This blog entry will try and elucidate the shift in investment from infectious to non-communicable diseases by the World Health Organisation (WHO) drawing successes from the Millennium Development Goals 6: “To combat HIV/AIDS, malaria, and other diseases”. Initially this blog entry will provide an overview of the management strategies and progress that has been made in addressing infectious diseases (using the “big three diseases” of the MDG 6 as examples). It will then highlight the financial investment from the different Global Health Actors towards these ‘big 3 diseases’ as compared to the other diseases and in conclusion determine if the WHO shift in investment is justifiable or not.
The term ‘infectious diseases’ (IDs) does not refer to a homogeneous set of illnesses but rather to a broad group of widely varying conditions (Saker, Lee, Cannito, Gilmore, & Campbell-Lendrum, 2004) that are transmitted from a person, animal or inanimate source to another person either directly, with the assistance of a vector or by other means, while non-communicable diseases (NCDs) are diseases or conditions that affect individuals over an extensive period of time and for which there are no known causative agents that are transmitted from one affected individual to another (Daar et al., 2007). If diseases are infectious, then they present in a pandemic (e.g. H1N1 influenza), epidemic (e.g. measles), or endemic (e.g. malaria) form, while if non-communicable as acute (e.g. accidents) or chronic (e.g. cancer) form (Roger, 2005).
For the purpose of this blog entry infectious diseases will be classified according to the causative agent, namely: Bacterial (e.g. Tuberculosis), parasitic (e.g. Malaria) and viral (e.g. HIV/AIDS).
Management strategies and progress against infectious diseases
Generally, control of infectious diseases can be directed either at the agent, the route of transmission, the host or the environment and sometimes a combination of the control strategies (Roger, 2005). The general methods of control are summarized in Figure 1 below.
We will now focus on the progress and management efforts that have been used to combat infectious diseases but mainly drawing management strategies from HIV/AIDS, Malaria and Tuberculosis.
On the global context the annual number of people newly infected and dying from HIV has greatly reduced, see Figure 2 below.
Based on the MDG Report 2015 (UNDP, 2015), in the last 15 years, Africa has made significant strides in combating HIV/AIDS. The progress in reducing the mortality rate and the pandemic status of HIV/AIDS has encompassed all five of Africa’s geographical sub-regions, see Table 1 below.
Progress in HIV/AIDS rests on a number of factors including: improvement in testing, counselling and access to antiretroviral therapy; the reduction in mother-to-child transmission; the increase in prevention through the use of condoms and treatment as prevention; and the improvement in the general awareness and knowledge of the disease, including a better understanding of the link between HIV and tuberculosis. Engaging men in the fight against HIV also proved a winning strategy (UNDP, 2015).
In the World Malaria Report 2015 (WHO, 2015f) it is highlighted that there has been a dramatic decline in the global malaria burden over the past 15 years (2000-2015) whereby 57 countries have reduced their malaria cases by 75%, with the global incidence and mortality rate reducing by 37% and 60%, respectively, see figure 3 below.
Progress was made possible through the massive rollout of effective prevention and treatment tools: Vector control interventions, use of insecticide-treated bed-nets, quality-assured artemisinin-based combination therapy and rapid diagnostic tests have expanded in Africa over the past 10 years. However, specific efforts to protect pregnant women and children against malaria are progressing rather slowly (WHO, 2015f).
The MDG target of halting and reversing TB incidence by 2015 was achieved globally, in all six WHO regions and in 16 of the 22 high TB burden countries (WHO, 2015b). Since 2000, the global community has experienced a downward trend in tuberculosis prevalence, incidence and death rates (WHO, 2015b) see Figure 5 below.
The changes in tuberculosis prevalence and death rates mirror the rate of detection and treatment success under the DOTS approach which remains at the heart of Stop TB strategy which entails: Political commitment with increased and sustained financing; Case detection through quality-assured bacteriology; standardized treatment, with supervision and patient support; an effective drug supply and management system and Monitoring and evaluation system, and impact measurement (WHO, 2015d). Between 2000 and 2014, TB treatment alone saved 35 million lives among HIV-negative people; TB treatment and antiretroviral therapy saved an additional 8 million lives among HIV-positive people (WHO, 2015b).
Investment in infectious and non-communicable diseases 2000-2014
Development assistance for health (DAH) Disbursement
In 2000, the international community put global health high on the development agenda. Three distinct Millennium Development Goals focused on health issues in the developing world. At the forefront was the fight against child mortality, maternal mortality, and three infectious diseases: HIV/AIDS, malaria, and tuberculosis (TB). The formation of the MDGs was followed by major increases in global health financing flows. Rapid growth took hold from 2000 to 2010, following the launch of the MDGs. From 2013 to 2014, Development assistance for health (DAH) dropped by 1.6% (IHME, 2014). From the purchase of antiretroviral drugs and long-lasting insecticide-treated nets to support for disease-specific planning and programming, DAH has funded an array of activities in pursuit of MDGs 4, 5, and 6 with the very least proportion (1.48% of total) directed towards the non-communicable diseases.
Figure 8 below shows that UN agencies, including UNICEF, WHO, and UNAIDS, concentrated their DAH contributions most substantially on Maternal, newborn and child health (43.6%), but also supported work on other infectious diseases (11.3%), HIV/AIDS (6.6%), and Sector wide approaches/health sector support (5.3%), and to a minor extent non-communicable disease (1.8%), tuberculosis (1.1%), and malaria (0.9%). The investment on non-communicable diseases is generally low across all funding sources as compared to the MDG focus areas diseases.
Interestingly, the WHO programme budget allocation for communicable/infectious diseases has been declining for the past 2 financial years while the programme budget for non-communicable has been increasing see Table 2 below.
Change in disease burden from infectious to non-communicable diseases?
Historically, infectious diseases (IDs) have been the most important contributor to human morbidity and mortality (WHO, 2002) until recent times, when dominance has shifted to non-communicable diseases (Beaglehole & Bonita, 2008) as shown in Figure 9 below. This dominance of NCDs could be as a result of low investment as we have established from the previous section above.
Non-communicable diseases (NCDs) are one of the major health and development challenges of the 21st century, in terms of both the human suffering they cause and the harm they inflict on the socioeconomic fabric of countries (Suhrcke, Nugent, Stuckler, & Rocco, 2006), particularly low-and middle-income countries (WHO, 2014), see Figure 10.
The number of deaths from non-communicable diseases is double the number of deaths that result from a combination of infectious diseases (including HIV/AIDS, tuberculosis and malaria), maternal and perinatal conditions, and nutritional deficiencies (Daar et al., 2007). Over the coming decades the burden from NCDs is projected to rise particularly fast in the developing world (WHO, 2005a). Non-communicable diseases (NCDs) are now recognized as a development issue.
Conclusion: Is there a necessity for WHO to shift from infectious diseases?
This far we can actually conclusively agree that the success in the progress of the MDG diseases (HIV/AIDS, Malaria and Tuberculosis) was as a result of heavy financial investment from several sources as development assistance for health (DAH) (IHME, 2014). This clearly confirms the fact that health interventions are largely based around economics; disease with the greatest perceived burden tend to be where most resources are targeted. This clearly affirms the statement, “Many may suggest that infectious diseases are suitably managed in terms of financial investment”
The huge emphasis placed on the burden created by HIV/AIDS, Malaria and Tuberculosis in the original 1990 Global Burden of disease study by (Murray & Lopez, 1996) had the unintended consequence, over the last two decades, of committing the majority of resources towards combating these three diseases, “ignoring” investment in the other diseases and of major concern resulting to the rising trend in non-communicable diseases.
The increased investment in non-communicable diseases by the World Health Organisation and statement by Dr. Margaret Chan (Director General of WHO) which stated, “Worldwide, NCDs have overtaken infectious diseases as the leading cause of mortality. This shift challenges traditional development thinking, which has long focused primarily on infectious diseases and maternal and child mortality as priorities for international action. We continue to support this focus, but need to make space for additional challenges” (WHO, 2015e); certainly informs us that the shift in focus is a timely investment to address the rising challenge of non-communicable diseases but what is required of the WHO is to develop a balanced approach of tackling both infectious and non-communicable diseases.
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