groups for peer education, encouragement and as avenues for
socialization become very important.
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8.3.6. Implications for Health and Social Care Provision
The growing burden of NCD with the associated morbidity and disability,
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together with older persons‘ often invidious poverty situations have

implications for policy and practice relating to care needs - on multiple levels.
To start with, a demand for public health care services and medical costs will
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rise sharply. During the 2003 SADHS, only 13% of persons 65+ reported
having access to a medical insurance. The majority were reliant on public
health services. In most SSA countries, health care policy has emphasised a
shift of service delivery to the primary care level (PHC), which prioritises
maternal and child health care. As a result, the provision of geriatric health
care services is deprioritised.
The preventive, curative and rehabilitative needs of older health care
clients are mainly integrated in general sessions at primary clinics, but in
practice, older clients are marginalised at these facilities, and few are referred
to secondary or tertiary levels for investigation and management. Providing
health care to older patients not only entails management of degenerative
diseases but also management of a complex of multiple diseases, reduced
physiological reserve and multiple drug prescriptions as well as psychosocial
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needs. A lack of adequate training means health professionals at these centres
are mostly poorly equipped in addition to lacking knowledge and skills to
address unique medical needs of older individuals. Although there is a general
lack of statistics on the quality of health services delivered to older clients,
client dissatisfaction with such services has been documented in several
studies (Joubert and Bradshaw, 2006; WHO, 2002). Complaints are directed
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mainly at several access barriers to care, and include costs; travel distance to a
facility especially in rural areas; discriminatory/ rude attitudes of health
professionals; overcrowded and understaffed clinics and long waiting times.
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Others include shortages of medications; unavailability of assistive devices,
perceived lack of interest and respect shown to older clients.
With regard to social care needs, very few residential care facilities exist
for older persons in the sub-region. South Africa has residential care facilities
mainly in urban areas and these are predominantly in areas previously reserved
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for the whites. The majority of ill or frail older persons are reliant on family
for care – where indeed family members are available to care for them.
Although household structures remain predominantly multi-generational, skip-
generation households and solitary living (11 % of older women live alone)
are increasingly common (UN/DESA, 2005). In urban areas, Non-Profit
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Organizations (NPOs) may provide some supplementary home care services to

ill, frail and homebound older women, but few such services are available in
rural areas. Where kin are not available to care for elders and
institutionalisation is not an option – through non-availability or cultural
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unacceptability, ill, frail and socially indigent older persons are at risk of
neglect.
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8.4. DISCUSSION
Planning and Provisioning of Care to Meet the Needs
The implications of the growing burden of disease and disability in older

women and their socio-economic vulnerabilities for the provision of health and
social care are compounded moreover by features of the societies that
discriminate against older persons, and mitigate against the health and
particularly the well-being of older women. The governments of the countries,
civil society, families and individuals must therefore plan to meet the
increasing treatment and care needs of the population as well as the related
costs – on multiple levels. Thus, planning required to meet an increasing
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demand for chronic care, rehabilitative care, palliative care and other types of
long-term care at a formal level implies a need for increased numbers of
appropriately trained health care staff and residential care facilities – the latter
indeed where feasible. Similarly required is planning to meet an increasing
demand for non-formal and informal care, and to equip such carers with
appropriate skills, as well as to support the organisations and carers. NPOs
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need to be helped to expand home and community support services to
vulnerable older persons, often in partnership with the government. Finally,
older persons themselves need to be empowered, through programmes
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implemented at formal and non-formal levels, to sustain their functionality and
self-sufficiency through self-care, and thus forestall a need for caregiving.
Health Care Facilities

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In a bid to integrate health and social care needs for the older population,
the government has established within the Department of Health a directorate
of chronic disease, disability and geriatrics, and in the Department Social
Development, a directorate for Care and Services to older persons.
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South Africa has luncheon clubs operated at senior centres countrywide.

Both the programme and the facilities are subsidised by the government.
Members of a luncheon club meet on one to five days a week and are served a
nutritious meal for a nominal fee. The clubs offer the members social,
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recreational, educational, spiritual and counselling opportunities. Some larger

clubs dispense repeat prescription medications to members on behalf of their
primary care clinic and pay out monthly pension benefits to registered
beneficiaries. In South Africa's Western Cape Province, the Abigail Women‘s
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Movement operates a community-based support system for older persons in

Khayelitsha, a low-income township. The project was designed and
implemented by older female volunteers, and provides practical home care to
frail older persons (Keikelame, 2000). Yet another best practice in South
Africa is the NPO Grandmothers Against Poverty and AIDS (GAPA)
programme, operated in three provinces by grandmothers, all carers to adult
children with AIDS and/or affected grandchildren. GAPA members benefit
from peer support, counselling, skills training, and engage in income

generation activities. A crèche bursary scheme and an after-school care centre
offer the members respite from caregiving (see www.gapa.org.za).
A poorly informed population with access barriers to health services
combined with a lack of professionals with knowledge and skills on a
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background of inadequate policy development and implementation contribute
to the inadequacy in management and prevention of non-communicable
diseases and disability. Older persons in the majority tend to seek medical
attention with acute or chronic disease causing symptoms and disability and
not for screening of pre symptomatic illness.
A co-ordinated approach is desired to meet the health needs of an ageing
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population and this is divided into 3 levels:
i. At a formal, or government level, strategies, practices and
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programmes are needed to achieve the following objectives: enhance
older persons‘ health and well-being; prevent morbidity and
disability; reduce a need for caregiving; and ensure sustainable
livelihoods. The suggestions include:
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 Better management of NCDs and co-morbidities, such as
hypertension, obesity and diabetes, and better screening for cancer
through health promotion involving behaviour modification and
lifestyle changes. A study in Ghana by Duda and colleagues (2006)
revealed that women would be willing to reduce their body sizes for
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the sake of overall healthier life. Improvement of older women's

mental health, through practices and programmes to encourage their
socialisation and physical activity could prevent or ease depression.
Stringent tobacco control legislation with tax increases, setting
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standards on the amount of sodium in processed foods as well as

intervention strategies against chronic alcoholism become essential.
 Health care reforms with improved access to age-friendly services and
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continued support in the community for those discharged from

hospital, as in the case of those needing rehabilitation and other forms
of continuing care. Special education and training of health
professionals in geriatric care in all relevant disciplines.
 Equal access to treatment, including those older persons infected with
the HI virus to anti-retroviral therapy along with the provision of
information about healthy sexuality and the risks of AIDS and
sexually transmitted infections
 Understanding and special attention given to older persons who have

been abused or have experienced other forms of violence. Financial
empowerment through the provision of a basic income grant to those
who are socio-economically disadvantaged, and the provision of long-
term care solutions
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 Provision of affordable, accessible, reliable and safe transport system
that is age-friendly and managed by skilled and trained personnel.
ii. At an informal care level, the capacity of families to care for older
persons needs to be expanded and supported. Family carers to ill,
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disabled and frail older members thus need:
 To be supported to ease the financial, physical and emotional burden
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of caregiving that contributes to ill health and the opportunity costs of
this essential role. Where applicable, to receive financial support
through subsidies, tax relief, or even payment for caregiving services
and co-residency of an older member.
 To be provided with easily accessible information on health
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conditions, treatment, medications, warning symptoms and lifestyle
modifications.
 To be equipped with caregiving skills, and trained in how to partner
formal and non-formal health care providers, identify available
resources, navigate systems and become advocates for care recipients.
 To be able to access respite programmes, and to have a forum such as
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a support group in which to verbalise their experience and receive

peer support.
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iii. At a non-formal, or intermediary level, given the relative dearth of

community based support services to vulnerable elders and informal
carers, NPOs need:
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 To be helped by the governments, in partnerships, to provide

community centres as meeting places for seniors' clubs and support
groups, to support older carers, and continuing education
 To develop and implement programmes aimed at encouraging older
persons to remain socially and physically active, to make healthy
choices, and to maintain a healthy weight and not to smoke.
 To carry out initiatives aimed at the removal of stigma associated with

HIV/AIDS and mental illness.
 To foster intergenerational efforts and co-operation to improve the
physical and emotional well-being of both older persons and younger
generations.
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 To contribute to the provision of long-term care options, both
residential and in the community, for vulnerable older persons.
However, a need for an increase in the number of institutional care
facilities is not clear and warrants investigation.
Finally, planning and provision to meet emerging health and social needs
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of older persons in the sub-region must be informed by research evidence.
Key areas for investigation and methods to establish such evidence include:
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 National profiles of chronic diseases and causes of death in older
persons, which include reliable morbidity and disability data, as well
as data on limitations on activities of daily living, cognitive
functioning and reproductive health.

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Surveys of health care seeking behaviour patterns and audits of health
care facilities' provision of services to older clients.
 Studies of kin availability and informal caregiving patterns to ill,
disabled and frail older persons‘, and resources needed.
 Studies on how dependent older persons are cared for where there are
no institutions, formal home based care and other long-term care
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options.
 Clarification of the roles and contributions of older carers, and how
their contributions and the challenges may be recognised, rewarded
and supported.
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 Studies on the living circumstances and caregiving needs of older

persons in rural and remote settings.
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CONCLUSION
With the recent demographic and epidemiologic transition taking place in
SSA, a coordinated approach to health care provision for older persons is
necessary with change of the current negative attitude. Hypertension, diabetes
mellitus, cancer, ischaemic heart disease, alcohol consumption, smoking and
obesity constitute major health problems in older persons. The chronic disease
and their risk factors have the potential of assuming greater dimensions and
causing more health hazards with increasing urbanization unless necessary
health promotion interventions are designed and implemented. A
comprehensive review of the contribution of NCD to the health situation in the
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older population has been provided with suggestions on approaches to meet
the various health challenges. The roles of policy makers and NPOs cannot be
downplayed but it behoves on individuals and supporting family members to
adopt health promotion strategies to guarantee good health in old age.
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ACKNOWLEDGMENT
The authors wish to thank Dr. Joubert and Debbie Bradshaw for provision
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of useful materials for this review. Professors Monica Ferreira, Naomi Levitt
and Krisela Steyn for their suggestions to the contents of the chapter.
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Chapter 9
TOWARDS ESTABLISHING AN NCD
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RESEARCH AGENDA
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N. Phaswana-Mafuya, K. Mokwena, A. Davids,
C. Tabane and S. Mkhonto
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ABSTRACT
Background: Strategies against the burden of NCDs require well
planned and executed research-informed responses. NCD research needs
to be contextualized to enable the identification of risk factors, and so
chart the way forward for the prevention, treatment and management,
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despite the financial, social and political factors inherent in health

systems of developing countries.
Objective: To identify areas of research that will enable the effective
strategies for the prevention, treatment and management of NCDs.
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Methods: NCD-related scientific articles and reports published

between 1998 and June 2009 were reviewed.
Key results: Research is key for obtaining local and contextualized
knowledge on all aspects of effective prevention and management of
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NCDs. Strengthening of research infrastructure (training, processes and

networks), as well as manifestation-specific factors of NCDs (social
determinants, health systems and gender factors) are essential
components of the NCD research agenda.
Conclusions: The NCD research agenda requires resource
investment, as well as social and political support.
210 N. Phaswana-Mafuya, K. Mokwena, A. Davids et al.
Keywords: Surveillance, training, gender manifestations, social

determinants
9.1. INTRODUCTION
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Chronic NCDs such as CVDs, type 2 diabetes, cancers and respiratory
conditions are growing in developing countries as has been demonstrated in
earlier chapters of this book. As NCDs increase, the need for innovative and
appropriate research in the area becomes apparent. Such research requires new
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tools, methodologies and strategies that are appropriate for developing
countries. An NCD research agenda for developing countries is needed in
order to ensure that an appropriate level of common oversight and
understanding of NCD research needs prevails and to provide best directed
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research. A research agenda is imperative because it is like a roadmap without
which there is no clear direction. This chapter proposes an NCD research
agenda that will close information gaps in developing countries in order to
allow rational and evidence based planning in as far as NCDs are concerned.
To help developing countries cope with the double burden of infectious and
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non-communicable diseases, health and clinical research resources in local
settings must be leveraged to improve human health and maximise scientific
discovery and innovation. The research areas proposed are viewed as of equal
importance, therefore there is no priority within the list assigned. Further,
these areas are not mutually exclusive.
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9.2. METHODOLOGY
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Information for this chapter was taken from scientific articles and reports,
which were published between 1998 and June 2009. A systematic review of
twenty six (26) documents was conducted from Pubmed, Embase and Medline
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databases, using the following key words: non-communicable, chronic disease,

surveillance, developing, developed, cancer, diabetes, obesity, heart disease,
hypertension, diabetes, vital statistics, disease registries, surveys,
administrative data collection systems, demographic surveillance systems,
demographic health surveys, burden of disease, assessment, implementation,
and monitoring and evaluation. Other data search engines included Science
Towards Establishing an NCD Research Agenda 211
Direct, WHO Library and Information Networks for Knowledge Database

(WHOLIS) and Google scholar.
9.3. RESULTS
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The results of the review identified focus areas for developing a research
agenda that would enhance the ability to prevent, treat and manage NCDs in
developing countries. The components of the NCD research agenda, which has
to be contextualized to serve the intended purpose, includes research needs of
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training and research budget, as well as specific areas of research, i.e.
surveillance, operational, prevention, health systems, gender manifestation of
NCDs, the strengthening of existing NCD research networks and social
determinants of NCDs.
9.3.1. Areas of Need

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NCD Research Training
Developing countries are at various stages of development
/planning/implementation of NCD programmes. Research is a low priority, so
is research training in NCDs. Further, most research in developing countries
has focused on communicable diseases. Therefore, most researchers in
developing countries are capacitated to do research in communicable diseases.
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They therefore lack requisite training in NCD research ranging from clinical,
epidemiological, basic, to social science and health system research. Although
research skills are transferable, there is a need to train health professionals,
public health researchers, policy makers and related professionals in the
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conduct of NCD research if quality research is to be conducted. Research

training may range from NCD research designs, data collection methods and
instruments (valid and reliable) and analyses of complex NCD
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epidemiological data. It can include mix of preventive and curative aspects,

focus on risk factors, employ an integrated approach as well as use health
promotion/care models. Such research training can aim at knowledge and skill
enhancement. Having said all this, research training needs assessment needs to
be conducted in order to accommodate diverse needs and to ensure that
research training is as comprehensive and as customized as possible.
Stakeholders for research training may include national research/academic
institutions, high income countries may be lead institutions, private
sector/NGOs and professional associations. Research training can employ

different methods according to researchers‘ needs, i.e. regular courses (MPH,
Diplomas, MD, PhDs), web based learning, distance learning courses,
global/regional/national networks and fellowships.
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Dedicated Budget for NCD Research
There is currently lack of adequate resources/poor donor response for
NCD in general and NCD research in particular research. Most funders are
more inclined to support research on communicable diseases. There is a need
to raise political awareness of chronic non-communicable diseases in order to
increase prioritization within budgets by increasing and sharing evidence of
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the negative economic, social and public health impacts of these diseases. It is
however encouraging that six of the world‘s foremost health agencies, who
collectively managing an estimated 80% of all public health research funding,
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have announced the formation of a landmark alliance to collaborate in the
battle against chronic, non-communicable diseases. These include
cardiovascular diseases (mainly heart disease and stroke), several cancers,
chronic respiratory conditions, and type 2 diabetes. Together, these agencies
have formed the Global Alliance for Chronic Diseases to support priorities for
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a coordinated research effort that will address the growing health crisis of
chronic NCDs. They argue that the health impact and socio-economic cost of
these largely-preventable diseases is enormous and rising and has the potent to
derailing efforts at poverty reduction world-wide. The work of the Alliance
will focus in particular on the needs of low and middle income countries, and
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on those of low income populations of more developed countries. The

Alliance‘s charter members are:
 Australia National Health and Medical Research Council

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 Canadian Institutes of Health Research

 Chinese Academy of Medical Sciences
 The Medical Research Council
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 The National Institutes of Health, specifically its National Heart,

Lung, and Blood Institute (NHLBI), and the Fogarty International
Center
The Indian Council of Medical Research, New Delhi, will be invited to

join the Alliance as a member. Research agencies from other countries and
private funders may also be invited to join in a second wave. The World
Health Organization (WHO) is joining the Alliance as an observer to facilitate
Alliance support for implementation of the World Health Assembly-approved

―Action Plan for the Global Strategy for Prevention and Control of Non-
communicable Diseases‖.
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9.3.2. Proposed Areas of Research
9.3.2.1. NCD Surveillance Research

Data on NCDs are lacking in developing countries in spite of the
increasing prevalence of these diseases. NCDs are increasing rapidly across
the globe, with an increasing trend in developing countries (Boutayeb and
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Boutayeb, 2005; Beaglehole, 2001; Unwin et al, 2006; WHO, 2000). Research
is needed to assess the local or regional burden of NCDs. Access to reliable
data on risk factors, morbidity, mortality and social determinants of NCDs is a
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necessary prerequisite for the effective planning and evaluation of NCD
prevention programmes (Nishtar, Bile, Ahmed, Amjad and Iqbal, 2005). In
many developing countries there is a lack of comprehensive data on NCDs and
since these are so important in the prevention and control of NCDs,
surveillance systems should be an integral part of any national health policy in
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developing countries there is a need to develop, institute and evaluate
surveillance systems for chronic non-communicable diseases. Although there
is a growing interest in NCD surveillance in developing countries, the
development of sustainable and systematic surveillance systems are
problematic due to the need for technical expertise and high costs. Changes in
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the population health profile, with an ever increasing burden of NCDs, have
not been matched by appropriate institutional developments like the
establishment of surveillance systems. The establishment of a surveillance
system for NCDs must be preceded and sustained through standardized and
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routine surveys of risk factors that are methodologically rigorous and

analytically sound. Only then can such surveys develop into a surveillance
system that can focus on linking the use of information for NCD prevention
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and health promotion. Unwin et al (2001) pointed to the need for improved
surveillance of all diseases within sub-Saharan Africa in order to place NCDs
properly within the context of the overall burden of disease. Surveillance
research may include studying how best to develop and establish context
specific yet internationally appropriate NCD surveillance tools and
discovering and developing tools for screening and stratifying populations
according to risk, among others.
9.3.2.2. NCD Operational Research

An equally important and substantially neglected field of NCD research is
operational research. This term broadly include any kind of research or
systematic collection of information and evidence which assists the
management and implementation of more effective programmes. The key to
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operational research is ‗learning while doing‘. The opportunities for
operational research in NCD are large and varied. They range on a spectrum
between the simple systematic collection of data to allow programme
managers to make improvements during the life of the programmes, right
through to ambitious randomized controlled trials. Operational research is
needed to advance novel interventions for NCDs and to reduce the risk of
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'Western lifestyle' conditions, such as high blood pressure and stroke. It will
aid surveillance and evaluation of changes in national and local policies
(Miranda et al, 2008). There is relatively limited operational research on
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NCDs compared to communicable diseases. NCD Operational research will
not only aid in early diagnoses and cost- effective management of individuals
with risk factors and chronic conditions (Leeder, Raymond, Greenberg, Liu
and Esson, 2004) but will also allow for comprehensive monitoring of NCD
data at primary care level (Steyn and Bradshaw, 2001). The effective
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management and prevention of NCDs in terms of reducing recurrence, slowing
progression, avoiding complications and maximizing function and quality of
life requires operational research. Operational research should be strengthened
to evaluate a full spectrum of medical technologies, including not just drugs
and vaccines but also open-source informatics and communications tools, as
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well as nanoscale diagnostics to improve preventative care . This may also

include creating a screening system for chronic non-communicable diseases
whereby inexpensive tests are used to screen large numbers of people and then
more expensive tests are utilized on those at highest risk
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9.3.2.3. NCD Prevention Research

Much of the robust evidence for prevention and control of chronic
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diseases comes from randomized clinical trials. Such trials tend to study highly
selected groups of people which means that the results may not be applicable
to the broader population, resulting in a conflict between the proof of concept
and generalisability (Mark et al. 2007 and Mendis et al, 2003). Trials often
fail to take into account whether the intervention, if found to be effective,
would be affordable, or do they provide information on prospects of scaling up
to achieve broad population coverage. For example , in South Africa,
application of coronary risk factor reduction community programme
unexpectedly failed to demonstrate the effects of personalized intervention in

high risk participants and was not tested in black or Asian South Africans
(Rossouw et al,1993 and Mendis et al, 2003). Evidence of how best to
implement clearly cost – effective interventions in developing countries
remains limited. Interventions such as lifestyle modification of diet, exercise
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and smoking targeted at individuals should be a common inclusion in national
chronic disease policies. Trials to demonstrate whether or not such
interventions are cost – effective in low and middle – income countries would
be helpful (Ebrahim and Davey Smith, 1997). Models of prevention and
intervention from ‗western‘ and other countries do not necessarily apply in
developing settings. As such, the usually large evidence base from which such
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models were derived should be supplemented by studies in developing country
settings. Clear evidence of cost – effectiveness of interventions that are
feasible to implement at individual and societal levels are likely to be culture
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specific and require nationally relevant evidence to be credible to policy
makers. Given the very scarce health care resources available, there is an
urgent need for research in low and middle income countries to examine the
whole spectrum of sustainable programs for the prevention, treatment and
management of chronic non-communicable diseases. Ethical, social, cultural
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and sustainability issues must be addressed before emerging interventions and
technologies can be taken up by communities and incorporated into public –
health and health care systems (Abdallah et al, 2007).
9.2.3.4. NCD Health Systems Research

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Historically, responsive health systems have changed to respond to

emerging health needs and challenges. This was seen in the western world,
when, in the 1970‘s, it became evident that the prevalence of NCDs was
increasing(specifically cardio-vascular diseases), there was a responsive
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increase in focus, funding and human resource allocation to address the

changing health delivery system landscape (Nissinen,2001). Health systems in
developing countries have, however, lagged behind in this response, and
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currently, are mostly still structured to deal with acute and curable diseases,
with the prevention aspects of NCDs not featuring in the agenda of many
developing countries (Sen, 1998; Unwin, 2001). This is partly because in these
systems, which are often fragmented and underfunded, the priority and focus
is on conditions which attract attention and that may cause death within a short
time. Patients utilizing these services also reinforce this prioritization by
ignoring conditions with the absence of symptoms (Bovet et al, 2008).
However, chronic NCDs create a heavy burden on the health care system, as
these diseases tend to be life-long and are usually managed over time, are not
treated to be cured but managed, result in debilitating complications and result
in slow painful deaths. There is a need to generate knowledge upon which
health systems can be orientated, resources within health systems can based on
burden of disease. Health systems research is needed to base health system
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interventions such as health professional training, increasing the number and
skills of NCD professionals. Health systems in developing countries have
evolved to deal with acute and curable diseases. However, chronic diseases
create a burden on the health care system as these diseases tend to be life-long
and are usually managed and not cured. Given the very scarce health care
resources available, there is an urgent need for research in low and middle
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income countries examining long-term care models for long-term conditions
and diseases (DOH, 2006) for both efficiency and cost-effectiveness, because
often the high cost of health care results in low utilization of health care
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services (Bovet et al, 2008). Health system research may include research to
integrate health system management of communicable and non-communicable
disease; develop best practices in delivering affordable and equitable health
care; provide more structured knowledge for health-promotion; provide
culturally specific and nationally appropriate resources for training of health-
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care workers; studying how best to ensure that disadvantaged communities
have adequate resource allocations in health care and in preventative practice;
Optimisation of use of electronic health records for predicting disease and
measuring the effect of health interventions.
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9.3.2.5. Research on Gender Related Manifestations of NCDs

Gender analysis refers to the process of identifying and developing action
to address health inequalities that are contributed to by the power relations
between men and women. However, these power relations differ across
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communities and therefore play out differently. Firstly, disease manifestation

between men and women is complex, and needs further research to answer
some questions, some of which have not been even asked. Yach and Brands
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(2002), reported that there is a rapid rise of NCDs among women, and that the
impact is worsened by the various barriers to accessing health resources
experienced by women. Secondly, some research has identified gender
differences in the experience of chronic diseases like coronary heart disease, as
well as metabolic factor prevalence (Smith and Essop, 2009). These
differences may impact on future risk assessment procedures and preventive
measures, which include how health education and promotion is received and
utilized. Recent ground-breaking research has revealed that socially
constructed psychological stress, like the experience of, and the extent to
which racism, has been internalized, results in gender-related differences on
metabolic disease (Tull et al, 2007). Christensen et al (2009), identified the
need to explore ethnicity on the effect of diabetes in African populations.
Further research required includes investigations of gender-related
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manifestation of other NCDs, including mental health and cancers that affect
both sexes and health seeking behaviour differences. There is a growing body
of research that suggests gender-related differences in health seeking
behaviour, with men less likely to seek health services even in the face of
health problems (Galdas et al, 2005; Ahmed et al, 2000 and Robertson et al,
2008). Such research would also explore the enablers and barriers of health-
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seeking behaviour on heterogeneous samples and assess whether these are
socially constructed (like femininity and masculinity expectations) or
hormonal, as reported by Hunt et al (2007). These authors found that higher
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‗femininity‘ scores in men were associated with a lower risk of CHD death.
Because differences in health seeking behaviour occur across all categories of
NCDs, there is a need to study impacts of these differences across categories.
Such research will inform health promotion interventions which may need to
be gender-sensitive to achieve desired effects. Gender-sensitive and gender –
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specific models of patient-empowerment need to be studied and developed.
Effective health care delivery includes the ability to empower patients to take
responsibility for their health and the extent to which patients contribute to
efforts to improve their wellbeing and are compliant to treatment. Societal
literacy levels, as well as other social experiences determine the shape and
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extent of such empowerment. Patient empowerment is also linked to health-

seeking behaviour and gender differences in health seeking behaviour are
likely to extend gender-specific patient empowerment attributes. Although
screening for some cancers, e.g. cancer of the cervix, has been implemented
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successfully in developed countries, the same results have not been

experienced in developing countries (Ayinde and Omigbodun, 2003). As an
example and on the contrary, cancer of the cervix is one of the leading causes
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of death in developing countries, even in countries where screening services

are available at no cost to the patient. To be included in the research agenda is
the identification of barriers to accessing health care services for gender-
specific cancers, as well and interventions to increase utilization of such
services.
9.3.2.6. Strengthen Existing NCD Research Networks

There is a need to expand existing research networks and create new part-
nerships to integrate local disease priorities and research capabilities. Existing
networks can play an important role in building local capacity to translate
clinical research findings into scalable field-based interventions by supporting
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dissemination strategies between national universities, private and faith-based
providers, and nongovernmental organisations. public–private partnerships
could also help support pilot studies to test the effectiveness of medicines and
devices for non-communicable diseases and to collect or assess evidence of
local product demand. Such partnerships could also help to develop local
sustainable-pricing models to make life-saving medicines more accessible and
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affordable. Maximising research networks in the developing world to improve
the discovery, development and access to life-saving therapies requires
additional capital investment as well as new strategies aimed at expanding
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existing capabilities through new partnerships and shared learning.
9.3.2.7. Need for Research on Social Determinants of NCDs

Conventional thinking among health care, public health workers, and
disease-oriented associations attributes increases in the presence of NCD
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prevalence, incidence and mortality to changes in dietary and physical activity
patterns (Ford et al., 2002). This is similar to traditional thinking concerning
cardiovascular-related issues (Raphael, 2002c). Yet, this dominant ―health
behaviours‖ paradigm takes little account of the increasing literature
concerning the importance of the social determinants of health in population
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health. Emphasis on biological and behavioural determinism as an explanation

of the late 20th century epidemic of NCDs distracts from consideration of the
types of social and economic issues that play a role in NCDs (McDermott,
1998). Brunner and Marmot point out that 90% of the variance in occurrence
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of metabolic syndrome observed in the UK Whitehall studies cannot be

accounted for by conventional behavioural risk factors (Brunner and Marmot,
1999).
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The social determinants (distal issues) of health are rarely if ever

considered by health researchers, public health workers, and disease-oriented
associations with very few exceptions (McKinlay and Marceau, 2000, Riste et
al., 2001. Virtually all research and health discourse is limited to the proximal
issues of health behaviours, pathophysiological changes, and in some cases,
neuroendocrine and immune processes. Thus, little is known about the social
determinants of NCDs, especially in developing countries. The increasing
prevalence of NCDs require new ways of thinking about these diseases, their
causes, and their management. Studies on the social determinants of health can
contribute to understanding of the causes of morbidity and mortality. This may
include studies on how poverty and its consequences impact lifestyle choices
and increase risk factors for non-communicable diseases; and, in turn, how
chronic NCDs affect economic output and productivity; Study and address the
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link between urbanization, its short- and long-term consequences (e.g. poor
urban planning, congestion, stress, pollution, reduction in open spaces, etc.)
and the adoption of poor lifestyle choices, Study and address the impact of
macroeconomic policies on health with a view to improving the prevention
and management of chronic non-communicable diseases
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CONCLUSION
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Despite the wealth of information available NCD in the developed world,
it is clear that there is an important research gap between developing and
developed countries. (Mendis et al, 2003). Research findings from developed
settings are not necessarily appropriate to other contexts and thus local
knowledge is imperative (Ebrahim and Davey- Smith, 2001 and Mendis et al,
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2003). To understand CNCD in today‘s low and middle – income countries
and their growing burden, a contextualization appropriate to their great
different circumstances is needed (Mendis et al, 2003). To understand the
unique contextual differences between countries affected by non-
communicable diseases at different times, we must understand that the speed
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of change appears unique owing to the timing of the economic, technological

and social transformation. The political environments also differ as does the
capacity of low and middle- income countries to address the rapid increase in
the prevalence of non- communicable diseases (Popkin, 2002). Addressing
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NCD research challenges requires research funding agencies to participate

(Abdallah et al 2007). Public and political awareness and advocacy of NCD
research in developing countries should be increased given the growing
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magnitude and devastating health impacts of NCDs. Research partnerships for

NCD prevention should be developed. NCD research will allow for the
development and implementation of evidence-based local, national and
international economic, environmental and legal policies that are geared
towards preventing further growth of NCDs.
ACKNOWLEDGMENT
We hereby acknowledge the Human Sciences Research Council for
bearing professional time costs for all HSRC staff that co-authored this
chapter.
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Acknowledgement is also given to the School of Public Health, Medunsa
Campus for in-kind contribution for this work
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ACKNOWLEDGMENT
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As is the case with all literary ventures, we could not have produced all
this work without the assistance, guidance and support of many individuals
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and institutions.
We are delighted that Professor Nigel Unwin, Chair of Public Health and
Epidemiology at the Cave Hill Campus of the University of the West Indies
has written the foreword to this book. He is a highly respected academic who
intimately understands the complexities and challenges within the NCD field
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and these qualities make him an ideal candidate to comment on this work.
Our appreciation is extended to the Editor of Nova Science Publishers for
considering this topic for publication; and, the production staff of Nova
Science for their excellent handling of our manuscript.
Finally, our families and loved ones, who have made enormous sacrifices
while we wrote this book.
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NOTICE: Although the internet sites provided for further information are
presented in good faith and believed to be correct, the authors, editor and
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publisher make no representations or warranties as to the completeness or

accuracy of the information and make no commitment to update or correct
any information that appears on the Internet.
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ABOUT THE EDITOR IN CHIEF
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NANCY PHASWANA-MAFUYA: Professor Nancy Phaswana-Mafuya
(PhD in Health Social Work) is Research Director at the Human Sciences
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Research Council (HSRC) and Visiting Professor at the Nelson Mandela
Metropolitan University, South Africa. She was Extraordinary Professor at the
University of the Western Cape (2006-2009) and Visiting Professor at
Newcastle Univeristy (UK) in May/June 2009. She is a nationally rated social
scientist with extensive knowledge, skills and experience in social sciences
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applied to health which she acquired through her graduate studies, university
teaching and 10 year research career as a public health social scientist. Most of
her previous research work focused solely on HIV/AIDS and she has a
burgeoning research track record in this field which has won her several
national and international awards. Since 2007, she expanded her research
focus to include chronic NCDs. she is currently Principal Investigator: of the
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first ever population based longitudinal Study on Global Ageing and Adult
Health focusing on major chronic NCDs among individuals aged 50+ years
and of the patient satisfaction survey involving approximately 19000 patients
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across 266 PHC facilities in South Africa. She is a merit-based member of

Academy of Science in South Africa, member of the South African
Consortium on NCD Surveillance, Prevention and Control, member of Health
Information System for South Africa, member of the Europe-Africa network
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on the development and prevention of DM and CVDs in SSA as well as

member of the African Research on Ageing Network. She is also a reviewer of
several local and international journals and an external examiner for six
universities in South Africa.
226 Nancy Phaswana-Mafuya and Dimitri Tassiopoulos
ABOUT THE MANAGING EDITOR

DIMITRI TASSIOPOULOS: Dimitri holds a PhD and is employed as a
Chief Research Manager at the Human Sciences Research Council (HSRC),
South Africa. Since 1993, he has been involved in various national and
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international research projects, of a multidisciplinary and multi-institutional
nature. Dimitri is a board member of number international peer-reviewed
research journals. He has presented several papers at national and international
conferences. Dimitri is the author and editor of multiple edition books. Dimitri
has written a number of academic articles and chapters on various topics.
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ABOUT THE CONTRIBUTORS
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ADESOLA OGUNNIYI: Adesola is a Professor of Medicine at the
University of Ibadan, Nigeria, and a Consultant Neurologist at the, University
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College Hospital, Ibadan. He received his medical training at the Obafemi
Awolowo University, Ile-Ife, Nigeria and later had residency training in
Internal Medicine and Neurology at the University College Hospital, Ibadan.
He went on a neuroepidemiology fellowship of the World Health Organization
– Fogarty International Center and the National Institute of Communication
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Disorders and Stroke to the National Institute of Health, Bethesda, Maryland,
USA. He holds the fellowship of the Nigerian Postgraduate Medical College,
West African College of Physicians, and the Royal Colleges of Physicians of
Edinburgh and London. His research interests include cross-cultural studies of
dementia, neurodegenerative diseases as well as epidemiology of epilepsy and
headache. He has published over one hundred and forty manuscripts in peer-
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reviewed journals and chapters in books.
ADLAI DAVIDS: Adlai is a senior research manager for the Social

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Aspects of HIV/AIDS Research Alliance (SAHARA), an initiative of the

Human Sciences Research Council (HSRC) in Port Elizabeth, South Africa.
He holds a Master‘s of Science (MSc) degree in geographical information
systems (GIS) from the International Institute for Geo-Information Science
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and Earth Observation (ITC), The Netherlands. His most recent collaborations
for peer-reviewed publications were on the use of an internationally
recognized instrument to evaluate general health practice, predictors of risk
factors of alcohol-exposed pregnancies, intimate partner violence and HIV risk
among women, and barriers to accessing services for the prevention of mother-
to-child transmission (PMTCT) of HIV. His current research involvement is
on a regional baseline survey on the knowledge, attitudes, perception and
behaviour of children related to sexuality, gender and access to reproductive

health services in South Africa and Zambia and a mid-term qualitative
assessment of experiences and perceptions of community dialogues in
Lesotho.
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ANDY GRAY: Andy holds B Pharm, MSc (Pharm), and is a Senior
Lecturer in the Department of Therapeutics and Medicines Management,
Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
Durban, South Africa. Mr Gray is a Fellow and Honorary Life Member of the
Pharmaceutical Society of South Africa, a past President of the South African
Association of Hospital and Institutional Pharmacists and of the Hospital
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Pharmacy Section of the International Pharmaceutical Federation (FIP). He is
currently Chair of the Board of Pharmaceutical Practice of the FIP. He is a
Member of the World Health Organization's Expert Panel on Drug Policies
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and Management and has served as a member and co-chairperson of the
Expert Committee on the Selection and Use of Essential Medicines, as
chairperson of the sub-committee on Essential Medicines for Children, and on
the WHO Guidelines Review Committee.
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CILY TABANE: Cily holds a Doctorate and is employed as a Post
Doctoral Fellow at the Human Sciences Research Council, at the rank of
Research Specialist in Social Aspects of HIV/AIDS and Health. Her areas of
expertise include amongst others: research methodology, institutional
diagnostic interventions, and strategy and leadership development. Her areas
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of research interest include: HIV and AIDS - with special emphasis on the
relationship between HIV/AIDS and culture, Clinical Social Work applied to
health, HIV Voluntary Counselling and Testing, Qualitative and quantitative
research. Her experience, however, extends beyond the realm of academic
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research, as it includes experience in the fields of management and training.

Over the past 20 years, these skills have been attained through the work she
has done in a spectrum of sectors, namely; public and private sectors, Higher
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Education and NGOs. She is a co-author in some of the HSRC publications

and has presented conference papers nationally and internationally.
DEBASHIS BASU: Debashis holds a Doctorate and is currently working

as a Public Health Medicine Specialist at the Wits School of Public Health,
University of the Witwatersrand, Johannesburg. He is involved in both post-
and under-graduate teaching in the School covering the areas of Non-
communicable diseases, and Clinical Epidemiology. He has four Masters
Degrees (Human Genetics, Public Health, Business Administration and Public

Health Medicine) from the University of the Witwatersrand. He is also a
Fellow of the College of Public Health Medicine of South Africa. He is
founder member of the Gauteng Metabolic and Endocrine Research Centre, a
unit set-up to conduct translational research in the field of non-communicable
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diseases. He is the principal investigator for the non-communicable diseases
surveillance project in the Gauteng Province. His research interest includes
non-communicable diseases, and clinical epidemiology.
ERIC UDJO: Eric is a Professor and Head of the Demography Research

Division at the Bureau of Market Research, UNISA. He was a Research
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Director at the Human Sciences Research Council and Director of
Demographic Analysis in Statistics South Africa. He has taught at the
Universities of Maiduguri (Nigeria), Zimbabwe (as post doctoral fellow of
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Population Council of America) and Botswana as well as visiting scholar to
the University of Pennsylvania. His speciality includes demographic
modelling and has written over 80 research articles either as book/book
chapters, peer reviewed journal articles, conference papers, or monographs. In
recognition of his contribution to science, was awarded membership in the
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New York Academy of Sciences in 1998, included in the 18th edition of
Marquis Who‘s Who in the World in 1999 and in the 10th edition of Marquis
Who‘s Who in the World in Science and Engineering in 2008-2009.
EVELYN P. DAVILA, M.P.H., PhD: Evelyn is an epidemiologist with

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research interests in chronic disease epidemiology, particularly cardiovascular

and nutritional epidemiology. She obtained her doctoral degree in Public
Health with specialization in Epidemiology and Biostatistics, from Florida
International University in April, 2O1O. She also has a Masters‘ degree in
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Public Health from Florida International University, which was awarded in

August of 2005. Her Bachelor of Science degree was in Food and Nutrition
from Florida State University in April 2001. She was a senior research
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associate for almost 3 years in the department of Public Health and

Epidemiology at the University of Miami, in Miami Florida. Before her work
at the University of Miami, she was a graduate research assistant at Florida
International University, where she taught epidemiology to undergraduate
students and assisted with research development, implementation, and
statistical analyses of a 3 year randomized control trial to evaluate the
effectiveness of multimedia education of food safety for the prevention of
diarrheal illness among low income mothers in Miami, Florida. She is
currently an Epidemic Intelligence Service Officer for the Centers for Disease
Control and Prevention in Atlanta, Georgia. Dr. Davila has over 25 peer
reviewed publications on studies related to topics from infectious diseases, to
sensory impairment, smoking cessation, occupational health, cardiovascular
health, metabolic disorders, and obesity prevention.
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FATIMA SULEMAN: Fatima holds B Pharm, M. Pharm, PhD, is Head of
School and is Senior Lecturer in the Division of Pharmacy Practice, School of
Pharmacy and Pharmacology, University of KwaZulu-Natal, South Africa.
She is also an Adjunct Assistant Professor at the College of Pharmacy and
Health Sciences in the Department of Clinical Sciences (2009-2012) at Drake
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University, and co-collaborator for the AIDS Online International course with
Dr Sharron Jenkins at Purdue University. She is a national executive member
of the Pharmaceutical Society of South Africa and a Fulbright Alumnus
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(Fulbright Scholar 2002-2004). Her previous appointments include being a
member of the South African Primary Health Care Essential Drugs List
Review Committee (1997 - 1998) and of the KZN Provincial Essential Drug
Programme Co-ordinating Committee (1997 - 1998). In 2009 she was
appointed by the National Minster of Health to the Medical Products
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Technical Task Team as well as to the Procurement Task Team. She has also
been appointed to the National Pricing Committee in 2009.
GEOFFREY SETSWE: Geoffrey is a Professor of Public Health at

Monash University, Australia and is the founding head of the School of Health
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Sciences at Monash South Africa. Before his current job, he was Research
Director in the Social Aspects of HIV/AIDS and Health research programme
at the Human Sciences Research Council and served as the founding Director
of the AIDS Research Institute at Wits University where he coordinated AIDS
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research between 2003 and 2005. He has also worked for the University of
Limpopo as lecturer, senior lecturer and professor of public health over an 11
year period. He has a Doctor of Public Health and Honours B. Cur degrees
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from the University of Limpopo, a Masters of Public Health from Temple

University in Philadelphia, where he was a Fulbright Scholar, a BA Cur degree
with UNISA and has six other Diplomas in health and management sciences.
GERALDINE S. PERRY, M.P.H., DrPH, R.D: Geraldine is a Lead

Health Scientist and Team Lead for the Sleep and Mental Team in the
Emerging Investigations and Analytic Methods Branch at the Centers for
Disease Control and Prevention (CDC), Atlanta, Georgia, USA. Dr. Perry
completed a fellowship in Applied Epidemiology at CDC in 1992. She

received a B.S. in Food Administration from Tuskegee Institute, an M.P.H. in
Nutrition from the University of Michigan, Ann Arbor, and a DrPH in
Nutrition from the University of California, Berkeley. Dr. Perry‘s research
interests focus on the relationship between mental health and obesity,
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depression and sleep and chronic disease. She has been involved in a number
of international and state consultancies on nutrition surveillance and
methodology in America Samoa, Azerbaijan, Egypt, Haiti, Guinea, and Sierra
Leone, with the U.S. Agency on International Development (USAID), Save
the Children, the Food and Agriculture Organization (FAO) and states. Dr.
Perry has authored or co-authored numerous peer reviewed journal articles and
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book chapters and is an active member of the American Public Health
Association.
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ITALIA ROLLE, M.S., Ph.D., R.D: Italia is an Epidemiologist with the
Field Epidemiology and Laboratory Training Program-Africa Branch in the
Division of Public Health Systems and Workforce Development, Center for
Global Health at the Centers for Disease Control and Prevention, Atlanta,
Georgia, USA. Dr. Rolle works with field epidemiology training programmes
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in the Central African region, Tanzania, Rwanda, and South Africa. She serves
as the lead for the branch on chronic disease activities in the African region.
Her background includes a PhD in Public Health (Epidemiology and Maternal
and Child Health) from the School of Public Health at the University of
Illinois-Chicago, USA, Masters in Nutritional Science from Tuskegee
University, USA, and Bachelor‘s of Science in Dietetics, Acadia University,
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Canada. She is certified as a Registered Dietitian with the American Dietetic

Association. Dr. Rolle‘s research interests include developing capacity in
chronic disease epidemiology and surveillance in low and middle income
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countries, the epidemiologic transition and its impact on the chronic disease
burden in low and middle income countries, and treating HIV as a chronic
disease.
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JANNETH M. MGHAMBA, MD, MSc (Epi and Biost), MSc (Applied

Epidemiology): Janeth is an Epidemiologist working with the Ministry of
Health and Social Welfare. She holds two Masters‘ degrees in the areas of
Epidemiology and Biostatistics from the University of Witwatersrand in South
Africa and Jomo Kenyatta University of Agriculture and Technology. She is a
medical doctor by profession, Muhimbili University of Allied Health Sciences
(Tanzania). Dr. Mghamba developed an interest in non-communicable
diseases when she was practicing as a physician. Her Masters‘ degree research
paper on breast cancer resulted in her being placed as a focal point for non-
communicable disease surveillance, prevention and control within the Ministry
of Health and Social Welfare, Tanzania. She has been involved in developing
national guidelines policies and strategies in non-communicable diseases. Dr.
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Mghamba is currently mentoring Masters‘ degree students who are
specializing in non-communicable diseases at Muhimbili University of Allied
health Sciences (Tanzania). She is also a visiting lecturer for the international
non-communicable disease short course at the University of Copenhagen
(Denmark).
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KEBOGILE MOKWENA: Kebogile holds a Doctorate in Public Health
Education from the University of South Carolina in 1998. She is the Head of
Social and Behavioural Health Sciences at the School of Public Health,
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Medunsa Campus, University of Limpopo. Her primary profession is
physiotherapy and she worked clinically in Johannesburg and Pretoria. Over a
span of 14 years as an academic in the undergraduate physiotherapy program,
she obtained a MSc (Physiotherapy) from the Medical University of Southern
Africa (MEDUNSA) and a Higher Education Diploma from UNISA. After
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completing her doctorate (curriculum development and Health Promotion and
Health Education), she founded the Department of Social and Behavioural
Health Sciences, and was later appointed the HOD. She served MEDUNSA on
many senior committees. Over years, she developed and taught several public
health online courses, specifically in social and behavioural health sciences.
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Her publications include articles on asthma and online education, and a

contribution to a chapter on educational technology.
LAETITIA RISPEL: Laetitia is an Adjunct Professor at the Centre for

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Health Policy, School of Public Health at the University of the Witwatersrand,

Johannesburg. She holds a PhD from the University of the Witwatersrand,
Johannesburg and has formal qualifications from universities in South Africa,
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the United Kingdom and the United States. Her research interests include
HIVand AIDS, health policy and systems and public health. Before joining
CHP, she was the Executive Director of the Social Aspects of HIV/AIDS and
Health Research Programme at the Human Sciences Research Council
(HSRC) of South Africa. From 2001-2006, she was the Head of the Health
Department in Gauteng Province, where she lead and implemented many of
the health transformation initiatives. Laetitia is the current President of the
Public Health Association of South Africa (PHASA). She was the 2003 health
category winner of the South African Shoprite/Checkers/SABC2 woman of

the year award.
MOISE MUZIGABA: Moise is a research assistant at the School of

Public Health, University of the Western Cape, South Africa. He has a BSc in
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Nutritional Sciences and is currently pursuing a Ph D in Public Health. His
research interests include non-communicable diseases, paediatric malnutrition
and health systems research in general.
SEBASTIANA ZIMBA KALULA, MB ChB (Zambia) MMed MPhil

(Cape Town) FRCP (UK) is Head of Geriatric Medicine and Acting Director
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of Institute of Ageing in Africa (IAA) in the Faculty of health Sciences at the
University of Cape Town (UCT) and the Director of International Longevity
Centre–South Africa (ILCSA) affiliated to the Institute. Kalula is a physician
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specialist in Geriatric Medicine. After medical training in Zambia, she
specialised in Geriatric Medicine in the United Kingdom, and later gained an
MPhil degree in Epidemiology at the University of Cape Town. In 2007 she
was elected to the Fellowship of the Royal College of Physicians (UK). Apart
from her clinical service and teaching responsibilities, she manages a focused
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and expanding research programme on functioning and clinical health care at
the IAA, and directs ILCSA‘s research programme. Her current research
interests are falls in older persons, physical and cognitive functioning, and the
epidemiology and management of dementia. Kalula serves on the UCT Health
Sciences Board of Graduate Studies is a member of the South African Older
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Persons Forum, the African Research on Ageing Network, and the South
African Geriatrics Society and South African Gerontology Society.
SETH STHEMBISO MKHONTO: Seth is a PhD research trainee in the

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Population Health, Health Systems and Innovation Unit of the HSRC. He

holds a MA degree from the University of Limpopo. Before joining HSRC in
March 2009, he did an internship with FPD for a year. For the period February
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2008 to December 2008 where he was placed at HSRC in SAHA Unit. His
areas of research interest includes chronic diseases and metabolic lifestyle
(environmental risk factors which includes physical inactivity, physical fitness,
obesity, smoking and tobacco use, fruits and vegetables and self-related health
in subject with hypertension and diabetes. He has a publication (Descriptive
Epidemiology of ambulatory activity in rural, black South Africans) with the
journal American College of Sports Medicine.
THANDI PUOANE: Thandi is a Professor at the School of Public Health,

University of the Western Cape, South Africa. She is a member of the
National Collaborative Research Programme (NCRP) in Cardiovascular and
Metabolic Disease of the Medical Research Council (MRC), Africa Taskforce
on Obesity coordinated by the HRSC, executive member for the Public Health
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Association of South Africa as well as a member of the Chronic disease
initiative for Africa (CDIA). Her research interests include peadiatric
malnutrition, prevention of non communicable diseases, obesity and socio-
cultural factors associated with non communicable disease and obesity.
TIFFANY L. GARY-WEBB, PhD, MHS: Tiffany is an Associate
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Professor at the Columbia University Mailman School of Public Health, in the
Department of Epidemiology. Before coming to Columbia, Dr. Gary-Webb
was on the faculty at the Johns Hopkins Bloomberg School of Public Health
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for over 8 years. Dr. Gary-Webb‘s research program is unique in that she
combines observational and intervention research to address the common
theme of ―reducing racial/ethnic disparities in diabetes and its complications
and improving diabetes care for urban African Americans.” She has
developed a national reputation in this area as evidenced by her publications
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(70+), presentations, and professional activities. Dr. Gary-Webb has recently
expanded her research program to include social epidemiology, advanced
statistical methods, and the content area of obesity. These expanded domains
provide a nice supplement to her existing work and have enhanced her
independent research agenda on reducing racial disparities in obesity and
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diabetes.
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INDEX
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agencies, 70, 172, 212, 219
# aging population, 7
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agonist, 162
20th century, 13, 218
agriculture, 118
21st century, 221, 222
AIDS, vii, 41, 45, 46, 50, 52, 73, 79, 108,
110, 142, 143, 183, 185, 197, 199, 200,
A 228, 230, 232
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airways, 22, 189
access, ix, 21, 25, 41, 50, 63, 69, 70, 94, Albania, 5, 55
114, 120, 121, 130, 131, 132, 135, 138, alcohol abuse, 49, 50, 89
139, 140, 141, 142, 143, 145, 146, 149, alcohol consumption, ix, 28, 63, 119, 179,
155, 156, 163, 167, 168, 170, 172, 181, 182, 190, 202, 204
197, 198, 200, 201, 218, 228 alcohol dependence, 184, 190
accessibility, 141, 167 alcohol use, 12, 55, 90, 206
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accountability, 139 alcoholism, 200

accounting, ix, 11, 110, 112 Algeria, 5, 33
adaptation, 64 algorithm, 78
adolescents, 6, 89, 173 alienation, 182
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adrenaline, 165 allergens, 22

adulthood, 6 allergy, 22
adults, xi, 13, 17, 18, 23, 34, 49, 61, 63, 87, American Samoa, 5
90, 92, 98, 105, 108, 109, 110, 112, 116, amputation, 11, 188
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164, 173, 176, 187, 190, 203, 206, 220, anaphylaxis, 164
222 angina, 16
adverse effects, 156, 164, 171 Angola, 5
advocacy, ix, 106, 114, 122, 123, 151, 219 ankles, 192
aetiology, xi anticholinergic, 166
affluence, xi, 191 anxiety, 11
Afghanistan, 4, 55 appointments, 230
African Americans, 234 Arab world, 25
ageing population, ix, 40, 200 Argentina, 5, 55
236 Index
Armenia, 5, 10, 20, 26 blame, 144, 171

arrhythmia, 194 blindness, 9, 188
arteries, 18 blood, viii, 6, 9, 11, 12, 14, 15, 17, 18, 19,
arthritis, 16, 64, 72 55, 62, 64, 84, 86, 87, 88, 96, 110, 111,
Asia, 13, 23, 25, 59, 135, 195 113, 117, 118, 119, 146, 170, 187, 205
Asian countries, 78 blood pressure, viii, 12, 15, 18, 19, 84, 86,
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assault, 182 87, 88, 96, 110, 111, 113, 117, 118, 170,
assessment, 3, 54, 58, 59, 77, 121, 156, 157, 187, 205
168, 173, 210, 211, 228 blood vessels, 9, 12, 14, 17, 18
asthma, 16, 22, 23, 24, 35, 64, 89, 119, 124, body mass index (BMI), 65, 96, 110, 184,
156, 157, 164, 165, 166, 171, 172, 176, 191
232 body size, 200
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atherosclerosis, 183 Bolivia, 5, 55
audits, 202 bone, 192
authorities, 87, 118 Bosnia, 5, 20, 26
authority, 139 Botswana, 5, 6, 185, 189, 190, 204, 229
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autonomic neuropathy, 193 brain, 15, 137, 159, 196
awareness, ix, xi, 63, 70, 91, 92, 94, 95, brain drain, 137, 159
118, 132, 135, 179, 187, 195, 203, 212, Brazil, 5, 12, 49, 51, 94, 142, 167
219 breast cancer, 28, 29, 30, 196, 232
Azerbaijan, 5, 20, 26, 231 breathing, 22
bronchioles, 22
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bronchitis, 25
B bronchodilator, 176
bronchus, 31, 56, 57
ban, 92
bruit, 194
Bangladesh, 4, 55, 67, 74, 108, 124, 167,
building blocks, 119
189, 206, 220
Bulgaria, 5, 14, 20
barriers, 121, 138, 146, 168, 170, 172, 174,
Burkina Faso, 4, 63, 185, 187, 206
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175, 198, 200, 216, 227

Burundi, 4
base, 103, 162, 215, 216
basic services, 121
behaviors, 55, 60, 63, 64, 75 C
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Belarus, 5, 14
Belgium, 32 cachexia, 31
beneficial effect, 190 calcium, 157, 174, 194, 204
beneficiaries, 199 calcium channel blocker, 174
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benefits, 87, 94, 95, 98, 148, 159, 199 calorie, 191
beverages, 89 Cambodia, 4, 55
Bhutan, 5 Cameroon, 5, 55, 185
bias, 205 campaigns, 113, 117, 118, 119
binge drinking, 64 cancer, 2, 3, 27, 28, 29, 30, 31, 32, 35, 36,
birth rate, 41, 180 37, 49, 55, 56, 57, 58, 59, 60, 62, 63, 65,
birth weight, 22 66, 68, 72, 76, 78, 79, 80, 81, 85, 105,
births, 60 107, 108, 109, 118, 130, 131, 133, 134,
bladder cancer, 80
Index 237
139, 157, 169, 175, 186, 191, 196, 200, childhood, 6, 76, 173
202, 203, 208, 210, 217, 220 children, 6, 8, 12, 13, 16, 23, 86, 89, 90, 92,
cancer care, 169 96, 112, 116, 118, 163, 164, 165, 170,
cancer death, 28, 30 174, 176, 199, 228
cancer screening, 197 Chile, 5, 102, 120
capacity building, 173 China, 5, 8, 12, 33, 49, 52, 61, 78, 81, 86,
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carbohydrate, 112 102, 104, 108, 119, 125
carcinoma, 75 cholera, 54
cardiovascular disease, vii, 1, 2, 3, 9, 15, 18, cholesterol, viii, 12, 17, 59, 64, 69, 84, 86,
33, 35, 40, 46, 47, 48, 49, 50, 55, 64, 72, 87, 88, 96, 113, 118, 182, 191, 195, 206
85, 105, 106, 108, 109, 110, 181, 196, chronic disease surveillance, viii, 54, 55, 57,
208, 212, 220, 221, 222 58, 59, 60, 62, 63, 64, 65, 67, 68, 70, 72,
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cardiovascular risk, 74, 86, 88 75
care model, 99, 102, 125, 211, 216 chronic illness, 204
caregivers, 96, 153 chronic NCDs, vii, ix, 1, 2, 33, 85, 86, 129,
caregiving, 195, 199, 200, 201, 202 212, 215, 219, 225
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Caribbean, 4, 5 chronic non-communicable diseases, vii,
carotid bruit, 194 viii, 2, 39, 42, 51, 52, 83, 84, 85, 86, 88,
carotid sinus, 194 89, 91, 92, 131, 143, 148, 150, 156, 173,
case studies, 175 174, 212, 213, 214, 215, 219
cash, 116 chronic obstructive pulmonary disease
category a, 3 (COPD), 22, 23, 25, 27, 35, 36, 37, 62,
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cation, 126 108, 157, 175, 186
causation, 112 cigarette smoke, 92
CDC, 6, 34, 60, 64, 68, 70, 71, 73, 74, 75, cigarette smokers, 92
230 cigarette smoking, 23, 89, 189
cell death, 183 citalopram, 194
cell phones, 63 citizens, 94, 131, 143, 150
census, 9 city, 53, 60, 75, 101, 104
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Central African Republic, 4 civil society, 95, 115, 122, 199

Central Asia, 4, 5, 135 classes, 161
central obesity, 220 classification, 40, 56, 68, 76
cerebrovascular disease, 12, 62 classroom, 96, 97
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certificate, 66 claudication, 193

certification, 42 cleaning, 22, 42, 64
cervical cancer, 29, 30, 72, 196 clients, 197, 202
cervix, 217, 220 clinical trials, 156, 157, 214
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Chad, 4 coding, 42
challenges, viii, xii, 33, 38, 41, 75, 77, 81, cognition, 194
125, 130, 131, 133, 135, 139, 140, 144, cognitive function, 202, 233
145, 146, 152, 156, 157, 172, 173, 202, cognitive impairment, 193, 195
203, 205, 215, 219, 223 collaboration, 67, 72, 91, 96, 115, 118, 119,
changing environment, 181 144, 150
chemicals, 22 Colombia, 5
Chicago, 231 colon, 191
238 Index
colon cancer, 191 cost effectiveness, 142

colorectal cancer, 29, 196 Costa Rica, 5
coma, 6 cough, 22
commercial, 161, 166 covering, 228
communication, 32, 70, 89, 94, 120, 149, creatinine, 193
185 Croatia, 5, 32
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communication skills, 89 crude death rate, vii, 39, 41, 43, 44, 46, 47,
communities, 70, 85, 87, 96, 98, 117, 120, 50
122, 146, 147, 172, 182, 187, 191, 195, Cuba, 5, 55
215, 216 cultural differences, 147
community support, 199 cultural norms, 204
compliance, 132, 148, 187 cultural practices, 195
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complications, xi, 3, 9, 10, 34, 86, 88, 120, culture, 147, 157, 215, 228
123, 124, 132, 141, 148, 149, 173, 186, cure, 156
189, 192, 205, 214, 216, 234 curricula, 91
compounds, 160, 165 curriculum, ix, 97, 144, 232
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computer, 62 curriculum development, 232
computing, 44 CVD, 2, 12, 13, 14, 15, 21, 29, 38
concordance, 171, 176 Czech Republic, 32
conduction, 148
conference, 228, 229
confidentiality, 69 D
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conflict, 159, 214
daily living, 192, 202
conflict of interest, 159
data analysis, 68
congenital malformations, 60
data collection, 3, 58, 68, 72, 131, 146, 210,
congestive heart failure, 12
211
Congo, 4, 5
database, 64, 69, 75, 85, 98
connective tissue, 16
death rate, vii, 25, 30, 39, 41, 43, 44, 46, 47,
consciousness, 7
O
48, 49, 50, 85, 108

constituents, 116
decision makers, 144
consulting, 170
defects, 75
consumers, 135, 138, 139, 190
deficiencies, 28
consumption, vii, viii, 1, 3, 12, 21, 23, 28,
O
dementia, ix, 56, 57, 181, 193, 194, 195,

65, 89, 113, 115, 116, 117, 123, 182,
227, 233
187, 190, 191, 207
demographic change, 66
consumption patterns, 116
demographic transition, viii, 40, 41, 50
contaminated food, 28
PR
demography, 51
contextualization, 219
Denmark, 32, 56, 65, 76, 80, 232
controlled trials, 214, 220
Department of Education, 95, 96
controversial, 164
Department of Health and Human Services,
cooperation, 168
74
coordination, 122, 137, 194
deposition, 17
coronary artery bypass graft, 193
depression, ix, 11, 63, 64, 65, 182, 190, 193,
coronary heart disease, ix, 12, 17, 64, 103,
197, 200, 231
118, 167, 179, 182, 205, 216, 220, 221
depressive symptoms, 194
Index 239
depth, 168 drug therapy, 132, 140, 141

detection, 2, 3, 30, 121, 133, 138 drug treatment, 119, 132, 149, 168
determinism, 218 drugs, 133, 142, 143, 161, 162, 163, 166,
developed countries, 7, 8, 12, 21, 27, 29, 30, 170, 187, 214
41, 43, 67, 83, 84, 103, 106, 110, 112, dusts, 22
122, 126, 134, 147, 153, 159, 171, 183, dyslipidemia, 189, 196
LY
212, 217, 219, 221 dyspnea, 22
deviation, 194
DHS, 57, 60, 63, 187
diabetic patients, 11 E
dialogues, 97, 228
earnings, 167, 168
diastolic blood pressure, 195
East Asia, 4, 5, 23, 25, 59, 153
N
diet, viii, 3, 6, 28, 49, 50, 55, 59, 61, 84, 86,
Eastern Europe, 23, 40
88, 110, 111, 112, 113, 117, 133, 139,
economic change, 112
185, 215
economic development, 11, 115, 173
dietary habits, 28, 112
economic status, 69
O
dietary intake, 112
economics, 51
direct cost, 11
economies of scale, 166
disability, 11, 15, 21, 32, 56, 80, 108, 179,
Ecuador, 5
185, 186, 189, 191, 192, 195, 197, 198,
editors, 153
199, 200, 202
education, 11, 69, 70, 92, 95, 96, 98, 100,
disclosure, 161
FS
106, 120, 121, 122, 123, 140, 142, 164,
discomfort, 192
182, 197, 200, 201, 229, 232
disease progression, 134, 141
educational attainment, 195
disease rate, 105, 108
educators, 97, 171
disorder, 193
Egypt, 5, 231
dissatisfaction, 198
El Salvador, 5
distance learning, 212
elderly population, 52
distress, 32
O
elders, 192, 198, 201

distribution, ix, 69, 116, 136, 142, 147, 155,
e-mail, 98
156, 159, 166, 173, 174, 180, 183
emergency, 193
District of Columbia, 63
emotional well-being, 202
diuretic, 159, 174
O
employees, 87, 91, 96, 102

diversity, 173
employers, 87
doctors, 63, 69, 91, 121, 142
employment, 32, 95, 182
DOI, 35, 175, 176
empowerment, 90, 140, 142, 201, 217
Dominican Republic, 5
PR
encouragement, 94, 197

dosage, 160, 174
endocrine, 40, 47, 50, 111
dosing, 174
endocrine disorders, 40, 47, 50
draft, 162
energy, 110, 112
drawing, 181
England, 120
drug abuse, 133, 154
environment, viii, 2, 87, 89, 91, 97, 106,
drug addict, 133
111, 112, 113, 115, 123, 133, 149, 182,
drug addiction, 133
206
drug interaction, 166
environment factors, 149
240 Index
environmental factors, 60, 196 fasting glucose, 222

environmental issues, 118 fat, 112, 115, 139, 182, 191
environmental tobacco, 22 fat intake, 112
enzyme, 157, 174 fear, 193
enzyme inhibitors, 157 feelings, 11
epidemic, viii, 50, 63, 77, 106, 125, 127, femininity, 217, 221
LY
197, 218 fertility, 40, 49, 173
epidemiology, 1, 3, 6, 69, 76, 130, 181, 227, fibrinogen, 196
229, 231, 233, 234 Fiji, 5, 55
epilepsy, 172, 190, 227 financial, x, 32, 65, 66, 113, 114, 121, 124,
epinephrine, 165 130, 137, 138, 149, 159, 168, 170, 201,
equipment, 11, 148 209
N
equity, 77, 113, 125, 138, 139 financial planning, 130
Eritrea, 4, 79 financial resources, 114, 137
erosion, 195 financial support, 32, 201
Estonia, 14, 20, 26 Finland, 56, 87, 117, 118, 126
O
ethical issues, 126 fitness, 94, 95
ethnic groups, ix, 31, 187, 188, 195, 222 flexibility, 70
ethnicity, 2, 217 fluid, 16
Europe, 4, 5, 25, 30, 222, 225 focus groups, 98
evidence, ix, 2, 22, 27, 28, 55, 68, 70, 74, food, vii, 1, 3, 28, 89, 90, 97, 112, 116, 117,
79, 83, 84, 88, 106, 108, 119, 121, 122, 118, 207, 229
FS
151, 155, 157, 158, 159, 160, 161, 162, food industry, 118
164, 165, 166, 167, 172, 173, 191, 202, food products, 97
210, 212, 214, 218, 219 food safety, 229
excess body weight, 205 force, 32, 161
excretion, 204 Ford, 218, 220
exercise, 6, 22, 59, 65, 94, 95, 215 forecasting, 167
exertion, 22 formation, 212
O
expertise, 157, 213, 228 fractures, 192, 193, 207

exposure, viii, 21, 22, 55, 113, 117, 123, fruits, 41, 64, 191, 197, 233
182 funding, 54, 58, 70, 72, 159, 162, 172, 215
funds, 66, 170
O
F
G
faith, 218, 223
PR
families, xi, 21, 85, 86, 119, 197, 199, 201, Gabon, 5, 6
223 gait, 193
family history, 55, 189 gangrene, 188
family life, 11 gastrointestinal tract, 196
family members, 11, 121, 167, 198, 203 gender differences, 65, 216
family support, 148 gender manifestations, 210
family system, 195 gender-sensitive, 217
family therapy, 171 genes, 23, 196
fasting, 222 genetics, 113
Index 241
Georgia, 5, 9, 14, 53, 73, 230, 231 health promotion, 85, 94, 120, 130, 133,
Germany, 32, 65, 78, 102 141, 143, 180, 200, 203, 211, 213, 217
gestational diabetes, 6, 35 health researchers, 147, 218
global scale, 221 health risks, 191
Global Youth Tobacco Survey, 112 health services, viii, 25, 86, 87, 88, 91, 100,
globalization, vii, 1, 3, 57, 81 106, 107, 123, 130, 137, 138, 140, 141,
LY
glucose, 6, 9, 15, 55, 62, 110, 111, 119, 126, 145, 146, 147, 148, 151, 172, 197, 198,
162, 163, 194 200, 217, 228
glucose tolerance, 119, 126 health status, 11, 96, 135, 181
governance, 144 heart attack, 13, 17, 18, 19
governments, 115, 138, 144, 145, 151, 173, heart disease, 3, 11, 12, 15, 16, 17, 18, 20,
181, 183, 199, 201 21, 26, 33, 56, 57, 58, 59, 62, 63, 64, 76,
N
grants, 161, 164, 166 107, 108, 131, 149, 185, 186, 188, 190,
graph, 44 210, 212
Grenada, 5, 10, 19 heart failure, 16, 36, 65, 132, 206
gross national income (GNI ), 55 heart valves, 16
O
growth, 22, 115, 182, 219 hemoglobin, 194
Guatemala, 5 hemorrhagic stroke, 15, 190
guidance, 113, 126, 223 hepatitis, 28, 197
guidelines, ix, 74, 89, 90, 94, 102, 114, 120, high blood cholesterol, 64, 84
121, 129, 131, 132, 133, 144, 145, 148, high blood pressure, 12, 18, 49, 64, 69, 84,
155, 158, 159, 161, 163, 164, 165, 166, 98, 176, 206, 214
FS
172, 173, 176, 232 high fat, 91
Guinea, 4, 231 high income countries (HIC), 55
Guyana, 5 high-risk populations, 144
hippocampus, 196
Hispanics, 61
H history, 22, 55, 222
HIV epidemic, viii, 50
O
Haiti, 4, 231
HIV/AIDS, x, 15, 39, 52, 56, 57, 67, 74, 80,
harmful effects, 98, 115
147, 159, 191, 202, 225, 227, 228, 230,
hazards, 107, 193, 203
232
head injury, 193
home care services, 198
O
headache, 227
homes, 189
health care costs, 138
Honduras, 5
health care professionals, 120
Hong Kong, 62, 81
health care sector, 122
hormone, 6
PR
health care system, 1, 3, 135, 143, 145, 150,

host, 112
173, 215
hot spots, 146
health condition, 141, 146, 186, 190, 201
housing, 121, 122, 195
health education, 69, 86, 216
human, viii, ix, 27, 54, 57, 70, 91, 106, 113,
health effects, 124
114, 123, 129, 136, 137, 139, 140, 142,
health information, 63, 115, 147
148, 197, 210, 215
health insurance, 51, 65, 79
human body, 27
health practitioners, 69, 135
human health, 210
health problems, 119, 143, 168, 203, 217
242 Index
human immunodeficiency virus (HIV), viii, industrialized countries, 28, 191

x, 15, 39, 41, 45, 46, 50, 51, 52, 54, 56, industries, 70
57, 67, 74, 80, 81, 108, 110, 120, 142, industry, 89, 116
143, 147, 159, 183, 191, 197, 202, 225, ineffectiveness, 131
227, 228, 230, 231, 232 inefficiency, 145
human papilloma virus, 197 inequality, 121, 220
LY
human resource development, 91, 129, 142 infancy, viii, 54, 55
human resources, ix, 70, 136, 140, 148 infection, 16, 22, 40, 197
human right, 106 inflammation, 16
Hungary, 31 infrastructure, ix, 62, 129, 137, 139, 182,
hydrogen, 165 195, 209
hyperglycaemia, 6 ingestion, 28, 197
N
hyperglycemia, 81 inhaler, 165, 166, 169
hyperkalemia, 194 inhibitor, 174
hyperlipidemia, 185 initiation, 147, 159
hypersensitivity, 194 injections, 6
O
hypertension, ix, 3, 18, 37, 55, 58, 59, 62, injuries, 56, 67, 106, 109, 110, 182, 183,
63, 64, 65, 89, 95, 107, 109, 110, 119, 185
131, 133, 156, 157, 159, 160, 164, 171, injury, 63, 77, 192, 193, 206, 207
172, 176, 179, 182, 185, 187, 188, 189, insecurity, 89
191, 193, 195, 200, 203, 204, 210, 220, institutionalisation, 198
233 institutions, 95, 132, 135, 202, 211, 223
FS
insulin, 6, 11, 81, 100, 119, 163, 167
insulin resistance, 6
I integration, 73, 147, 152, 153
interface, 147
ideal, 55, 144, 195, 223
internalised, 146
identification, x, 3, 34, 35, 90, 91, 121, 209,
International Bank for Reconstruction and
217
Development, 77
O
illiteracy, 7, 25
International Classification of Diseases, 43,
immune system, 183
61
immunization, 63
international investment, 173
impact assessment, 153
internship, 233
O
improvements, 90, 156, 171, 214

intervention, viii, 37, 46, 54, 83, 85, 87, 88,
in transition, 74
92, 94, 95, 96, 97, 98, 100, 103, 115,
incidence, 7, 9, 13, 16, 28, 29, 31, 33, 68,
117, 119, 120, 122, 123, 126, 170, 171,
78, 108, 110, 192, 196, 218
173, 200, 204, 214, 222, 234
PR
increased access, ix, 130

intervention strategies, 173, 200
India, 5, 8, 12, 33, 67, 108, 119, 185
investment, 127, 142, 150, 209, 218
Indians, 180
Iran, 5, 33, 68, 79
individuals, xi, 11, 12, 21, 69, 86, 91, 92,
Iraq, 5
95, 96, 106, 107, 108, 113, 117, 119,
irony, 134
123, 159, 168, 195, 198, 199, 203, 214,
ischaemic heart disease, 12, 19, 89, 110,
215, 223, 225
187, 191, 193, 194, 202
Indonesia, 5, 67
isolation, 11, 32
industrialization, vii, 1, 3, 12, 121, 182
Index 243
issues, 61, 63, 70, 94, 122, 145, 148, 154, life course, 181
156, 181, 187, 215, 218, 222 life expectancy, 19, 39, 41, 48, 110, 180
Italy, 32, 56 lifestyle behaviors, 55
lifestyle changes, 12, 156, 172, 182, 200
Limpopo, 49, 129, 230, 232, 233
J lipids, 12, 110, 111
LY
literacy, 141, 142, 174, 217
Jamaica, 5, 10, 55
Lithuania, 5, 55
Japan, 30, 56
liver, 28, 29, 62, 190, 197
joints, 16, 183, 192
liver cancer, 28, 29
Jordan, 5, 55, 64, 74, 124, 157, 167, 174,
liver disease, 62, 190
175
living conditions, 120
N
logistics, 156
K longevity, 16, 40, 48, 180, 196
Louisiana, 9
Kazakhstan, 5 low and middle income countries (LMIC),
O
Kenya, 4, 33, 63, 112, 185 55
kidney, 9, 11, 28, 62, 80, 98, 186, 191 low-density lipoprotein, 182
kidney failure, 9, 11 lung cancer, 27, 29, 30, 31, 56, 57
knees, 192 lung disease, 105, 109
Korea, 4, 20 lying, 111
FS
L M
labor market, 51 Macedonia, 5, 20, 26

landscape, 144, 215 macroeconomic policies, 219
language barrier, 174 magnesium, 204
larynx, 28, 190 magnitude, 16, 46, 110, 120, 219
O
later life, 6 majority, xi, 12, 41, 72, 96, 105, 109, 138,
Latin America, 4, 5, 23, 25, 152 159, 164, 171, 180, 181, 197, 198, 200
Latvia, 5, 14, 20, 26, 32 malaria, 57, 80, 108, 159, 183
laws, 92 Malaysia, 5
O
laws and regulations, 92 malnutrition, 59, 183, 233, 234

lead, 9, 86, 91, 106, 145, 171, 211, 231, 232 mammography, 61
leadership, 144, 145, 153, 228 man, 40
leadership development, 228 manipulation, 135
PR
learners, 96, 97, 103, 143 manpower, 84, 142

learning, 95, 97, 212, 214, 218 marketing, 91, 112, 115, 160, 165
Lebanon, 5 Marshall Islands, 5
legislation, 106, 116, 133, 158, 200 Maryland, 227
leisure, 11, 32, 94, 118 masculinity, 217
leisure time, 94, 118 mass, 94, 98, 110, 117
leukotriene antagonists, 164 mass media, 94, 117
leukotriene modifier, 164 materials, 97, 203
Liberia, 4 matter, xii, 195
244 Index
Mauritania, 4 models, 62, 113, 120, 215, 217, 218

Mauritius, 5, 6, 112, 180 modifications, 197, 201
Mayotte, 5, 6 modules, 64, 206
measles, 54 mold, 22
measurement, 190 Moldova, 5, 14
measurements, 64 momentum, viii, 50, 112
LY
media, 96, 117, 118, 149 Mongolia, 5, 64
median, 41, 64, 180, 185 monopoly, 168
medical, 11, 32, 42, 88, 96, 100, 102, 132, Montenegro, 5, 14, 20, 26
140, 161, 163, 171, 181, 193, 197, 198, mood disorder, 192
200, 214, 227, 231, 233 morbidity, viii, ix, 3, 9, 13, 22, 29, 40, 53,
medical care, 32, 161, 163 60, 62, 63, 65, 67, 72, 81, 85, 112, 123,
N
medical history, 193 130, 131, 134, 141, 151, 179, 181, 183,
Medicare, 65, 79 185, 187, 188, 189, 193, 197, 200, 202,
medication, 65, 156, 164, 174, 175 213, 219, 221
medicine, 160, 161, 163, 165, 167, 168, Morocco, 5
O
170, 222 mortality rate, 16, 24, 30, 42, 118, 124
medicines selection, 155, 157, 174 Mozambique, 4
Mediterranean, 23, 25, 104, 106 multidimensional, 140
mellitus, 2, 6, 7, 11, 109, 163, 164, 171, multimedia, 229
185, 191, 205 multiple factors, 91
membership, 229 multiple myeloma, 31
FS
memory, 171, 195 multiplication, 27
mental disorder, 55, 133, 182, 185 mutations, 196
mental health, 63, 133, 146, 200, 217, 231 Myanmar, 4
mental illness, 202 myocardial infarction, 16, 185, 193
mentoring, 232
messages, 89, 94, 117, 149
metabolic, 132, 229, 234 N
O
metabolic disorder, 130, 139, 230

Namibia, 5
metabolic syndrome, 81, 132, 218, 220
NAP, 97
metabolism, 192
national income, 33, 55
metformin, 126, 162, 163, 164
O
National Institutes of Health, 176, 212

methodology, 100, 228, 231
national strategy, 67
Mexico, 5, 8, 10, 100, 119
Nauru, 20
Miami, 229
negative consequences, 115
micrograms, 165
PR
neglect, 198
Middle East, 4, 5
Nelson Mandela, 225
middle income developing countries, vii, 1,
neoplasm, 40, 46
2
Nepal, 4, 167
migrants, 78, 122
Netherlands, 27, 120, 191, 203, 227
migration, 112, 182, 197
neurodegenerative diseases, 227
minors, 89, 92
neurohormonal, 16
mitral valve, 194
neuropathy, 11
modelling, 229
New England, 36, 203, 207
Index 245
New Zealand, 102 osteoarthritis, 191, 192, 194

Nicaragua, 5 outreach, 92, 95, 98, 151
nicotine, 116 overlap, 114, 120
Nigeria, 4, 109, 185, 227, 229 oversight, x, 210
nitrates, 194 overtime, 45
non- communicable diseases, 37, 88, 219 overweight, 12, 28, 49, 50, 59, 63, 65, 72,
LY
nongovernmental organisations (NGOs), 84, 94, 110, 112, 162, 183, 191
118, 152, 212, 218, 228 ownership, 90
non-institutionalized, 63 oxygen, 15, 17
non-smokers, 89
North Africa, 4, 5
North America, 8, 23, 30, 206, 222 P
N
North Korea, 20
Pacific, 4, 5, 23, 25, 59, 74
nurses, 69, 91, 99, 119, 120, 133, 142
pain, 16, 31, 32, 192
nutrients, 17, 112
Pakistan, 4, 167, 204, 221
nutrition, 3, 55, 57, 58, 72, 85, 86, 96, 97,
palliative, 199
O
103, 104, 107, 116, 117, 124, 126, 181,
Panama, 5, 55
208, 221, 231
pancreas, 6
nutritional deficiencies, 185
panic disorder, 182
Paraguay, 5
O parasitic diseases, 110, 173, 183
FS
parents, 96
obesity, ix, 3, 7, 12, 28, 33, 49, 50, 55, 58, participants, 64, 87, 215
59, 63, 64, 65, 72, 81, 85, 86, 107, 110, pathogenesis, 23, 195
111, 112, 113, 116, 125, 131, 145, 149, pathophysiological, 218
179, 182, 184, 187, 189, 191, 192, 195, pathways, 149, 170
197, 200, 203, 204, 210, 230, 231, 233, patient adherence, ix, 155, 156
234 patient care, 11
O
obesity prevention, 116, 230 peer review, 229, 230, 231

obstructive lung disease, 22 peer support, 200, 201
occlusion, 15 pelvis, 80
occupational health, 230 penalties, 92
O
Oceania, 23 penicillin, 169

oedema, 162 pericarditis, 16
oesophageal, 28, 30 perinatal, 39, 40, 42, 45
old age, 181, 186, 196, 203 peripheral vascular disease, 193
PR
open spaces, 219 persuasion, 173

operations, 137 Peru, 5
opportunities, 27, 32, 113, 117, 182, 199, pharmaceutical, 159, 164, 166, 172
214 pharynx, 28
opportunity costs, 201 Philadelphia, 125, 230
oral cavity, 28 Philippines, 5, 92
organ, 40 physical activity, vii, viii, 1, 3, 49, 55, 58,
organic food, 118 61, 63, 64, 72, 84, 86, 88, 92, 94, 95, 96,
organs, 183
246 Index
97, 103, 107, 112, 116, 118, 119, 133, proliferation, 161
139, 182, 191, 200, 218 prophylaxis, 120
physical exercise, 96 prostate cancer, 29, 79
physical fitness, 233 protection, 106, 168
physical inactivity, 3, 7, 12, 33, 49, 55, 78, prototype, 73, 152
84, 110, 113, 117, 189, 191, 233 psychological distress, 63, 64
LY
physicians, 94 psychological stress, 217
pilot study, 67, 103, 192, 204 psychosocial interventions, 121
platelets, 194 public education, 92
plausibility, 69 public health measures, viii, 123
Poland, 5 public policy, 117, 126, 139
policy, viii, xi, 2, 64, 67, 70, 73, 84, 88, 89, public sector, 41, 167, 180
N
97, 106, 113, 114, 115, 119, 122, 123, public service, 138, 181
125, 135, 145, 146, 152, 157, 166, 168, public welfare, 181
175, 176, 197, 200, 203, 211, 213, 215, Puerto Rico, 9, 63
221, 232 pulmonary diseases, 2, 22
O
policy issues, 152
policy makers, xi, 135, 157, 203, 211, 215
policy responses, 125, 175 Q
policymakers, 115, 173
qualifications, 232
political leaders, 115
quality assurance, 121
political system, 153
FS
quality control, 76
politics, 154
quality improvement, 100
pollutants, 133
quality of life, 11, 32, 63, 64, 141, 149, 196,
pollution, 22, 182, 219
214
population group, 196
quality of service, 158
post-traumatic stress disorder, 182
quantitative research, 228
potassium, 194, 204
quartile, 9
poverty, 7, 25, 41, 89, 104, 110, 121, 122,
O
questionnaire, 63
146, 194, 197, 212, 219, 222
poverty reduction, 212
power relations, 216 R
pregnancy, 6, 160
O
premature death, viii, 21, 33, 108, 123, 130 race, 41, 221
president, 228, 232 racism, 146, 154, 217, 222
preventative care, 214 radio, 94
price competition, 166 rape, 182
PR
primary school, 103 ratification, 115

principles, 68, 87, 158, 170 reactions, 166
probability, 110 reality, 54
professional development, 151 recognition, 116, 229
professionals, 130, 136, 137, 142, 143, 144, recommendations, 69, 74, 124, 154, 175,
150, 151, 198, 200, 211, 216 176
prognosis, 16, 133, 148, 196 recreation, 87, 90, 95
project, 7, 37, 67, 87, 95, 100, 103, 199, 229 recreational, 199
Index 247
rectum, 31 root, 152

recurrence, 214 Royal Society, 33, 74, 206
reflexes, 194 rules, 87
reform, 154 rural areas, 92, 95, 109, 182, 187, 189, 198
reforms, 118, 200 rural population, 91
regions of the world, 83, 84, 134, 136, 150 Russia, 27, 33
LY
registries, 3, 54, 58, 60, 61, 62, 66, 210 Rwanda, 4, 192, 206, 231
registry, 60, 75
regression, 205
regulations, 121 S
rehabilitation, 32, 120, 133, 200
safety, 116, 155, 156, 157, 160, 161, 165,
reinforcement, 171
172
N
relief, 201
SAHA, x, 233
renal failure, 193
Samoa, 5, 231
representativeness, 70
saturated fat, 112
Republic of the Congo, 55
scaling, 214
O
reputation, 234
scarce resources, 172, 173
requirements, 12
school, viii, 84, 85, 86, 87, 90, 92, 94, 97,
research funding, 212, 219
102, 104, 116, 117, 118, 120, 141, 143,
researchers, 56, 61, 211
200
resistance, 18, 157
science, 107, 211, 229
resource allocation, 126, 139, 215
FS
scope, 147
resource availability, 120
search terms, 181
resources, 30, 32, 33, 54, 62, 72, 87, 121,
secondary data, 112
123, 124, 130, 131, 132, 134, 137, 140,
security, 69, 117, 150
141, 145, 146, 147, 151, 153, 158, 162,
sedentary lifestyle, vii, 1, 3
164, 171, 172, 197, 201, 202, 210, 212,
self-monitoring, 12, 171
215, 216
self-sufficiency, 199
respiratory rate, 194
O
senescence, 183, 196

response, viii, 22, 67, 95, 106, 114, 118,
sensitivity, 70, 148
120, 123, 131, 132, 137, 151, 212, 215
Serbia, 5, 14, 20, 26, 55
responsiveness, 139
serum, 87, 118, 191, 193, 194
restaurants, 92
O
services, 45, 98, 99, 114, 115, 117, 118,

retail, 116
120, 122, 123, 133, 135, 137, 138, 139,
retinopathy, 11
140, 141, 142, 144, 145, 146, 148, 149,
retirement, 8
150, 151, 168, 170, 173, 179, 182, 197,
rheumatic fever, 169
PR
198, 199, 200, 201, 202, 215, 217, 220,

rheumatic heart disease, 12
227
rhythm, 194
settlements, 121
rights, 51, 89
sex, 44, 47, 48, 84, 183
risk assessment, 96, 189, 216
sexual behavior, 55
risks, 31, 86, 92, 107, 117, 172, 188, 189,
sexuality, 200, 228
200, 208
sexually transmitted infections, 200
robberies, 182
Seychelles, 5, 6, 19, 112
Romania, 5, 14, 19
shape, 217
248 Index
shortage, 146 SSA, 7, 179, 180, 181, 182, 183, 185, 195,
shortness of breath, 22 197, 202, 225
showing, 8, 67, 83, 84 stability, 70
sibling, 78 staffing, 120
Sierra Leone, 4, 231 stakeholders, 68, 69, 70, 95, 118, 141, 149,
signs, 194 151
LY
sinus rhythm, 194 standardization, 44
skilled personnel, 167 standardized mortality ratios (SMR), 44
skills training, 200 state, 9, 22, 32, 63, 64, 94, 134, 135, 148,
skin, 31, 40 167, 231
skin cancer, 31 states, 9, 12, 18, 34, 63, 64, 75, 166, 231
skin diseases, 40 statistics, 3, 38, 42, 51, 52, 58, 72, 78, 139,
N
Slovakia, 19 143, 198, 210
smoking, viii, 3, 12, 23, 27, 49, 50, 58, 61, stigma, 202
64, 65, 84, 85, 87, 88, 92, 107, 112, 115, stomach, 28, 29
116, 133, 149, 182, 184, 189, 190, 193, storage, 166
O
195, 196, 202, 204, 215, 230, 233 strategic planning, 89
smoking cessation, 230 strength training, 194
snacking, 112 stress, vii, 1, 3, 22, 57, 113, 117, 133, 146,
social attitudes, ix, 114, 123 182, 195, 197, 219
social care, 197, 198, 199 stroke, 11, 12, 15, 33, 59, 63, 64, 67, 68, 76,
social consequences, 12 79, 80, 108, 130, 146, 185, 187, 188,
FS
social events, 190 189, 190, 191, 192, 195, 196, 204, 205,
social exclusion, 122, 126 212, 214
social institutions, 139 structure, 43, 46, 50, 129, 161
social justice, 144 style, 40, 49, 55, 132, 149
social life, 11 sub-Saharan Africa, 24, 37, 39, 40, 41, 74,
social sciences, 225 77, 85, 109, 110, 114, 119, 124, 127,
social security, 69, 168 179, 180, 181, 206, 213, 222
O
social services, 41, 181 substance abuse, 122

social skills, 144 Sudan, 5, 188
social support, 133 sulfate, 165, 169
socialization, 197 sulfonylurea, 162, 163
O
society, 21, 84, 107 supervision, 147

socioeconomic status, 13 support services, 201
sodium, 160, 187, 200, 204 support staff, 171
software, 43 survival, 78
PR
Solomon I, 4 survivors, 76
solution, 165 sustainability, 94, 119, 120, 147, 215
Somalia, 4 Sweden, 120
South African ethnic groups, ix, 188 swelling, 16, 27
South Asia, 4, 5, 51, 134, 154, 204 Switzerland, 80, 81, 104, 125, 127
specialization, 229 symptoms, 16, 22, 27, 31, 91, 156, 170, 200,
sputum, 22 201, 215
Sri Lanka, 5, 167, 187 syndrome, 132, 195
Index 249
198, 200, 209, 210, 211, 216, 227, 228,

T 231, 233
transformation, 219, 232
Tajikistan, 4, 19
translation, 70
Tanzania, 4, 33, 53, 55, 63, 66, 67, 73, 76,
transmission, 69, 227
77, 79, 80, 220, 231
transport, 7, 167, 170, 201
LY
tar, 116
transport costs, 167
target, 86, 149, 162, 173
transportation, 94
tax increase, 116, 200
trauma, 192
taxation, 115, 168, 173
trial, 159, 229
taxes, 89, 92, 115, 116, 168
triggers, 22
teachers, 86, 92, 96, 143
Trinidad, 10, 154
teams, 155
N
Trinidad and Tobago, 10
techniques, 158
tuberculosis, 54, 57, 80, 108, 112, 159, 183,
technologies, 162, 215
189
technology, 96, 150, 173, 191, 232
tumours, 27
telephone, 63, 69, 98, 171
O
Turkey, 5, 55, 62, 73
temperature, 28
Turkmenistan, 5, 19, 55
term plans, 143
Tuskegee University, 231
territory, 13, 19
type 1 diabetes, 156, 164
testing, 11, 69, 98, 119, 194
type 2 diabetes, ix, 3, 6, 8, 36, 55, 81, 89,
Thailand, 5, 55, 67, 118, 126
126, 164, 171, 176, 179, 182, 191, 210,
FS
thalamus, 196
212, 222
theft, 166
therapy, 156, 159, 163, 165, 171, 174, 176,
200 U
thiazide, 157, 161
thiazide diuretics, 157 Ukraine, 5, 14, 55
threats, 150 undernutrition, 94
O
tobacco, vii, viii, 1, 3, 12, 21, 22, 23, 28, 30, uniform, 42
37, 49, 50, 55, 59, 63, 72, 84, 89, 90, 92, unintentional injuries, 110, 191
110, 112, 113, 115, 116, 117, 119, 123, united, xi, 8, 11, 25, 32, 55, 60, 61, 63, 64,
124, 127, 189, 200, 204, 233 65, 67, 69, 72, 74, 75, 77, 79, 180, 192,
O
tobacco smoke, 22, 37, 89, 115 203, 205, 207, 232, 233
tobacco smoking, 92 United Kingdom (UK), 11, 32, 67, 77, 192,
Togo, 4 203, 218, 225, 232, 233
Tonga, 5 United Nations (UN), xi, 180, 198, 205, 207
PR
tonsillitis, 16 United States, 8, 25, 55, 56, 60, 61, 63, 64,
tonsils, 16 65, 69, 72, 75, 77, 79, 232
total cholesterol, 182, 191 universal access, 146
total energy, 112 universities, 66, 218, 225, 232
trade, 91 urban, 30, 33, 36, 37, 41, 43, 61, 69, 78, 80,
trainees, 142 81, 95, 103, 109, 110, 112, 116, 121,
training, 2, 70, 92, 97, 100, 121, 136, 137, 182, 187, 188, 189, 191, 196, 197, 198,
140, 142, 143, 144, 150, 161, 163, 174, 203, 206, 219, 234
urban areas, 41, 43, 109, 116, 122, 182, 198
250 Index
urban population, 206 wealth, 162, 219

urban settlement, 182, 187, 191 wear, 183, 192
urbanization, vii, ix, 1, 3, 7, 12, 28, 57, 73, web, 85, 98, 103, 113, 161, 212
112, 121, 180, 181, 182, 185, 189, 194, websites, 181
195, 203, 206, 208, 219 weight reduction, 98
ureter, 80 well-being, 11, 199, 200
LY
urine, 6, 11, 194 wellness, 87, 96
Uruguay, 5 West Africa, 125, 203, 206, 227
USA, 27, 37, 53, 74, 154, 227, 230, 231 West Bank, 5
uterus, 31 West Indies, xii, 154, 223
Uzbekistan, 4 Western Cape Province, 199
Western Europe, 23
N
wheezing, 22, 166
V withdrawal, 11
wood, 22
vaccine, 149
work environment, 117
validation, 61
O
workers, 69, 89, 99, 100, 136, 142, 145,
Vanuatu, 5
146, 147, 151, 153, 166, 168, 170, 182,
variables, 42, 144
216, 218, 220
variations, 183, 188
workforce, 84, 152
vascular dementia, 195, 196, 205
working conditions, 84, 113, 136
vascular diseases, 11, 132, 215
workload, 18, 121
FS
vegetables, 28, 64, 112, 149, 191, 197, 233
workplace, viii, 84, 85, 87, 90, 91
Venezuela, 5, 55
workplace interventions, viii, 84, 87, 91
victims, 21, 196
World Bank, 5, 9, 23, 37, 38, 55, 56, 57, 77,
Vietnam, 4, 66, 67
78, 80, 86, 103, 108, 125
violence, 183, 191, 201, 227
worldwide, 7, 9, 10, 12, 13, 14, 15, 16, 17,
viral infection, 6
18, 19, 20, 23, 25, 26, 29, 31, 64, 106,
virus infection, 28
109, 121, 132, 134, 191, 196
O
vision, 134, 144

visual acuity, 194
vitamin D, 192, 194 Y
vulnerability, 182, 195
O
Yemen, 4
yield, 41, 147
W young people, 6, 182
wages, 167
PR
walking, 149, 192, 193 Z

war, 130
Washington, 9, 37, 74, 78, 125, 126 Zimbabwe, 4, 55, 65, 74, 146, 154, 222, 229
waste, 167 zinc, 163, 169
water, 122, 183 Zulu, 37, 103, 204
weakness, 31, 193, 194
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Epidemiology of chronic non-communicable diseases in low and middle income

Article · January 2011

Refilwe Nancy Phaswana-Mafuya Dimitri Tassiopoulos

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Library of Congress Cataloging-in-Publication Data

Non-communicable diseases (NCDs) in developing countries / editors, Nancy

1. Chronic diseases--Developing countries. I. Phaswana-Mafuya, Nancy. II.

Chapter 3 An Overview of Chronic Disease Surveillance 53

Chapter 4 Interventions to Prevent and Control of Chronic

Chapter 5 Public Health Implications of Non-Communicable

Chapter 7 Medicines for Chronic Non-Communicable Diseases 155

mellitus, cardiovascular diseases, cancers, and chronic pulmonary disease. The

changes in patterns of consumption of food and alcohol, increased tobacco use

Chapter 2 focuses on the role of chronic NCDs on mortality in South

diseases and malignant neoplasms. As the demographic transition in South

of chronic non-communicable disease include policy action, facility and

management of NCDs would require a comprehensive and integrated

response, including action to address social attitudes and inequities; and

and were associated with increasing urbanization. Hypertension remains a

Chapter 9 provides suggestions for future research endeavours. In this

implementing what is already known. Enough is already known on what needs

EPIDEMIOLOGY OF CHRONIC NON-

developing countries, which impose more constraints to an already

epidemiology literature in low and middle income countries. Information

Results: NCDs are becoming a significant burden in middle income

taken. Conclusion: Prominent causes for CVDs, diabetes, cancer and

increasing trend in developing countries. NCDs progressed from 18.7% in

2000). Undoubtedly, there is mounting evidence pointing to the rise in NCDs

communicable, chronic disease, surveillance, developing, developed, cancer,

Income group Region Economy

Europe and Central Asia Kyrgyz Republic; Tajikistan; Uzbekistan

Latin America and Caribbean Haiti

Middle East and North Africa Yemen, Rep.

South Asia Afghanistan; Bangladesh; Nepal; Pakistan

Sub-Saharan Africa Benin; Burkina Faso; Burundi; Central African

Income group Region Economy

Latin America and Caribbean Bolivia; Colombia; Dominican Republic;

East Asia and Pacific

Source: World Bank (2009).

The low and middle-income group economies are depicted in Table 1.

economies in this income group. The Sub-Saharan African economies of

Diabetes is a chronic (lifelong) disease marked by high levels of glucose

if it resolves after pregnancy, it hugely increases the risk of T2DM in later

1. 2.2. Diabetes Risk Factors

The rising prevalence of diabetes in the LMICs region is attributed to risk

1. 2.3. Diabetes Prevalence

Diabetes 84m 228m 170% 51m 71m 42%

Source: WHO/IDF 2006.

Approximately 250 million people worldwide have diabetes (3.7% of the

indicate nearly 50% of newly diagnosed cases of diabetes in children to be

Contrary to popular perception, over 70-80% of people with diabetes live in

It was difficult to find data on diabetes morbidity in developing countries.

prone to secondary problems (complications), which can be very disabling.

leg has to be amputated. Eye disease caused by diabetes commonly causes

Diabetes caused 1.7% of all deaths worldwide in 2002, an average of 158