Non-communicable Diseases in Ethiopia: Disease burden, gaps in health care delivery and strategic directions.

Abstract Introduction: In Ethiopia, non-communicable diseases (NCDs) cause 42% of deaths, of which 27% are premature deaths before 70 years of age. The Disability Adjusted Life Years (DALYs) increased from below 20% in 1990 to 69% in 2015. With no action, Ethiopia will be the first among the most populous nations in Africa to experience dramatic burden of premature deaths and disability from NCDs by 2040. However, the national response to NCDs remains fragmented with the total health spending per capita for NCDs still insignificant. The focus of this paper is highlighting the burden of NCDs in Ethiopia and analyzing one of the two major WHO recommended policy issues; the status of integrated management of NCDs, in Ethiopia. NCDs are complex conditions influenced by a range of individual, social and economic factors, including our perceptions and behavior. Also, NCDs tend to be easily overlooked by individuals and policy makers due to their silent nature. Thus, effectively addressing NCDs requires a fresher look into a range of health system issues, including how health services are organized and delivered.Methods: A mixed method approach with quantitative and qualitative data was used. Quantitative data was obtained through analysis of the global burden of diseases study, WHO-STEPs survey, Ethiopian SARA study and the national essential NCD drug survey. This was supplemented by qualitative data through review of a range of documents, including the national NCD policies and strategies and global and regional commitments.Results and discussion: In 2015, NCDs were the leading causes of age-standardized death rate (causing 711 deaths per 100,000 people (95% UI: 468.8–1036.2) and DALYs. The national estimates of the prevalence of NCD metabolic risk factors showed high rates of raised blood pressure (16%), hyperglycemia (5.9%), hypercholesterolemia (5.6%), overweight (5.2%) and Obesity (1.2%). Prevalence of 3-5 risk factors constituting a metabolic syndrome was 4.4%. Data availability on NCD morbidity and mortality is limited. While there are encouraging actions on NCDs in terms of political commitment, lot of gaps as shown by limited availability of resources for NCDs, NCD prevention and treatment services at the primary health care (PHC) level. Shortage of essential NCD drugs and diagnostic facilities and lack of treatment guidelines are major challenges. There is a need to re-orient the national health system to ensure recognition of the NCD burden and sustain political commitment, allocate sufficient funding and improve organization and delivery of NCD services at PHC level. [Ethiop. J. Health Dev. 2018;32 (3):00-000]Key words: Non-communicable diseases, health-system re-orientation, NCD burden, metabolic risk factors, Service delivery, Primary Health Car

Non-communicable diseases in Ethiopia: policy and strategy gaps in the reduction of behavioral risk factors

Introduction: Non-communicable diseases (NCDs) are the leading cause of death worldwide. Over 80% of NCD deaths occur in developing countries. Four modifiable behaviors, namely tobacco use, consumption of unhealthy diet, physical inactivity, and the harmful use of alcohol, contribute to 80% of the NCD burden. Studies show that the vast majority of NCDs can be prevented through behavioral risk-reduction interventions. Properly executed, the interventions could lead to a decrease in the burden of NCDs, ranging from a 30% drop in the prevalence of cancer to a 75% reduction in cardiovascular diseases. This study examined the policy and strategy gaps in the reduction of the modifiable NCD behavioral risk factors in Ethiopia to inform and guide policy-makers and other stakeholders. Methodology: This study used a data triangulation methodology with a sequential, explanatory, mixed-method design conducted in two stages. The authors carried out quantitative analysis on the prevalence and distribution of behavioral risk factors from the Ethiopia NCD STEPwise approach to surveillance (STEPS) survey. Qualitative data on national policies and strategies complemented the analysis of the progress made so far and the existing gaps. Results and Discussion: Ethiopia has made substantial progress in responding to the NCD epidemic by developing a health sector NCD strategic action plan, generating evidence, and setting time-bound national targets on NCD behavioral risk factors. Activities mainly aimed at reducing tobacco use, such as implementation of the ratified WHO Framework Convention on Tobacco Control (FCTC), using evidence of the Global Adult Tobacco Survey (GATS), and the articulation of legislative measures are ongoing. On this paper our analysis reveals policy and strategy gaps, status in law enforcement, social mobilization, and awareness creation to reduce the major behavioral risk factors. Conclusions: NCDs share common risk factors and risk reduction strategies creates an opportunity for an effective response. However, the national response still needs more effort to have a sufficient impact on the prevention of NCDs in Ethiopia. Thus, there is an urgent need for the country to develop and implement targeted strategies for each behavioral risk factor and design functional, multisectoral coordination. There is also a need for establishing sustainable financial mechanisms, such as increasing program budgets and levying ‘sin taxes,’ to support the NCD prevention and control program. Ethiop. J. Health Dev. 2019; 33(4):259-268] Key words: NCDs, behavioral risk factors, policy, strategy, multisectoral coordination, Ethiopi

Reasons for defaulting from childhood immunization program: a qualitative study from Hadiya zone, Southern Ethiopia

Abstract Background Reduction of mortality and morbidity from vaccine-preventable diseases in developing countries involves successfully implementing strategies that ensure high coverage and minimize drop-outs and missed opportunities. Achieving maximum coverage, however, has been a challenge due to many reasons, including high rates of defaulters from the program. The objective of this study was to explore the reasons behind defaulting from the immunization program. Methods A qualitative study was conducted in two districts of Hadiya zone, Southern Ethiopia between November 2014 and April 2015. A total of twenty-six in-depth interviews were held with mothers of defaulted children aged 6-11months old and key informants from the communities, health centers, and health offices. Observations and review of relevant documents were also conducted. Thematic analysis was used to analyze the data. Results In this study, the main reason for defaulting from the immunization was inadequate counseling of mothers that led to a lack of information about vaccination schedules and service arrangements, including in unusual circumstances such as after missed appointment, loss of vaccination card and when the health workers failed to make home visits. Provider-client relationships are poor with mothers reporting fear of mistreatment and lack of cooperation from service providers. Contrary to what health workers and managers believe, mothers were knowledgeable about the benefits of vaccination. The high workload on mothers compounded by the lack of support from male partners was also found to contribute to the problem. Health system factors that contributed to the problem were poorly arranged and coordinated immunization services, vaccine and supplies stock outs, and lack of viable defaulter tracking systems in the health facilities. Conclusions The main reasons for defaulting from the immunization program are poor counseling of mothers, unsupportive provider-client relationships, poor immunization service arrangements, and lack of systems for tracking defaulters. Efforts to reduce defaulter rates from the immunization program need to focus on improving counseling of mothers and strengthening the health systems, especially with regards to service arrangements and tracking of defaulters

Chronic viral hepatitis: policy, regulation, and strategies for its control and elimination in Ethiopia

Abstract Background Hepatitis B and C are silent killers not yet recognized as major public health challenges in many developing countries with huge disease burden. In Ethiopia, Hepatitis B is endemic with an average prevalence of 10.8 %, and the prevalence of Hepatitis C is 2 %. The prevalence of both infections, however, is likely to be underreported due to the lack of diagnostic facilities and appropriate surveillance systems. Ethiopia is also among the many Sub-Sahara African countries lacking a coordinated and systematic national response to chronic viral hepatitis. The objective of this study is to examine the current level of response to viral Hepatitis B & C in Ethiopia with the aim to bring identified gaps to the attention of relevant stakeholders and policy makers. Methods This cross-sectional qualitative study was based on semi-structured in-depth interviews with 21 key informants from health facilities, health offices, pharmaceutical companies, regulatory bodies, professional association and blood bank units. Participants were selected purposively based on their role in the national hepatitis response. The investigators also reviewed available policy and strategy documents, standards of practice and surveys, and paid visits to pharmaceutical premises to check the availability of antiviral drugs. Thematic analysis was employed to make sense of the data. During the data analysis process, all the authors critically read the materials, and data was triangulated by source, interpreter view and thematic perspective to ensure accurate representation and comprehensiveness, and validation of the interviewees’ responses. Once each investigator reviewed the data independently, the team reached a common understanding of the scope and contexts of the information attained. Data were subsequently reduced to key concepts, and case stories were taken with successive revisions. The key concepts were later coded into most basic meaningful categories. The World Health Organization (WHO) global hepatitis response framework was used to organize the analysis. Results Ethiopia is in the process of preparing strategic plan and guidelines for viral hepatitis. However, the country still lacks the required partnerships, and resource mobilization as a national health response is limited. Community awareness on the disease transmission and its sequel is poor. Viral hepatitis screening services are not widely available except for the occasional mandatory medical checkups for work or travel purposes. Healthcare providers often take no further action after diagnosing patients with viral hepatitis due to lack of treatment guidelines and strategic frameworks for screening, diagnosis, and treatment. Besides, drugs that are effective in the treatment of viral hepatitis are not available, mainly due to regulatory challenges. Conclusions Viral hepatitis and its disease burden are getting little attention in Ethiopia and many low-income countries. The levels of technical guidance and financial support from the international community are low. To date, the response to the infections in Ethiopia is patchy. Thus, the country needs to formulate policy and strategies in the areas of disease surveillance, risk group identification and screening, use of the birth dose of hepatitis B vaccine, and care and treatment. Improving availability of data on viral hepatitis, access to low-cost generic drugs and developing and dissemination of treatment guidelines are also critical. Leveraging the successful Health Extension Program for a hepatitis response, and exploring ways to learn from and integrate into the HIV/AIDS program should also be considered

Determinants of malnutrition among pregnant and lactating women under humanitarian setting in Ethiopia

Abstract Background Despite significant gains and progress in the last decade, malnutrition remains a major public health problem in Ethiopia. Pregnant and lactating women (PLW), along with children, are among the most vulnerable groups of population during emergencies and droughts. Identifying and targeting of PLW with malnutrition is among the priorities in humanitarian emergencies. However, there is dearth of evidence on PLW nutritional status and its determinants in humanitarian context. Methods A community-based cross-sectional study was conducted in 10 kebeles of Rayitu district of Ethiopia in June 2013. A total of 900 PLW were assessed for malnutrition using mid-upper-arm circumference (MUAC). Result Using MUAC < 21 cm as a criteria, 216 (24%) surveyed mothers were found to be malnourished. In multivariable logistic regression analysis, those mothers who did not received antenatal care (ANC) during their pregnancy had 1.83 higher odds of (adjusted odds ratio[AOR] = 1.83, 95% confidence interval [CI]:1.10,3.02) to be malnourished (MUAC < 21 cm) as compared to mothers who received ANC. Housewives had lower odds of (AOR = 0.59, 95 %CI: 0.37, 0.95) to be malnourished compared to those who engaged in as a pastoralist. Mothers belonging to families from which at least one person did not receive targeted supplementary feeding (TSF) in the 6 months before the study had lower odds of (AOR = 0.38, 95 %CI:0.23,0.62) to have acute malnutrition compared to those who lived in families who received TSF. Conclusions Malnutrition is common among PLW in humanitarian settings, including those with ongoing interventions. Attending antenatal care, maternal occupational status and being a member of families who received TSF were factors associated with maternal nutritional status in this study. This signifies the need for sustainable solutions that address the high prevalence of malnutrition among PLW. Interventions targeting health system responses such as comprehensive nutrition education, support through antenatal care and women empowerment are recommended

Impact of good governance, economic growth and universal health coverage on COVID-19 infection and case fatality rates in Africa

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic has disrupted lives across all countries and communities. It significantly reduced the global economic output and dealt health systems across the world a serious blow. There is growing evidence showing the progression of the COVID-19 pandemic and the impact it has on health systems, which should help to draw lessons for further consolidating and realizing universal health coverage (UHC) in all countries, complemented by more substantial government commitment and good governance, and continued full implementation of crucial policies and plans to avert COVID-19 and similar pandemic threats in the future. Therefore, the objective of the study was to assess the impact of good governance, economic growth and UHC on the COVID-19 infection rate and case fatality rate (CFR) among African countries. Methods We employed an analytical ecological study design to assess the association between COVID-19 CFR and infection rate as dependent variables, and governance, economic development and UHC as independent variables. We extracted data from publicly available databases (i.e., Worldometer, Worldwide Governance Indicators, Our World in Data and WHO Global Health Observatory Repository). We employed a multivariable linear regression model to examine the association between the dependent variables and the set of explanatory variables. STATA version 14 software was used for data analysis. Results All 54 African countries were covered by this study. The median observed COVID-19 CFR and infection rate were 1.65% and 233.46%, respectively. Results of multiple regression analysis for predicting COVID-19 infection rate indicated that COVID-19 government response stringency index (β = 0.038; 95% CI 0.001, 0.076; P = 0.046), per capita gross domestic product (GDP) (β = 0.514; 95% CI 0.158, 0.87; P = 0.006) and infectious disease components of UHC (β = 0.025; 95% CI 0.005, 0.045; P = 0.016) were associated with COVID-19 infection rates, while noncommunicable disease components of UHC (β = −0.064; 95% CI −0.114; −0.015; P = 0.012), prevalence of obesity among adults (β = 0.112; 95% CI 0.044; 0.18; P = 0.002) and per capita GDP (β = −0.918; 95% CI −1.583; −0.254; P = 0.008) were associated with COVID-19 CFR. Conclusions The findings indicate that good governance practices, favourable economic indicators and UHC have a bearing on COVID-19 infection rate and CFR. Effective health system response through a primary healthcare approach and progressively taking measures to grow their economy and increase funding to the health sector to mitigate the risk of similar future pandemics would require African countries to move towards UHC, improve governance practices and ensure economic growth in order to reduce the impact of pandemics on populations