Burden of disease
Burden of disease is calculated in relation to the disability-adjusted-life-year (DALY). The DALY provides a consistent and comparative description of the burden of diseases and injuries needed to assess the comparative importance of diseases and injuries in causing premature death, loss of health and disability in different populations. The DALY extends the concept of potential years of life lost due to premature death to include equivalent years of "healthy" life lost by virtue of being in a state of poor health or disability. One DALY can be thought of as one lost year of "healthy" life, and the burden of disease can be thought of as a measurement of the gap between current health status and an ideal situation where everyone lives into old age, free of disease and disability.
Once more, the WHO African Region has the highest total burden of disease compared with other WHO Regions. The ratio in 2004 was 511:1000, approaching double that of the WHO Eastern Mediterranean Region, where the 2004 ratio was 273:1000, and the WHO South-East Asian Region where it was 265:1000.
The devastating role of HIV/AIDS, with its attendant elevated risks of malaria and tuberculosis, and its concomitant social and economic ramifications, provides a headline explanation of why the WHO African Region leads the world in many aspects of morbidity and mortality. With the prevalence of HIV/AIDS among African adults at 4.9% in 2007 – by far the greatest burden worldwide – it is easy to look no further. However, this may not be the only explanatory factor in all circumstances and vigilance needs to be maintained through monitoring, evaluation and health surveillance measures to ensure that all relevant factors contributing to health status and trends in the WHO African Region are identified and suitably reflected in policy and programme content (see table).
The particular dilemma faced by the WHO African Region can be seen when analysing the share of communicable and noncommunicable diseases present in African populations. The WHO African Region leads other WHO Regions by a considerable margin with regard to the percentage of communicable diseases that make up the total burden of disease. Bundled together, communicable diseases, maternal and perinatal conditions, and nutritional deficiencies – the traditional “developing country” pattern of ill health – constituted 71% of the DALY count in the WHO African Region in 2004.
At present, the corresponding share of noncommunicable conditions is 21%, but as shown elsewhere in this profile, the risk factors for chronic disease are rising rapidly in many African countries, with several diseases imminently taking on epidemic characteristics. Present and future demand on health services, and the requirement for higher levels of health financing, can therefore only increase as patterns of infectious and noncommunicable diseases coincide in the same populations. Increasing efficiency and efficacy in planning, financing and delivering proven health interventions will be of paramount importance in improving health status throughout the Region.
There is, once again, a significant difference between this pattern in the WHO African Region and in other areas of the world where infectious disease still consistently occurs. In the WHO Eastern Mediterranean Region, infectious and noncommunicable disease patterns were almost equally divided in 2004, standing at 44% and 41%, respectively. The situation in the WHO South-East Asia Region was similar, with figures for infectious and noncommunicable diseases of 42% and 44%, respectively.
It is already clear that an increase in noncommunicable disease rates in the African Region is inevitable, and that concerted efforts are needed to roll back the “traditional” disease burden and at the same time prevent the advance of lifestyle diseases. With the bulk of African countries showing communicable–maternal–nutritional disease burden rates of over 60% of total DALYs, urgent action to diminish the simultaneous occurrence of these two dimensions of ill health is imperative.
Redressing low health status in the Region
The disproportionately high levels of disease burden in the WHO African Region compared with other WHO Regions, and the falls in life expectancy and health status over the past two decades, have been examined and explained in many reports and publications. The causes are in principle well known. Much can be ascribed to the HIV/AIDS epidemic, the resulting resurgence of malaria and tuberculosis throughout affected populations, the increase in poverty, and the weakening of the social and economic fabric of the Region.
Population displacement following conflicts and emergencies hits the WHO African Region particularly hard, further aggravating the position of hard-pressed health services. Also well known is the fact that effective interventions are known for many, if not all, of the health problems that affect African populations so disproportionately. Getting the right interventions to the right people at the right time, and at the right price, remains the challenge.
Moves in the right direction are being made. Political commitment is high, and the Abuja Declaration’s undertaking to devote 15% of gross domestic product to health spending is necessary and timely. Per capita health spending has increased over the past decade to US$ 137, despite strong economic pressures on households. Effective partnerships with donors have been forged, and scaling-up measures for proven interventions are under way. However, efforts to reach the Abuja 15% health spending target need to be intensified and measures to address present deficiencies in the health workforce prioritized, if health status in Africa is to overcome the losses sustained in recent years.
It is also now widely understood that health is not “produced” by the health sector alone and that health status is crucially affected by:
- environmental and, in particular, sanitary conditions
- infrastructural deficiencies
- legal and regulatory shortfalls.
Without advances in these areas, efforts to strengthen the health sector alone will not pay maximum dividends.
The world is already preparing to evaluate its situation in 2015 in relation to the Millennium Development Goals. There is still a window of opportunity for improvement in many areas before 2015 arrives. Although as a whole, the WHO African Region will miss most of the Millennium Development Goals, a number of countries have succeeded in meeting or almost meeting some individual targets. It would be timely to carry out an exhaustive examination of the factors contributing to these successful initiatives in enhancing health status and to apply them in a broader context in the post-2015 environment.