**7. Challenges of NCD control in urban Africa**

Several challenges hinder efforts to address the NCD burden in cities. The main challenges include lack of data needed to inform primary prevention, care and treatment, low community awareness on NCDs and risk factors, weak policies and poverty in the informal settlements.

#### **7.1 Dearth of NCD data**

Limited availability of representative data on the burden of NCDs in Africa [97], leads to a gross underestimation of burden, thus the inability to lobby for investment in NCD care service delivery. Some countries have collected national NCD data through the NCD WHO STEPwise surveys. Up to 33 countries in WHO African Region have conducted at least one round of STEPwise survey which draws a nationally representative sample and about 19 countries have conducted the global school-based student health surveys (GSHS) [98]. Routine data captured by health facilities on morbidity and mortality could be a potential sources of data, but these data are limited by non-representativeness due to differential use of health services, inaccuracies from paper-based data capture systems, thus the data are largely regarded as of poor quality [99]. Insurance firms also provide important morbidity data, but these have limited value since a small proportion of the population access health insurance. The Global Burden of Disease study combines several datasets to model national NCD morbidity and mortality estimates, but rarely reports NCD burden by rural versus urban locations. Data challenges such as the variation in methodologies used to capture data, the rigor of instruments, sampled populations, design used as well as the variations in how the indicators are defined continue to hamper the comparability and learning across countries [100]. Planning of NCD services without reliable data is almost impossible.

#### **7.2 Lack of community awareness**

Lack of knowledge and awareness on risk factors at community level hinders healthy behavior change and uptake of early NCD screening and treatment services [101]. A study in Abuja reported a high prevalence of hypertension among the elderly populations, and majority of whom were unaware about their conditions [102]. Other studies have suggested that low levels of knowledge and awareness of hypertension are associated with undiagnosed, severe or complicated, and uncontrolled hypertension [103], lack of patients' adherence to lifestyle modifications and to medications [104, 105]. Certainly raising awareness particularly on uptake of screening services for most NCDs could be beneficial at both individual and population-levels. And in the context of urban Africa, such efforts could leverage on wide spread mass-media for health promotion. Low levels of NCD awareness or knowledge levels among health workers is also associated with reduced ability for case-finding, treatment and referrals [106].

**41**

they need [116].

**7.5 Poverty in informal settlements**

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review*

Urban populations in Africa tend to be very diverse by education, religion, socioeconomic status and culture [5]. As a result, NCD prevention and control policies and programs need to be tailored to cater for variations at population levels [107]. In a review CVD policies in Kenya Asiki et al. (2018) found no standalone policies for CVD management and care but some aspects of CVD policy were covered in general NCD policy document [108]. NCD policies in most African countries suffer the same deficiencies as they do not reflect the typical realities of urban living –pervasive food marketing and complex urban food environments that may offer diversity as well as greater exposure to unhealthy foods [8]. These policies are also not well integrated with policies in other sectors such as spatial planning, infrastructure and housing, transport planning, education policy, access to energy, and water and sanitation policies and interventions [53]. As such minimum intersectoral and multisectoral engagements in policy formulation lead to standalone NCD policies that are not coherent with other policies [90]. Furthermore, national policies and plans for the prevention and control of NCDs often suffer from underfunding [109], and are thus not implemented. In addition, interference from commercial and economic interests of industry for tobacco, alcohol, and food industries makes it difficult to regulate these NCD risk factors as policy makers and law enforcers are often bribed or threatened not to formulate and or implement such policies [110].

Health systems in SSA are characteristically weak and overburdened by the rapidly increasing double burden of communicable diseases and NCDs [17]. With more focus and investment on infectious diseases such as malaria, TB and HIV, very little attention is given to the rising NCD burden in cities [111]. As a consequence, several gaps and missed opportunities exist to offer services for patients and many miss diagnosis, and treatment to when they present to hospitals with other diseases [112]. Inadequate staff and as well as capacity of health staff in most countries, negatively affects NCD prevention and treatment at facilities. For instance, nurses at primary healthcare facilities should have skills to use simple point-of-care equipment such as glucometers for early screening, treatment and referral of individuals with abnormal blood glucose [113]. Frequent stock-outs of medicines and supplies remains a critical barrier to prompt treatment and adherence to these treatments. In Nairobi, Kenya medicines for NCDs are hardly available in public hospitals, and there is lack of integration of NCD services with other chronic diseases such as HIV or TB services [114]. Knowing that interventions targeted against one of the disease burdens will impact the other, it is critical that interventions are conducted jointly instead of competing for limited resources. A study in Malawi reported that the full cost of NCD care is often borne directly by patients through out-of-pocket (OOP) payments individuals [115]. Similarly, a study by Mwai and Muriithi (2016) in Kenya reported that NCDs reduce household income by almost 30%, compared to other general ailments that reduce household income by 13.6%. As a consequence, many people suffering from NCDs in Africa face risks of experiencing catastrophic health expenditures, impoverishment and may be deterred from seeking the care

Poverty is common among urban residents in Africa and this plays a fundamental role in the onset, progress and mortality of NCD patients [117]. Studies

*DOI: http://dx.doi.org/10.5772/intechopen.89507*

**7.4 Slow health system response**

**7.3 Weak policies**

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review DOI: http://dx.doi.org/10.5772/intechopen.89507*

#### **7.3 Weak policies**

*Public Health in Developing Countries - Challenges and Opportunities*

**7. Challenges of NCD control in urban Africa**

services without reliable data is almost impossible.

**7.2 Lack of community awareness**

case-finding, treatment and referrals [106].

poverty in the informal settlements.

**7.1 Dearth of NCD data**

essential to help reverse the negative trends of NCDs in urban Africa.

these health promotion approaches are aimed at achieving positive health behaviors at individual and community levels [95]. For example in Kigali, Rwanda physical activity is promoted among city residents by encouraging people to leave work early once in a week to engage in physical activity [96]. Such preventive approaches to NCD control targeting the behavioral risk factors are more cost-effective than treating the NCDs. A more concerted, strategic, and multi-sectorial policy approach is

Several challenges hinder efforts to address the NCD burden in cities. The main

challenges include lack of data needed to inform primary prevention, care and treatment, low community awareness on NCDs and risk factors, weak policies and

Limited availability of representative data on the burden of NCDs in Africa [97], leads to a gross underestimation of burden, thus the inability to lobby for investment in NCD care service delivery. Some countries have collected national NCD data through the NCD WHO STEPwise surveys. Up to 33 countries in WHO African Region have conducted at least one round of STEPwise survey which draws a nationally representative sample and about 19 countries have conducted the global school-based student health surveys (GSHS) [98]. Routine data captured by health facilities on morbidity and mortality could be a potential sources of data, but these data are limited by non-representativeness due to differential use of health services, inaccuracies from paper-based data capture systems, thus the data are largely regarded as of poor quality [99]. Insurance firms also provide important morbidity data, but these have limited value since a small proportion of the population access health insurance. The Global Burden of Disease study combines several datasets to model national NCD morbidity and mortality estimates, but rarely reports NCD burden by rural versus urban locations. Data challenges such as the variation in methodologies used to capture data, the rigor of instruments, sampled populations, design used as well as the variations in how the indicators are defined continue to hamper the comparability and learning across countries [100]. Planning of NCD

Lack of knowledge and awareness on risk factors at community level hinders healthy behavior change and uptake of early NCD screening and treatment services [101]. A study in Abuja reported a high prevalence of hypertension among the elderly populations, and majority of whom were unaware about their conditions [102]. Other studies have suggested that low levels of knowledge and awareness of hypertension are associated with undiagnosed, severe or complicated, and uncontrolled hypertension [103], lack of patients' adherence to lifestyle modifications and to medications [104, 105]. Certainly raising awareness particularly on uptake of screening services for most NCDs could be beneficial at both individual and population-levels. And in the context of urban Africa, such efforts could leverage on wide spread mass-media for health promotion. Low levels of NCD awareness or knowledge levels among health workers is also associated with reduced ability for

**40**

Urban populations in Africa tend to be very diverse by education, religion, socioeconomic status and culture [5]. As a result, NCD prevention and control policies and programs need to be tailored to cater for variations at population levels [107]. In a review CVD policies in Kenya Asiki et al. (2018) found no standalone policies for CVD management and care but some aspects of CVD policy were covered in general NCD policy document [108]. NCD policies in most African countries suffer the same deficiencies as they do not reflect the typical realities of urban living –pervasive food marketing and complex urban food environments that may offer diversity as well as greater exposure to unhealthy foods [8]. These policies are also not well integrated with policies in other sectors such as spatial planning, infrastructure and housing, transport planning, education policy, access to energy, and water and sanitation policies and interventions [53]. As such minimum intersectoral and multisectoral engagements in policy formulation lead to standalone NCD policies that are not coherent with other policies [90]. Furthermore, national policies and plans for the prevention and control of NCDs often suffer from underfunding [109], and are thus not implemented. In addition, interference from commercial and economic interests of industry for tobacco, alcohol, and food industries makes it difficult to regulate these NCD risk factors as policy makers and law enforcers are often bribed or threatened not to formulate and or implement such policies [110].

#### **7.4 Slow health system response**

Health systems in SSA are characteristically weak and overburdened by the rapidly increasing double burden of communicable diseases and NCDs [17]. With more focus and investment on infectious diseases such as malaria, TB and HIV, very little attention is given to the rising NCD burden in cities [111]. As a consequence, several gaps and missed opportunities exist to offer services for patients and many miss diagnosis, and treatment to when they present to hospitals with other diseases [112]. Inadequate staff and as well as capacity of health staff in most countries, negatively affects NCD prevention and treatment at facilities. For instance, nurses at primary healthcare facilities should have skills to use simple point-of-care equipment such as glucometers for early screening, treatment and referral of individuals with abnormal blood glucose [113]. Frequent stock-outs of medicines and supplies remains a critical barrier to prompt treatment and adherence to these treatments. In Nairobi, Kenya medicines for NCDs are hardly available in public hospitals, and there is lack of integration of NCD services with other chronic diseases such as HIV or TB services [114]. Knowing that interventions targeted against one of the disease burdens will impact the other, it is critical that interventions are conducted jointly instead of competing for limited resources. A study in Malawi reported that the full cost of NCD care is often borne directly by patients through out-of-pocket (OOP) payments individuals [115]. Similarly, a study by Mwai and Muriithi (2016) in Kenya reported that NCDs reduce household income by almost 30%, compared to other general ailments that reduce household income by 13.6%. As a consequence, many people suffering from NCDs in Africa face risks of experiencing catastrophic health expenditures, impoverishment and may be deterred from seeking the care they need [116].

#### **7.5 Poverty in informal settlements**

Poverty is common among urban residents in Africa and this plays a fundamental role in the onset, progress and mortality of NCD patients [117]. Studies have suggested that the groups most at risk of NCDs in the next decade will be the urban poor [118]. While NCD epidemiology in high income countries is largely driven by explosion of traditional risk factors in Rwanda, increasing evidence points to a greater contribution of malnutrition, infections, and toxic environments - all exacerbated by poverty [119]. Poverty also limits access to quality NCD care. Majority of the urban poor lack access to health insurance and therefore resort to out-of-pocket payments, consequently leading to catastrophic spending [120]. Research on social and economic implications of NCDs remain scarce in most SSA countries yet such information is important for prioritization of NCDs by all relevant sectors [121].

#### **8. Conclusion**

The rapid urbanization in Africa continues to drive the NCD epidemic, increasing vulnerability of individuals, threatening development and sustainability of African cities. To mitigate this rising threat - effective evidence-informed multisectoral policies are needed to address prevention and control of NCD focusing on the major NCD risk factors. While several countries have developed national strategies for NCD prevention following the global WHO NCD prevention strategies, implementation of these policies is still inadequate. Thus there is need for governments to put more effort in strengthening implementation of these policies including allocation of financial and other resources to support implementation. NCD policies need to be integrated into urban planning to address air pollution as well as physical inactivity by designing and developing parks and recreational facilities including pedestrian and cycling tracks, zoning walk-ways where motorized vehicles are not allowed and providing incentives for the non-use of motorized vehicles. Fiscal policies and regulatory measures to restrict unhealthy food environment in urban areas of Africa are also needed to curtail the ever growing food marketing by a burgeoning food industry.

There is need to strengthen health care systems to make them more responsive to NCD prevention and control. This include building capacity of health workforce on prevention and control of NCDs, strengthening infrastructure, providing essential commodities and supplies and strengthen surveillance systems to be able to plan, monitor, and assess the effects of NCDs on population health and monitor the performance of interventions. A good balance of investment is required for the delivery and coordination of both curative and preventive and promotive services to avert the NCD disease burden. Countries need to explore various models of partnership with private sector partners aimed at scaling up their contributions to addressing NCDs directly or indirectly through various multi-sectoral strategies.

There is need to strengthen primary prevention interventions at communitylevels. These interventions include early detection, active screening, case finding, referral and treatment and working with at-risk individuals to reduce high risk behavior. Expanding opportunities for early detection at the community and in primary health facilities could yield positive outcomes, especially through deliberate implementation of task shifting and task sharing models, involving community health workers (CHWs), while consistently mentoring and evaluating performance of such a model. Further community interventions include health education and promotion focusing on NCD risk factors including importance of reduced alcohol and tobacco consumption, physical activity and decreased consumption of highcalorie foods and highly processed foods while increasing consumption of fruits and vegetables. Some evidence exist on the potential positive results of such small-scale healthy food interventions utilizing platforms such as school feeding programs and

**43**

**Author details**

Kenneth Juma1

and Gershim Asiki1

\*, Pamela A. Juma<sup>2</sup>

\*Address all correspondence to: kjuma@aphrc.org

provided the original work is properly cited.

1 African Population and Health Research Center, Nairobi, Kenya

2 London School of Economics and Political Science, London, UK

3 Aga Khan Foundation and Aga Khan University, SONAM-EA, Nairobi, Kenya

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Constance Shumba<sup>3</sup>

, Peter Otieno1

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review*

workplaces. While documented community interventions addressing alcohol and tobacco consumption are scarce, interventions to enhance awareness and engagement in physical activity in major cities such as in Rwanda and Cameroon have been shown to work. Above all pro-poor primary health care programs targeting vulnerable and disadvantaged groups in African cities are needed to reduce the equity gap

*DOI: http://dx.doi.org/10.5772/intechopen.89507*

in NCD services.

*Non-Communicable Diseases and Urbanization in African Cities: A Narrative Review DOI: http://dx.doi.org/10.5772/intechopen.89507*

workplaces. While documented community interventions addressing alcohol and tobacco consumption are scarce, interventions to enhance awareness and engagement in physical activity in major cities such as in Rwanda and Cameroon have been shown to work. Above all pro-poor primary health care programs targeting vulnerable and disadvantaged groups in African cities are needed to reduce the equity gap in NCD services.
