Elsevier

The Lancet

Volume 374, Issue 9693, 12–18 September 2009, Pages 934-947
The Lancet

Series
The burden of non-communicable diseases in South Africa

https://doi.org/10.1016/S0140-6736(09)61087-4Get rights and content

Summary

15 years after its first democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative effect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

Introduction

South Africa is in the midst of a health transition that is characterised by the simultaneous occurrence of epidemic infectious diseases and a rise in non-communicable diseases, in a population facing a heavy burden of perinatal and maternal disorders, injury, and violence.1, 2, 3 Cardiovascular disease, type 2 diabetes, cancer, chronic lung disease, and depression are the major non-communicable diseases now reaching epidemic proportions in the former socialist states and low-income regions of the world.4

The past 15 years of political transition in South Africa have seen a rise in non-communicable diseases, driven by an increase in relevant risk factors in urban and rural areas,5 and by an ageing population despite the substantial overall reduction in life expectancy as a result of HIV/AIDS. South Africans seem not to have derived all the benefits that were anticipated from progressive health-care policies, such as free primary health care, that were introduced by the first democratically elected government in 1994, partly because of a low quality of health care and an uneven access to services.6, 7, 8 However, it is also because the upstream determinants of ill-health lie beyond the reach of the health sector, such as poverty and insufficient quality education. Furthermore, the prevention and treatment of non-communicable diseases are marginalised in South Africa because of the overwhelming prevalence of communicable diseases such as HIV/AIDS and tuberculosis.

The burden of disease related to non-communicable diseases is predicted to increase substantially in South Africa over the next decades if measures are not taken to combat the trend.9 An insight into the extent of and risk factors for non-communicable diseases in South Africa is crucial for effective advocacy and action. This report presents a review of the challenge of acute and chronic non-communicable diseases that confronts contemporary South Africa and makes recommendations to deal with the burden. We have used information from several key sources (panel 1), including the national burden of disease study, Statistics South Africa, the South African demographic and health surveys (SADHS), population-based demographic surveillance systems, and surveillance studies. The design and methods of these studies have been described previously.1, 2, 5, 10, 11, 12, 13, 14, 15 We obtained information about the cost-effectiveness of interventions from the Disease Control Priorities in Developing Countries Project.16

Key messages

  • •

    The burden of non-communicable diseases is rising in rural communities, disproportionately affects poor people living in urban settings, and is resulting in an increase in the demand for care for chronic diseases.

  • •

    The rising burden of non-communicable diseases is shown by an increasing number of deaths from diabetes, chronic kidney disease, and cancer of the prostate and cervix, and by the increasing proportion of disability-adjusted life years attributed to neuropsychiatric disorders.

  • •

    The number of deaths attributable to stroke, chronic obstructive airways disease, and lung cancer has fallen in the past 2 years. We need to understand the reasons for these trends, with a view to informing prevention efforts.

  • •

    The rising demand for chronic care for communicable and non-communicable diseases needs an integrated model of care at all levels of the health system, supported by a robust surveillance system.

  • •

    We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings to develop, implement, and assess integrated care interventions for communicable and non-communicable diseases.

Section snippets

Burden of non-communicable diseases

WHO estimates of the burden of disease in South Africa suggest that non-communicable diseases caused 28% of the total burden of disease measured by disability-adjusted life years (DALYs) in 2004.17 Cardiovascular diseases, diabetes mellitus, respiratory diseases, and cancers together contributed to 12% of the overall disease burden, and neuropsychiatric disorders (such as schizophrenia, bipolar depression, epilepsy, and dementia) accounted for 6%.17 In the context of the growing HIV/AIDS

Risk factors

Demographic change is one of the major factors of the increase in non-communicable diseases in low-income countries, largely owing to the increase in the number of older people who are at greatest risk of developing chronic diseases. The 2001 South African population census reported that 7·3% of the population were aged 60 years and older. The child population aged 0–14 years is expected to grow by 10% from 1985 to 2025, whereas the population aged 60 years and older is projected to rise almost

Social determinants

The WHO Commission on Social Determinants of Health has focused global attention on the social and economic factors, such as poor living environments and social exclusion, that result in poor health.30 Although more research is needed to clarify the links between these determinants and non-communicable diseases, the effect of living in poverty, low socioeconomic status, unemployment, and social conflict on people's mental wellbeing is clear, and contributes to the perpetuation or exacerbation

Neuropsychiatric disorders

The South African Stress and Health Survey (SASH), undertaken in 1999, was the first prevalence study of mental disorders derived from a nationally representative sample of South African adults. It showed that 8·1% had an anxiety disorder, 4·9% a mood disorder, 5·8% a substance misuse disorder, 1·8% an intermittent explosive disorder, and 16·5% any of these disorders.35, 36 The 2003 SADHS reported that 21·4% of men and 6·9% of women aged 15–64 years had problems related to alcohol consumption.11

South Africa's response to the challenge of non-communicable diseases

Responses to the burden from non-communicable disease have featured in the policy changes since 1994. In 1996, the Directorate of Chronic Diseases, Disabilities, and Geriatrics was established and developed several interventions at legislative, policy, health-service management, and community levels to prevent and control non-communicable diseases.

South Africa has been a global leader in development and implementation of appropriate legislation for tobacco control. The Tobacco Products Control

Identification of priorities for the next 15 years

The rising incidence of deaths from non-communicable diseases in rural areas and the increasing pressure on health-care services from acute and chronic diseases suggest that South Africa's response to non-communicable diseases has, so far, had little effect nationally (with the exception of tobacco control).6, 7 Achievement of a reduction in mortality and improvement in acute and chronic care for patients with non-communicable diseases will need a new approach to health-systems development. It

Conclusions

Evidence of a rise in mortality and morbidity from non-communicable diseases in all strata of South African society is compelling. These findings represent the most advanced end of the range of rural and urban sub-Saharan transitions. Further, there is good evidence regarding the rise of vascular disorders—including hypertension, stroke, and ischaemic heart disease—elsewhere in east and west Africa,111, 112 suggesting that complex health transitions are underway in several settings. The widely

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