Tackling the national burden of cardiovascular diseases

In Nigeria, the burden of  noncommunicable diseases (NCDs) emanates primarily from cardiovascular diseases (hypertension, stroke, coronary heart disease), diabetes mellitus, cancers, sickle cell disease and chronic obstructive airway diseases including asthma. Others leading causes of morbidity and mortality include mental health disorders, violence and road traffic injuries. This group of chronic diseases exerts a lot of stress on our socioeconomic life and put significant strain on the very fragile health care infrastructure.

The WHO data has consistently shown that cardiovascular diseases (CVDs) are the leading cause of death globally. The 2010 WHO Global Status Report on NCDs shows that in 2008, the 4 major NCDs namely cardiovascular diseases (CVDs), diabetes, cancers and chronic respiratory diseases put together killed 36 million (63%) persons out of the 57 million global deaths recorded. Of these, CVDs ranks 1^st with 17 million deaths (48%) out of the 36 million NCD deaths.

Furthermore, the 2014 report showed that in 2012, the 4 major NCDs claimed 38 million (68%) lives out of the world’s 56 million deaths, and over 40% of the deaths were premature deaths under the age of 70 years. CVDs alone killed 17.5 million people representing 31% of all the global deaths and 46% of the NCD deaths.  Over 75% of the CVD deaths occurred in low-income and middle-income countries (LMIC), of which Nigeria is one. During the same period, heart attacks and strokes alone accounted for 80% of all the CVD deaths, and together they all to the top three causes of years of life lost due to premature mortality.

In terms of prevalence, hypertension is the leading CVD in Nigeria and the world at large. Although the current exact prevalence of hypertension in Nigeria is unknown, extrapolation from the last national survey conducted in 1990/92 which was published in 1997 put the prevalence of hypertension at over 20%, suggesting that one out of every five Nigerians is hypertensive. Current hospital records estimates showed that the prevalence of hypertension is 25% while estimated mortality from stroke is 40 – 50% within the first 3 months of diagnosis. Another hospital based study showed that 39% of those who survived stroke after 3 months died within 12 months and the remaining 12% developed severe disability.

We should not be too surprised about the figures stated so far because we know that sudden deaths are commonplace and everyone seated here can recall immediately recent cases of prominent Nigerians who have died suddenly and majority of these are probably due to heart attack, stroke or diabetic complications.  We can also easily call to mind numerous relatives and friends who are living with disability resulting from stroke or limb amputation from diabetes. I can also say without fear of contradiction that at least 5 out of 10 adults seated here tonight have elevated blood pressure and more than half of these are not aware of their situation. This is frightening because the dire consequence of neglected hypertension is stroke without warning.

The economic consequences are enormous. Deaths from these causes mean permanent loss of livelihood and affected individuals who survive lose productivity and in both cases the families suffer. Socially it is traumatic for the affected individuals who survive as they are virtually dependent on others for even the most routine of chores and this can be psychologically devastating. Family members who take care of these individuals are also unproductive and families can plunge into penury for these reasons.

The cumulative economic losses due to NCDs under a “business as usual” scenario in low – and middle-income countries have been estimated at US$ 7 trillion in 2011-2025. This sum, far outweighs the annual US$ 11.2 billion cost of implementing a set of high-impact interventions to reduce the NCD burden (WHO NCDs Global report 2014).

In Nigeria, the economic loss from heart disease, stroke and diabetes alone was estimated by WHO at US$400 million in 2005 and projected to rise to US$8 billion in the next 10 years unless we take drastic and sustained actions. Otherwise, we will keep counting loses.

Risk factors

Prevention as always is not only better but also cheaper than cure, and it is important to leverage your commitment and enthusiasm to advance this course. Fortunately, the NCDs share common risk factors.

The major NCD risk factors are use of tobacco products, unhealthy diet, harmful alcohol intake, physical inactivity and air pollution. These factors are aggravated by poor awareness, harmful cultural practices, beliefs and misconceptions by the public.

Tobacco use is the most significant risk factor for NCDs and accounts for 80% of the six million premature deaths annually in LMIC including Nigeria. 5.6% adults (4.5 million adults) currently use tobacco products out of which 4.1 million are men and 0.45 million are women. In addition, 29.3% of adults (6.4 million adults) are exposed to tobacco smoke when visiting restaurants, hotels and other public settings (GATS 2013).

Alcohol consumption is another risk factor and this is quite high in Nigeria, with a per capita consumption of 10.57 litres to rank among the highest in Africa. So also is physical inactivity. About 30.3 – 74.6% of Nigerian children and youths aged 5 – 25 years are not sufficiently active (NHF, 2013) and 80% of working-class adults in urban areas in Nigeria do not meet the WHO recommended level of physical activity.

Unhealthy diets contribute significantly to the development of NCDs in Nigeria. Sadly, there is widespread low consumption of proteins, fruits and vegetables and increasing patronage of fast food outfits by the population. There is also large promotion of sweetened products such as carbonated drinks, pastries, candies, and other refined sugars, while excessive intake of salt is promoted by food additives such as monosodium glutamate (MSG) common in local delicacies such as suya, kilishi, isi-ewu, ngwo-ngwo among others. The high caloric intake resulting from refined sugars promote overweight and obesity especially in a country where exercise is not a norm.

You will recall that in the not too distant past, non-communicable diseases were erroneously believed to be the problem of the affluent. But the reality is that both the rich and the poor are affected and the poor actually bear the greater brunt for obvious reasons.  The poor generally find it more difficult to access requisite health care services for prevention and adequate management of NCDs. The reason is not all financial. They also usually have lower levels of education, which constrain them from adopting preventive measures. Also they are more exposed to some of the risk factors especially air pollution arising from use of inefficient fuel for cooking.

To begin to address these issues, the Federal Government enacted the National Tobacco Control Act in 2015 to address the menace of tobacco use in Nigeria. While this Act falls short of the recommendations of the WHO Framework Convention for Tobacco Control, it provides a good opportunity to get our people to shun tobacco use.

The NTC Act will enable enforcement of the ban of smoking in public places as well as protection of minors from being initiated into tobacco smoking among other beneficial provisions. This is important because tobacco is the singular most important risk factor for cardiovascular and other non-communicable diseases. We are working hard to disseminate the provisions of the NTC Act 2015 to the public and enforce the provisions. Let me quickly inform you that the FMOH has recently inaugurated NATOC committee and they have started working. It is my hope that all stakeholders would cooperate with them to discharge their duty.

I want  to call on Nigerians to adopt healthy lifestyles to stem the rising tide of cardiovascular and other NCDs. To this effect, I am advising that fruits and vegetables should be included every meal we take. Fatty foods and fizzy drinks loaded with sugar should be reduced and possibly avoided.

Every individual should do minimum of 30 minutes physical exercise per day at least 5 times in a week. Alcohol, when necessary socially should be taken sparingly and binging should not be done. Similarly tobacco in any form must be avoided and conscious efforts must be made to maintain tobacco smoke free environment.

On our part as government, we have put in place a number of other measures aside from the NTC Act of 2015. There is a Division under the department of Public Health solely dedicated to Non-Communicable Diseases to serve as a coordinating point for all NCD-focused activities in the country. The FMOH through this Division is putting up measures to enhance the capacity of the Ministry to be more responsive in dealing with the threat to citizens posed by NCDs.

To this effect a nation-wide survey on NCDs is planned in the early part of next year to generate necessary data for effective planning and service delivery. All interested individuals and organizations are welcomed to be part of it. Similarly a robust national strategic plan of action is being developed to provide a framework for effective control and management of NCDs in the country.

We have developed guidelines on nutrition for the prevention, control and management of NCDs; as well as guidelines for the control and management of sickle cell disease. These guidelines are available to set the clinical and institutional standards for preventing and managing these interrelated conditions.

Through public-private sector collaboration, we are committed to modernizing our health facilities at all levels of care so as to deliver quality, affordable, accessible and acceptable health services to the citizens. Our focus will be on the upgrade of existing Reference and Specialized Centres to enable them provide specialized care such as high-tech cardiovascular procedures in order to stop capital flight and build trust in the health system.

We see the private sector as an instrumental partner in this effort, recognizing the plethora of opportunity for the private sector to engage across the healthcare value chain to tackle cardiovascular diseases. This includes the broader corporate (non-health) private sector – the financial sector, extractives, manufacturing and other fast moving consumer goods and on the other hand, the private sector in health which includes high, middle and low-income commercial enterprises in health who are in the business of service provision or in an allied health field such as the pharmaceutical or medical technologies industries.

There is strong impetus for the private sector to invest in health – be it through financing, research and innovation, service delivery or partnerships. The IFC Health in Africa report demonstrates that the health sector can directly be a net contributor to economic growth. Healthcare investment in Sub-Saharan African were projected to reach US$11-20bn between 2007 and 2016. US$500million of this alone was service provision while other high investment areas include distribution and retail, life sciences, medical education and health insurance/payer functions. In recent times, we have also seen in absolute terms, the amount of capital lost from the economy due to medical tourism which the CBN and Price Waterhouse Cooper estimated at US$1bn or more annually – I have earlier spoken about the fact that a significant proportion of these are for cardiovascular conditions along with  orthopaedics, oncology and renal disease.

Research and evidence have also demonstrated the indirect and reinforcing effect of investing in healthcare on the economy through studies that demonstrate that better health indices, decreased mortality and improved life expectancy can boost economic productivity, per capita income and GDP growth.

Despite this, we recognize the challenges that have limited private sector participation in health led to low-level investor confidence in the sector. Early diagnostic work by the leading private sector groups, development partners and consulting firms suggest that this suboptimal participation is driven by limited access to finance and inadequate de-risking of healthcare businesses; unclear regulatory frameworks which negatively impact the business environment; fragmentation of the private health sector leading to lack of cohesive representation and engagement in policy dialogue; varied quality of care; inadequate knowledge of business operations amongst healthcare professionals; and, lack of adequate incentives for investments which are typically long term and require patient capital.

The Federal Ministry of Health has set out multi-pronged approach to engage with the private sector in a bid to stimulate the healthcare market and has made investment in specialized ultra-modern cardiovascular centres, a leading priority. It aims to achieve this through dialogue, policy and investments.

To move beyond rhetoric to action, the FMOH recently met with the private health sector and has jointly established several Technical Working Groups (TWG) to move the agenda forward: Firstly, the TWG committee focusing on finance seeks to carry out advocacy to the Central Bank and other finance institutions to unlock low interest capital for health MSMEs and engage in the dialogue to mobilize domestic resources for healthcare from the range of identified tax and innovative financing options. The idea of a bank for health to increase the availability of dedicated funds for health sector investments has also been mooted and early discussions on this are being explored.

Secondly, the TWG will engage in Advocacy & Policy with a focus on ensuring the adequacy of the Policy on Incentivizing Healthcare Investments and widespread buy-in from state actors such as the Nigeria Investment Promotion Council (NIPC) and Infrastructure Concession Regulatory Commission (ICRC) with the goal of ensuring its passage at the next National Council on Health (NCH). The private sector also seeks to lend its voice to advocacy on National Health Act and the Basic Healthcare Provision Fund as this also presents an opportunity for ready off-takers and de-risking of small- and medium- scale enterprises. Similarly, the private sector seeks to advocate for the amendment of the National Health Insurance Scheme (NHIS) bill which like-wise, will provide a ready-market for the purchasing of healthcare services. The basic bouquet of services proposed to be purchased in both instances includes basic cardiovascular disease prevention services.

Thirdly, the private sector Strategy group is developing a business case for health to facilitate engagement with actors in the non-health private sector who may be potential investors or can provide requisite business support to healthcare enterprises.

Lastly, a group on Quality Improvement/Human Resource and Capacity Development will focus on the issues of standardizing, quality of healthcare services, capacity of healthcare professionals and regulatory issues such as the development of guidelines/code of ethics for healthcare professionals and healthcare institutions on advertising health services/individual providers.

It is our vision that this agglomeration of strategies will help fast-track the establishment of these highly specialized centres to deliver affordable, quality cardiovascular care to even the poorest of Nigerians. I am very pleased to say here today that we have already begun a pilot with the Lagos University Teaching Hospital (LUTH).

Another aspect in which private sector partnerships may support our efforts is through the nature of health promotion and wellbeing programs as well as care offered to its employees. Most multinational and large-scale local operators have employee bases in the thousands. Disseminating the right health messages, promoting health lifestyles within corporate cultures and using them as diffusers of such positive messages to the communities in which they are embedded will be valuable.

Since health is in the concurrent list, the Federal Ministry of Health is in discussion with State Governments for the quick revamping of our Primary Health Care facilities in order to provide primary and essential services such as basic cardio-risk assessment and referral.

As an agency under my purview, I will ensure that NAFDAC plays the crucial role of regulating cross border movement of unhealthy foods, which are high in saturated fats, trans-fatty acids, free sugars, excessive salt and all similar harmful ingredients. Similarly the FMOH through NAFDAC would enforce product labeling with ingredient lists and nutrition information labels to facilitate healthier choices.

We also need to increase the availability and access to local foods by enhancing support to farmers, fishermen for home production, through technical assistance, tax breaks, subsidies and other support measures. Discussion is also ongoing to raise taxes and levies on products such as tobacco, alcohol, and sugar.

I implore all well-meaning organizations to support the Federal Ministry of Health to achieve the global target of 25% relative reduction in the overall mortality from cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases by the year 2025.

Being excerpts of keynote address by the minister of health, Professor Isaac Adewole at the Tristate First Annual Black Tie Ball held in Lagos recently.