A Wake-up Call: What Covid-19 Reveals about Elderly and NCD Care in Sub-Saharan Africa

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The Issue

  • The Covid-19 outbreak is an alarm bell, revealing the growing disease burden posed by the elderly and those living with non-communicable diseases (NCDs) in sub-Saharan Africa. While scholars and doctors in the past have called NCDs an “invisible pandemic,” the novel coronavirus has made tackling these diseases increasingly urgent.

  • Covid-19 is ravaging both populations, which are growing at a faster rate in sub-Saharan Africa than anywhere else in the world. The population of elderly people in sub-Saharan Africa is projected to reach 67 million by 2025 and 163 million by 2050.

  • Sub-Saharan African countries, however, are unprepared for this health and demographic transition. In contrast to high-income countries, African governments have historically neglected elder care and failed to adequately promote healthier diets and lifestyles.

  • It is imperative for African governments and international donors to increase and refine public health programming and funding. Regional and international stakeholders should integrate elderly and NCD care into regional health systems, including those for communicable diseases such as HIV/AIDS, tuberculosis (TB), and malaria, to protect these growing patient populations. 

Introduction

The Covid-19 pandemic is exposing gaps in health care provision across sub-Saharan Africa. Glaring weak spots have emerged around two populations in particular: the elderly and individuals living with NCDs. The virus is disproportionately targeting these groups, which are growing faster in sub-Saharan Africa than anywhere else in the world. Regional governments, however, are ill-equipped to care for these two populations. To make matters worse, the pandemic is disrupting existing programs and care for HIV/AIDS, TB, and malaria.

Regional governments and international partners should heed Covid-19 as a wake-up call and move swiftly to incorporate NCD and elderly care into existing health policies and programs while sustaining action against infectious diseases. The time is ripe for fresh interventions that reflect the region’s shifting demographics and disease landscapes.

Global Elderly and NCD Populations at Increased Risk

According to the Centers for Disease Control and Prevention (CDC), two populations—the elderly and people with pre-existing medical conditions—are most at risk for severe illness and death due to Covid-19. Since February, individuals aged 65 and older have comprised a colossal 80 percent of Covid-19-related deaths in the United States but represent only 16 percent of the population.1 Similarly, the UK government reported that individuals 65 and older comprise 92.5 percent of all confirmed Covid-19 deaths.2

Individuals living with underlying medical conditions such as chronic kidney disease, obesity, and heart failure are also at an increased risk for severe illness and death due to Covid-19.3 The Pan American Health Organization (PAHO) found that patients with diabetes are twice as likely to develop a severe conditions or die from Covid-19, and that 29 percent of cancer patients who contracted Covid-19 died, compared with just 2 percent of overall patients.4 PAHO director Carissa F. Etienne has warned that “we have never seen such a deadly relationship between an infectious disease and non-communicable diseases.” Meanwhile, in England and Wales, patients with ischemic heart disease represent 9.9 percent of all Covid-19-related deaths, making it the second most common pre-existing condition in Covid-19 deaths after dementia and Alzheimer’s disease.5

Covid-19 Trends at Play in Sub-Saharan Africa

Sub-Saharan Africa’s elderly and NCD populations are also disproportionally affected by Covid-19. As the virus spreads, regional governments are reporting statistics on par with death rates in the United States and United Kingdom. According to South Africa’s Department of Health, individuals aged 60 and older account for 55 percent of Covid-19 deaths but represent only approximately 9 percent of the population.6

The region’s NCD population is also experiencing higher death rates from Covid-19. A June study from South Africa’s Western Cape government found that people living with “uncontrolled” diabetes are approximately 13 times more likely to die from the virus.7 According to interviews with doctors across the region, a “majority” of patients dying from Covid-19 have underlying NCDs. In a Tanzanian hospital, for example, 88 percent of patients who died from Covid-19 had a comorbidity such as diabetes.8 Africa CDC Director Dr. John Nkengasong has underscored that “the rising number of non-communicable diseases will also play against us.”9

Neglected Elderly and NCD Populations

The staggering, disproportionate death rates from Covid-19 among elderly and NCD populations should sound an alarm bell for countries across sub-Saharan Africa. Regional governments are ill-equipped to face this double burden due to a lack of infrastructure and services geared toward these groups. Over the past few decades, regional governments have neglected their elderly and NCD populations, prioritizing treatment for infectious diseases such as HIV/AIDS, pneumonia, Ebola, TB, and malaria—a critical focus reinforced by the donor community. While donors should avoid cutting or redirecting HIV/AIDS funds to elder care and NCDs, for example, the global health community has an opportunity to adopt a more holistic funding architecture.

Sub-Saharan African governments have long neglected care for older people, instead favoring expenditures that invest in the “long-term productive potential of the young,” according to the African Development Bank.10 In particular, regional governments have failed to develop or fund programs, such as social security schemes and systemic geriatric care. The lack of pension plans forces elderly individuals to continue to seek formal or informal employment, making them vulnerable to communicable diseases—and now Covid-19. Moreover, pension plans are often riddled with corruption, ineffective benefits structures, and exclusionary norms that grant access to only a small percentage of retired workers.11 At the household level, families are failing to plan for longer lives, according to Tanzanian health specialist Dr. Kaushik Ramaiya. This results in a lack of support for older family members, both in terms of physical care and monetary assistance.12

Sub-Saharan African governments have also deprioritized NCD diagnosis and treatment. Across the region, the majority of NCD financing comes from out-of-pocket payments from patients rather than health sector allocations or donor funding.13 African governments “are underspending on health and massively underspending on NCDs,” according to Andreas Seiter, global lead for private-sector health, nutrition, and population at the World Bank.14 The lack of funding, both from African governments and international donors, directly results in deficiencies in research, medical training, and health service delivery for NCDs across the region.15 In fact, of the 20 countries slowest to implement the World Health Organization’s (WHO) “best buy” interventions—universally accepted measures to curb NCDs—17 are from sub-Saharan Africa.16 The lack of serious policy progress is exacerbated by poor civil society engagement on the issue, resulting in few domestic programs to curb dangerous habits such as tobacco usage and unhealthy food consumption.

Care Hindered by Weak Health Systems

The relative neglect of elderly and NCD populations is compounded by the region’s fragile and overlooked health systems. Governments across sub-Saharan Africa are failing to invest in their health sectors meaningfully, devoting a mere 5.18 percent of their GDP to health on average, compared to 9.9 percent globally.17 In addition, there has been slow progress toward the 2001 Abuja Declaration, in which signatories committed to spend 15 percent of their annual budgets on health. By 2013, only three countries had reached the pledged amount: Botswana (17 percent), Rwanda (20 percent), and Zambia (16 percent).18 According to Human Rights Watch, as of 2020 there have only been “modest” increases in the health budgets of a few African countries.19

A lack of funding has led to weak health care capacity in the region. According to the 2019 Global Health Security Index, which measures global health security capabilities across 195 countries, sub-Saharan Africa has the weakest health systems of any region in the world. The region scored particularly low on: (1) capabilities to prevent the emergence or release of pathogens and (2) a sufficient and robust health sector to treat the sick and protect health care workers.20 According to a 2018 Afrobarometer survey, 53 percent of Africans went without “needed” medical care at least once during the previous year. And nearly one in two Africans (46 percent) say their government is performing “fairly badly” or “very badly” on improving basic health services.21

The spread of Covid-19 in the region is exposing severe shortages in personnel and infrastructure. Most African countries are experiencing dangerous deficiencies in medical personnel, particularly critical care nurses and anesthesia providers. A Reuters report found that the continent averages less than one intensive care unit (ICU) bed and one ventilator per 100,000 people—a stark reminder of the dire implications facing people with chronic respiratory diseases.22

Covid-19 Strains Care for HIV/AIDS, TB, and Malaria

The Covid-19 pandemic is battering some of the most resource-poor countries in the world, many of which already face high rates of HIV/AIDS, TB, and malaria. The shift in local government and donor resources to address the pandemic is undercutting existing diagnostic and treatment services for these diseases and endangering countless people. Lockdowns and border closures are causing hospitals and clinics to run low on antiretroviral (ARV) therapies, and an increased number of patients are missing their doses. At the same time, the pandemic has disrupted ongoing HIV/AIDS programs for the PrEP drug, HIV testing and treatment, and even condom production and distribution. Researchers estimate that a complete disruption of ARV therapies in sub-Saharan Africa for six months could lead to more than 500,000 additional deaths from AIDS-related illnesses in the region in 2020–21, according to a July 2020 report by the Joint United Nations Program on HIV/AIDS (UNAIDS).23

Covid-19 disruptions also pose a threat to the fight against TB in sub-Saharan Africa. The Stop TB Partnership, a Switzerland-based NGO, has warned that health care disruptions due to Covid-19 in sub-Saharan Africa could result in 6.3 million additional TB cases and 1.4 million additional deaths over the next five years. International medical worker Anne Jung told Deutsche Welle that “because of coronavirus, the masks which are needed to help treat tuberculosis patients are now missing everywhere in Africa.”24

In addition, malaria-related deaths are expected to skyrocket during Covid-19 due to the disruption of normal health services and potential under-availability of antimalarial medicines. The WHO has warned that disruptions to mosquito net campaigns and access to antimalarials could result in double the malaria deaths in sub-Saharan Africa in 2020 than in 2018.25 This means the region could see 769,000 malaria deaths this year—more than five times the WHO’s estimated number of Covid-19 deaths across Africa over the next year if the virus is left to spread out of control.26


The Next Pandemic

Covid-19’s assault on elderly and NCD populations offers a preview of some of the challenges posed by shifting demographic and disease landscapes in sub-Saharan Africa. The region’s governments, as well as its civil society stakeholders and international partners, are ill-equipped to tackle childhood and infectious diseases while simultaneously realigning resources to manage NCDs and geriatric care. Although some scholars and doctors have called NCDs an “invisible pandemic” in the past, these diseases have become an increasingly visible and urgent problem.

This emerging public health crisis may have been unavoidable; it is a product of policy priorities and tradeoffs that coalesced to meet the challenge of the HIV/AIDS epidemic and support the Millennium Development Goals. Moreover, NCDs may be comparatively more complex to address, as they encompass four distinct disease groups. But this public health crisis also reflects a failure to envision a continent undergoing simultaneous demographic and disease transitions—i.e., longer life expectancies and the sharp rise of NCDs—even though its population’s median age remains relatively young.

These demographic transitions are transforming the region at an unprecedented rate. In fact, both elderly and NCD populations are growing at a faster pace in sub-Saharan Africa than anywhere else in the world.27

  • The population of people over age 60 in sub-Saharan Africa is projected to reach 67 million by 2025 and 163 million by 2050.28 This means the number of older people is expected to grow by 260 percent in sub-Saharan Africa over the next 30 years, compared to only 60 percent in high-income countries. The world’s highest expected growth of people aged 60 and older is in Kenya, where the elderly population is expected to increase by 420 percent between 2015 and 2050.29
  • NCDs are likely to increase by 27 percent in sub-Saharan Africa over the next 10 years, compared to a 17 percent increase globally.30 It is projected that NCDs will overtake infectious diseases as major sources of morbidity and mortality in sub-Saharan Africa by 2030.31 NCDs are already the cause of over 50 percent of reported adult deaths in Mauritius, Namibia, Seychelles, and a handful of other African countries.32 A recent study found that three quarters of Nigerians are at risk of NCDs; study lead Dr. Obi Igbokwe warned that “even when the pandemic has passed, we will still have to deal with the burden of tackling these chronic diseases which by all accounts are here to stay.”33

Behind the Trend Lines

The high growth rates of elderly and NCD populations in sub-Saharan Africa are affected by a number of factors, including access to life-saving medication, urbanization, and shifting nutrition and exercise habits.

• Access to Life-Saving Medication. The increase in the availability and affordability of medications for HIV/AIDS, malaria, and TB—as well as treatments for influenza, pneumonia, and everyday infections—are leading to a rise in average life expectancy across the continent. According to Dr. Nicaise Ndembi of the Africa Centers for Disease Control and Prevention (Africa CDC), not only are life-saving medications resulting in fewer childhood deaths, they are also helping people manage chronic disease and live well into their seventies, eighties, and beyond.34

• The highest rate of NCD growth is occurring in sub-Saharan African cities. Living in an urban environment is associated with raised blood pressure, blood sugar, and body mass index (BMI), particularly among recent settlers, whose increased blood pressure is evident within months of migrating from rural to urban areas.35 According to the World Bank, urban residents have a 1.5–4 times higher prevalence of diabetes than their rural counterparts and have increased risk of cardiovascular diseases.36

• Deteriorating Nutrition and Exercise Habits. Sub-Saharan Africa is experiencing a nutrition transition. More people are shifting to diets rich in fats and oils, sweeteners, and animal products, abandoning traditional African diets based on whole grains, legumes, and traditional vegetables. At the same time, better infrastructure and socioeconomic conditions have decreased the duration and intensity of physical activity among both children and adults across the region. These lifestyle changes often lead to biological risks such as obesity, high blood pressure, increased blood glucose, and elevated blood lipids, which contribute to nearly all prominent NCDs in the region, particularly cardiovascular diseases and diabetes.


Straining Health Systems, Stressing Societal Divisions

Sub-Saharan Africa is unprepared for this health and demographic transition. In contrast to high-income countries, African governments have historically neglected elder care and failed to adequately promote heathier diets and lifestyles.37 The region—and its private sector and foreign partners—will soon confront the triple challenges of addressing infectious diseases, such as measles and TB, while treating NCDs and managing the health care of the elderly.38 The region’s weak health systems and limited social safety nets are at risk of buckling under this pressure.

  • Because they are a low priority, NCDs are already taxing the region’s health care facilities. According to a 2017 study, NCDs are responsible for 81 percent of hospital admissions among older patients in Nigeria, Sudan, and Tanzania, while TB, malaria, and HIV/AIDS account for only 4.6 percent.39
  • Geographical barriers also pose obstacles. Where there are few specialized technicians, patients often have to travel long distances to receive treatment. In Kenya, for example, the only oncologists are in the capital city of Nairobi.40
  • Health responses to HIV/AIDS, malaria, TB, and other diseases are often siloed, meaning they fail to deliver comprehensive care or consider underlying conditions. However, the S. Department of State—through the President’s Emergency Plan for AIDS Relief (PEPFAR)—has formalized pathways for strengthening health systems in partner countries, including intergovernmental planning and training, as well as the development of national frameworks, policies, and strategic plans.41 In addition, the United States Agency for International Development (USAID) has begun to explore integrating NCD prevention and diagnosis into existing priority health responses.42

Sub-Saharan African societies are equally unready as their governments and health systems to weather this shift in demographics, which is contributing to rising cross-generational and class tensions. With the exception of Botswana, Mauritius, Namibia, and South Africa, formal pensions or other social welfare schemes are virtually nonexistent.43 This situation translates into older individuals, especially women, living in desperate circumstances or leaning on family and household members to provide personal care, which is often unavailable.44 The resulting stressors are likely to fuel resentment between generations and underpin domestic violence against the elderly.

  • According to a 2014 Pew Research Center study on global attitudes about aging, 28 percent of Nigerians, 39 percent of South Africans, and 47 percent of Kenyans say the growing percentage of aging people is a “problem.”45 The study’s authors conclude that Kenyan pessimism may be grounded more in current economic conditions than in future demographic realities. Indeed, 71 percent of Kenyans said they were “very” or “somewhat” confident they will have adequate living standards when they are old.
  • Older people often suffer from age discrimination and experience neglect and domestic abuse at home.46 More troublingly, older women in some communities are accused of being “witches” or using witchcraft—and are subsequently chased from their homes, beaten, and sometimes even murdered. This is particularly prevalent in Ghana, South Africa, and Tanzania.47

The shift in disease profile also may widen the gap between access to in-country public and private health infrastructure, as well as to medical services abroad. The region’s political and economic elites—who are susceptible to NCDs but also more likely to live longer—may opt to fund private hospitals to cater to certain NCDs and invest in exclusive nursing or long-term health care facilities. Once travel restrictions are lifted, Africa’s middle and upper classes may also revert to traveling abroad to receive medical treatment. Africa’s elite historically have preferred to jet off to the United States, Europe, or the Persian Gulf rather than brave local health facilities.48 This disparity of access to and quality of health care, especially in wake of the Covid-19 pandemic, could engender more animosity between socioeconomic classes.

Policy Recommendations for a Covid-19 and Post–Covid-19 World

It is imperative for African governments and international donors to increase and refine public health programs and funding in the wake of the Covid-19 pandemic. In addition to strengthening health systems and continuing to invest in water, sanitation, and hygiene (WASH), African governments and their international partners—including foundations and private sectors—must elevate geriatric care and NCDs as priority responses. These patient populations will form a more prominent share of the region’s overall disease burden and almost certainly remain uniquely vulnerable to future pandemics.49

In the near term, the region’s governments and international partners should prioritize the elderly and people with NCDs. These groups need preferential testing as well as special isolation and protection measures. They need to be among the 20 percent of the population prioritized to receive vaccines that are proven safe and effective. The elderly and those with NCDs must be proportionately represented in vaccine and therapy field trials in Africa. Gavi, the Vaccine Alliance—which has played a central role in expanding immunization infrastructure for children—may need a significant reorientation and expansion to provide universal immunization against Covid-19, with a special focus on elderly and those with NCDs.

Over the longer term, the region and the international community must adopt a more holistic approach to health care and prevention; enlist African political leaders as advocates; solicit global best practices; and engage the private sector.

Broaden, Don’t Pivot. Current programs on communicable diseases are and will remain critical. However, it will be necessary to expand them to include other patient populations, focus on primary care interventions to prevent both communicable and non-communicable diseases, and decrease the two disease sets’ competition over resources.50 This is reflected in the recent order that USAID direct at least 10 percent of every global health program’s budget to “cross-cutting health system capacity,” as stipulated in the 2021 House Appropriations Bill.51 For instance, treating viral Hepatitis B and C has the potential to mitigate liver disease, which is growing in the region. Deaths related to cirrhosis—liver scarring attributed to Hepatitis B and C as well as alcoholism—doubled in sub-Saharan Africa between 1980 and 2010.52 Scaling up treatment of Hepatitis B and C has the potential to reduce the likelihood of NCD risk factors as people age.

Promote African Champions. Africa’s elite are especially susceptible to these diseases and medical challenges associated with advanced aging, which suggests there is an opportunity to enlist their support. Nearly 70 percent of sub-Saharan African heads of state are over the age of 60. At least 30 cabinet ministers across sub-Saharan Africa—and several legislators and governors—have tested positive for Covid-19, as well as three of South Sudan’s five vice presidents.53 In addition, it is widely believed that Burundi’s president Pierre Nkurunziza died of the disease.54 It may be smart to harness current anxiety about the pandemic to address systematic shortfalls. Thirty-one African governments indicate they have national programs for older people, but they are significantly underfunded.55 Moreover, there has been little progress across the region in implementing NCD prevention approaches such as instituting tobacco taxes, strengthening health systems, and imposing restrictions on marketing unhealthy food and drink products to children.56

Increase Domestic Health Resources. African governments should commit to increasing health sector spending, directing specific allocations toward NCDs and elder care while retaining existing infectious disease programs. Africa CDC should work with regional governments to make this a reality. Donor funds are crucial for African health sectors, but they will never be a sustainable solution for regional governments grappling with competing priorities. In addition, program funding must be complemented by additional research and data collection; experts note there are deficiencies in basic science research on NCDs and a dearth of empirical research on long-term trends in the welfare of older people.57

Recruit International Partners. There are several countries in the developed and developing world that have core competencies in these issues and are eager to expand their engagement in Africa. For instance, Canada, Germany, Norway, the Netherlands, Sweden, and Japan all landed on HelpAge’s top ten list in 2015 for quality of life of elderly individuals.58 Canadian Prime Minister Justin Trudeau has traveled twice to the region; Germany, the Netherlands, and the Scandinavian countries are active in the Sahel; and last year Japan hosted its triennial Tokyo International Conference on African Development (TICAD). These countries can share best practices on elder care with the region’s governments and civil society; indeed, several side events at TICAD focused on this topic. In addition, stakeholders could consider expanding the mandate of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The mandate's existing priorities could be enriched with crosscutting NCD and elder care frameworks.

Prime U.S. Private Sector. This is an alluring opportunity for the U.S. private sector to engage and support African countries to tackle NCDs and provide elder care. Sub-Saharan African countries will almost certainly require education and training services for caregivers and medical staff on providing specialized care for older people and those with NCDs.59 Stephen Morrison, director of the CSIS Global Health Policy Center, has noted that private companies are nimble and can invest in research and promising technologies to improve the quality of life of people living with NCDs.60 There is, however, a need to foster trust and transparency between U.S. companies and potential partner governments in Africa. If U.S. medical services, manufacturers, and pharmaceutical companies remain squeamish or skeptical about engaging in the region, they will miss an opportunity to expand overseas. There is also an opportunity for already engaged U.S. medical companies to broaden their offerings beyond infectious disease treatments and support in the region.

Judd Devermont is director of the Africa Program at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Marielle Harris is program manager of the CSIS Africa Program.


This brief is made possible with generous support from Gilead Sciences, Inc.


CSIS Briefs are produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2020 by the Center for Strategic and International Studies. All rights reserved.

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Marielle Harris