Ghana's Burden of Chronic Non-Communicable Diseases: Future Directions in Research, Practice and Policy

Summary

The prevalence of major chronic non-communicable diseases and their risk factors has increased over time and contributes significantly to the Ghana's disease burden. Conditions like hypertension, stroke and diabetes affect young and old, urban and rural, and wealthy and poor communities. The high cost of care drives the poor further into poverty. Lay awareness and knowledge are limited, health systems (biomedical, ethnomedical and complementary) are weak, and there are no chronic disease policies. These factors contribute to increasing risk, morbidity and mortality. As a result chronic diseases constitute a public health and a developmental problem that should be of urgent concern not only for the Ministry of Health, but also for the Government of Ghana. New directions in research, practice and policy are urgently needed. They should be supported by active partnerships between researchers, policymakers, industry, patient groups, civil society, government and development partners.

Introduction

Major causes of death in Ghana have shifted from predominantly communicable diseases to a combination of communicable and chronic non-communicable diseases (NCDs) over the last few decades. Hypertension, stroke, diabetes and cancers have become top 10 causes of death.¹ Urbanization, changing lifestyles (including poor diets), ageing populations, globalization and weak health systems are implicated in chronic disease risk, morbidity and mortality.^1,2 Despite recognition of a growing chronic disease burden in the early 1990s, a series of low-level interventions over the last fifteen years, and a national health policy that emphasises health promotion and prevention of lifestyle diseases, Ghana does not have a chronic disease policy or an integrated plan.^3,4 These structural deficiencies compound the financial and psychosocial challenges faced by individuals, caregivers and families affected by chronic diseases.

This Ghana Medical Journal Supplement Issue on Ghana's chronic disease burden developed from the proceedings of the first annual workshop of the UK-Africa Academic Partnership on Chronic Disease held at the Noguchi Memorial Institute for Medical Research in April, 2007. The workshop aimed to collate interdisciplinary information on Ghana's chronic disease burden as a starting point for engaging with national policy development and implementation, as well as with broader regional and international trends at subsequent meetings. The partnership's flagship special issue published in Globalization and Health addressed local and global perspectives on Africa's chronic disease burden.⁵

This supplement offers insights into four key areas of the Ghana's NCD burden: epidemiological, clinical, psychosocial and intervention/policy. Some papers offer important comprehensive reviews of NCD research conducted over the last 40 years. Brief comments are made on these themes and future directions in research, practice and policy are outlined.

Themes of the supplement

The epidemiological themes focus on hypertension⁶, stroke⁷, diseases of ageing⁸, asthma⁹ and mental illness.¹⁰ Cross-cutting themes suggest that epidemiological studies are limited, prevalence of focal conditions are rising and future research must prioritise robust population-based research to improve prevention, detection, treatment and control of common conditions.

The clinical themes focus on management of stroke⁷, asthma⁹, type 1 diabetes¹¹ and cancers¹². NCD management is generally poor. Poor clinical care and poor self-care - both due partly to limited professional and lay knowledge - are implicated in avoidable complications and premature deaths.

The psychosocial themes illuminate the psychological, social, cultural and economic contexts of living with type 1 diabetes¹¹, terminal chronic conditions¹², mental illness¹⁰ and other common NCDs¹³ and provide insights into lay ideas and beliefs about common NCDs.¹⁴

There is agreement that policy responses to Ghana's NCD burden has been inadequate and that greater efforts are needed to bridge the gap between policy rhetoric and action.⁴

Future directions in research, practice and policy

Research

Population-based studies, as well as action oriented research - e.g. implementation, impact, operational, evaluation studies - should be prioritised. More research is required, for example, on asthma in the adult population⁸, to understand what happens to stroke patients after discharge⁶, the help-seeking behaviour across medical systems^10,15 and to estimate the indirect costs of NCDs on households¹³. Impact studies on the psychosocial benefit of patient support groups are required to incorporate the work of patient and advocacy groups more adequately in medical care.^9,10 Robust qualitative and ethnographic studies are needed to increase understanding of the complex psychological and cultural contexts of risk, illness experience, caregiving and social attitudes.

Interventions

Interventions must be multi-pronged and encompass primary and secondary prevention. Improved health communication strategies are needed to improve awareness and behaviour change.¹⁴ It is essential that interventions are targeted to young persons, regions with high prevalence (e.g. Greater Accra and Ashanti), and high-risk populations (obese individuals; individuals with multiple risks and co-morbid conditions).

Health services need to be strengthened, to improve the capacity of peripheral institutions to deliver quality care and to reduce the congestion in the tertiary level facilities.⁴

Poor knowledge and attitudes of health practitioners on chronic diseases undermine quality of care. It is important to include chronic disease management in the continuous professional development activities of health workers and to develop guidelines valid for local use.

Policy

Policy neglect has been due partly to limited research, weak surveillance systems and the lack of reliable data, limited political interest and donor investment.⁴ Innovative ways of mobilizing funds and strengthening political will to support NCD control and prevention are required. In Ghana, achievable interventions include passing tobacco legislation and passing or enforcing laws on food labelling to reduce salt and energy content of processed foods. The drive to enrol more registrants to the NHIS should be intensified as well as restructuring benefits package to include more chronic disease medicines and treatment. Best practice models in other African countries - such as South Africa and Cameroon - can inform Ghanaian research, practice and policy.⁵

Conclusions

Chronic NCDs contribute significantly to the nation's disease burden. They constitute both a public health and a developmental issue that should be of urgent concern not only for the Ministry of Health, but also for the Government of Ghana. Pertinent challenges include limited knowledge of NCDs in the general population which contributes to late reporting to clinics for care, high costs of medicines and high rates of preventable complications. NCDs affect poor communities; the catastrophic costs of care drive them deeper into poverty.

The UN convened a High-level Meeting on NCDs in September 2011. Ghana participated in the conference, and endorsed the draft political declaration passed on NCDs. Central themes of the declaration included the adoption of a “whole-of-government and a whole-of-society effort” in tackling national NCD burdens.¹⁵ Ghana has a history of participating and endorsing several international, regional and sub-regional resolutions and declarations on chronic diseases which do not get implemented.⁴ To bridge the gulf between policy rhetoric and implementation, joint action by government (and its various relevant sector ministries), health and public policymakers, industry, civil society, researchers and patient groups is urgently needed.^5,16

The government needs to give high priority to policies and funded programmes for the prevention and control of chronic diseases.

Public-private partnerships with the pharmaceutical industry should aim to ensure availability, affordability and accessibility of low-cost generic drugs for the management of chronic diseases. Researchers need to focus efforts on implementation research questions relevant to Ghana.