**6. Prevention of cardiovascular diseases and insurance health system of African countries**

#### **6.1 Prevention of cardiovascular diseases**

According to the WHO, primary prevention of CVDs is defined as measures put in place to decrease the incidence of cardiovascular events (ischaemic heart disease and strokes) in individuals at risk of CVDs who have not yet developed overt or clinical CVDs. Efforts geared at preventing recurrent clinical cardiovascular events in individuals with CVDs are called secondary prevention [22]. Reports have shown the beneficial impacts of pharmacological interventions in primary and secondary the prevention of CVDs, though with caveats for population-based interventions. The need for economic assessment of these studies to identify those which have best value for money is paramount in inform decision making by health policy makers in designing a health system insurance policy [23]. Furthermore, WHO projects that by 2030, NCDs will overtake all other causes of mortality in all Africa [24]. With the increasing CVDs burden in Africa, the AHN was created in 2001. The AHN is a joint collaboration of various cardiovascular societies and national heart foundations sharing the same agenda: curbing CVDs in Africa, thereby improving the cardiovascular health for all Africans. The vision of the AHN is to play a leading role in the prevention and reduction of the burden related to CVDs, including cerebrovascular accident to halt from no longer being the major etiology of disability and premature death in the African continent. The AHN shares the vision of the World Heart Federation (WHF), the main organization of national and continental cardiovascular societies and foundations globally. The WHF's global target of '25 by 25' represents the objective of decreasing premature deaths caused by CVDs by 25% by the year 2025—an interim goal addressed by the Sousse' Declaration of 2018 [25]. The objective of the AHN held in Tunisia in 2018

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

not the least compounding factor for the emergence of CVDs in Africa.

The African population is experiencing an increasing rate of urbanization, with a shift in migration from rural to urban areas, with changes in lifestyle habits in particular, as the traditional diet rich in fruits and vegetables is gradually being replaced by a diet rich in calories densed foods from snacks, sweetened beverages, animal fats and low in complex carbohydrates. This change in diet is accompanied by weight gain (overweight and obesity) and a decrease in physical activity due to the abolishment of traditional agriculture for sedentary work [9]. This change in lifestyle is contributing to an increase in the prevalence of cardiovascular risk factors in Africa, with a tendency to equalize the prevalence in high-income countries. The prevalences of some cardiovascular risk factors in SSA are given below in comparison with high-income countries (HICs): Smoking rates are 10% in SSA versus 30% in HIC; hypertension prevalence in individuals ≥18 years old is 30% in SSA (40% in urban and 20% in rural populations) versus 20% in HIC; diabetes mellitus prevalence in persons aged above 17 years is 7.1% in adult males and females in SSA compared with up to 8% in males and up to 6% in women in HIC. Also, dyslipidemia prevalence in adults is 25% in SSA versus 40–60% in HICs; physical inactivity prevalence is 22% in SSA versus 29–40% in HIC; and obesity whose prevalence rates are variable in SSA and higher among women (2–40%) compared with men (1–15%) versus 18–35% in women and 12–30% among men in HIC [17]. Poverty has several consequences, including the development of communicable and

In the 1980s, a real revolution in the understanding of chronic diseases in adults was initiated with the pioneering work of an English epidemiologist named David Barker. During an observational study, he found that regions of UK that had a high rate of cardiovascular mortality, also had a high infant mortality rate [18]. Then a meticulous study of patients with NCDs [18], allowed him to put forward a hypothesis on the "origin of the development of health and disease" or early origin of adult diseases based on the premise that environmental factors during foetal life have a considerable impact on the susceptibility to various pathologies later in life of these exposed persons [18]. More precisely; malnutrition occuring in utero permanently changes the body's structure and function in ways that "programme" the appearance of disease in child-

At present it has been recognized that malnutrition during pregnancy is the cause of an alteration in the fetus in the short term of the programmed metabolism of carbohydrates and lipids and of the functions of the genes. In the long term, these changes will lead to reduced cognitive development, decreased educational performance, compromised immunity, lower physical capacity and an increased risk of several NCDs [18–21]. The physiopathological mechanisms by which foetal malnutrition can lead to NCDs are better elucidated to date. Gluckman and collaborators have shown that malnutrition is responsible for a modification of gene expression via epigenetic modification by methylation of foetal DNA. They

leads to malnutrition, especially maternal malnutrition, which causes low birth weight, stunted infants and adolescents. These individuals will be disadvantaged later in life because they may show a reduction in physical and mental development leading to low skills and reduced human capital. Competence is one of the faculties developed through adequate nutrition of children and adolescents. Wachs has defined competence as the ability to adapt and interact with one's environment [15]. Human capital refers to well-nourished, healthy, educated, skilled and alert individuals - an improved human condition - resulting in a workforce that could be the most productive asset of any country. However, the absence of this productivity, particularly economic productivity, perpetuates poverty [16]. Alongside poverty, we also have a trend towards the Westernization of the African lifestyle, which is

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non-communicable diseases.

hood, adolescenthood or adulthood [18].

was on the prevention of CVDs. The conference was endorsed by the Minister of Health of Tunisia, highlighting the importance of governmental collaborations in attending 'health-for-all'. Themes arising from the conference included the management of various cardiovascular risk factors, legislation of these cardiovascular risk factors, and using the leverage of other local and international organizations to improve cardiovascular health in Africa. Cited cardiovascular risk factors to be urgently cared for in Africa include diabetes mellitus, hypertension and dyslipidaemia. There is therapeutic inertia in the therapeutic algorithms of these conditions especially hypertension. The AHN emphasized on the importance of the timely treatment of resistant hypertension. Obesity was highlighted as the main driver of the diabetes epidemic in Tunisia as well as Africa, with 75% of patients with Type 2 diabetes mellitus dying from CVDs. A 1% improvement in glycosylated hemoglobin was shown to decrease mortality from ischemic heart disease by more than 14% in the Tunisian population although glycemic control is not often achieved in the African continent due to low awareness, treatment and control of diabetic patients who often present late with acute complications of diabetes mellitus such as hyperglycemic comas. Various barriers to control had been identified, namely the inability of clinicians to apply treatment guidelines, inadequate monitoring or surveillance of blood pressure and glycaemia, lack of community education and empowerment, and most importantly, the cost of accessing healthcare. There is also a poor awareness of the cardiovascular risks associated with dyslipidemia in SSA. The South African perspective displayed an increase in the burden of dyslipidemia due to anti-retroviral therapy (ART) induced dyslipidemia in patients living with HIV/AIDS and treated with ART. This needs to be promptly managed in order to prevent CVDs. Previous studies have identified the huge burden of premature ischemic heart disease partly due to dyslipidemia in Africa compared to other regions [26]. This reflects a lack of prevention, early detection and effective management of CVDs in Africa. Preventing CVDs remains a major challenge for development within the region as it results in significant health, financial and social consequences for individuals and government. Likewise, the control of tobacco use, known a risk factor of six of the eight leading causes of CVDs death was highlighted as being important. The role of healthcare providers and health authorities in preventing CVDs due to tobacco use was addressed through a governmental vote on the increment of tobacco taxation as there remains a discrepancy between taxes paid and the treatment cost of tobacco related health disease and death. The WHO 'MPOWER' package was emphasized as a tool to assist countries with tobacco reduction measures. In addition, patients should be motivated by clinicians and family members to quit smoking with both counseling and the early use of pharmacotherapy. In the same vein, the formulation of legislations to control cardiovascular risk factors including the control intervention for the effective implementation of physical exercise and encouraging a low-calorie dense foods to prevent CVDs mortality related to obesity and diabetes mellitus are strongly recommended. This will however, require an involvement from policy makers for the formulation of public health interventions geared at curbing the burden of CVDs in Africa. Moreover, there is a shortage in drugs and equipment for monitoring CVDs between African countries which needs to be addressed for CVDs prevention. This is due to preference in healthcare expenditures for infectious diseases at the detriment of CVDs in Africa. Various partnerships including the WHF, the United Nations the Non-communicable disease alliance (NCD Alliance), Pan African Society of Cardiologists (PASCAR), American Heart Association (AHA), Medtronic Foundation, Heart and Stroke Foundation of South Africa, World Heart Day events, The Kenyan-Heart Talking Walls project are key continental and inter-continental foundations trying to achieve and prevent

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*Lifestyle and Epidemiology: Poverty and Cardiovascular Diseases a Double Burden in African…*

cardiovascular health for all in Africa. Also, the social media is a crucial platform to increase awareness in communities regarding CVDs awareness and prevention. Successful CVDs preventive interventions such as the RESOLVE and the WHO Global Hearts projects need to be taken by African Stakeholders to improve cardiovascular health by addressing important issues such as improved management of hypertension, decreasing salt intake and tobacco use. It is worth to mention that CVDs prevention in Africa can significantly be achieved by identifying health advocates as well as effective leadership and the coalition of professional groups. Hence, an 'Africa-specific' guidelines for CVDs prevention need to be formulated and adopted. CVD risk factors prevention in Africa cannot be overemphasized as cardiac surgery to amend cardiovascular diseases still remain expensive and scarce

The International Forum for Hypertension Control and Prevention in Africa formulated treatment guidelines for CVDs prevention in 2003 [27]. Since then, CVDs preventive interventions to identify cardiovascular risk factors and set guidelines are now under way. Some African countries have conducted epidemiological studies, a few have begun to continually monitor and assess their programmes, and others, Nigeria and South Africa, have their own guidelines for managing hypertension. There is hope though, and some attention has finally been focused on CVDs prevention in Africa. However, challenges such as poor healthcare infrastructure, underfunded and understaffed health systems in Africa, inadequate access to cheap generic drugs and lack of public recognition and acceptance of the importance of CVDs will continue to hinder the effective implementation of both populationbased health programmes and those aimed at people at high CVDs risk [28, 29]. The continent's people need education on healthier lifestyles such as weight reduction,

CVDs are very burdensome to manage in Africa due to a lack of a national health insurance policy in most SSA countries [30]. Health systems insurance is primordial for achieving universal healthcare by providing financial protection to patients. It helps protect people from high healthcare costs by pooling funds to allow a cross-subsidization between the rich and poor and between the healthy and the sick [31]. Healthcare insurance coverage is still inexistent or at an embryonic stage in most African countries. This has largely contributed to poverty, poor cardiology service delivery and mortality from CVDs in Africa. Implementing an African health system insurance remains an important goal to improve the health status of individuals in Africa [4]. Reports illustrates that in the several SSA countries, direct out-of-pocket payments as a share of total health expenditure are still above 40%, exorbitantly high above WHO 20% threshold level of the total health expenditure below which financial risk protection can be ensured, and thus leading to poverty in Africa [32]. There is a serious handicapping sparsity of health systems insurance in most African nations where only about 15% of the 55 countries have national comprehensive health insurance schemes [33]. Evidence abounds that in SSA, the poor bear the highest burden of diseases and subsequently, experience very high expenses on healthcare costs [34]. Hence, the development of a health system insurance scheme should be advocated in public health and financial planning within African countries for better healthcare delivery in general. A universal healthcare system with national-level health insurance scheme would probably be more efficacious to avoid the low-socioeconomic class of the population from being marginalized. Strategies such as compulsory taxations from employees, deductions from sales taxes, and an increment on tobacco taxes have been shown to be effective in

*DOI: http://dx.doi.org/10.5772/intechopen.95785*

in a continent already overburdened with poverty.

smoking cessation, and greater physical activity.

**6.2 Insurance health system of African countries**

#### *Lifestyle and Epidemiology: Poverty and Cardiovascular Diseases a Double Burden in African… DOI: http://dx.doi.org/10.5772/intechopen.95785*

cardiovascular health for all in Africa. Also, the social media is a crucial platform to increase awareness in communities regarding CVDs awareness and prevention. Successful CVDs preventive interventions such as the RESOLVE and the WHO Global Hearts projects need to be taken by African Stakeholders to improve cardiovascular health by addressing important issues such as improved management of hypertension, decreasing salt intake and tobacco use. It is worth to mention that CVDs prevention in Africa can significantly be achieved by identifying health advocates as well as effective leadership and the coalition of professional groups. Hence, an 'Africa-specific' guidelines for CVDs prevention need to be formulated and adopted. CVD risk factors prevention in Africa cannot be overemphasized as cardiac surgery to amend cardiovascular diseases still remain expensive and scarce in a continent already overburdened with poverty.

The International Forum for Hypertension Control and Prevention in Africa formulated treatment guidelines for CVDs prevention in 2003 [27]. Since then, CVDs preventive interventions to identify cardiovascular risk factors and set guidelines are now under way. Some African countries have conducted epidemiological studies, a few have begun to continually monitor and assess their programmes, and others, Nigeria and South Africa, have their own guidelines for managing hypertension. There is hope though, and some attention has finally been focused on CVDs prevention in Africa. However, challenges such as poor healthcare infrastructure, underfunded and understaffed health systems in Africa, inadequate access to cheap generic drugs and lack of public recognition and acceptance of the importance of CVDs will continue to hinder the effective implementation of both populationbased health programmes and those aimed at people at high CVDs risk [28, 29]. The continent's people need education on healthier lifestyles such as weight reduction, smoking cessation, and greater physical activity.
