March 2001 Insights Health Issue #1

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The worst of two worlds
Adult mortality in Tanzania

Many Tanzanians have entered the 21st century suffering the worst of two worlds. They share the crushing debt and poverty of other developing countries, yet are increasingly afflicted by chronic health conditions usually associated with richer nations.

What is the role of NCDs in the overall disease burden of Tanzania? In 1992, the Tanzanian Ministry of Health established the Adult Morbidity and Mortality Project (AMMP) in partnership with the UK University of Newcastle upon Tyne to answer this question. With support from the UK Department for International Development, AMMP has provided information about the leading causes of death and ill-health (including NCDs) at the community level to policy-makers and service providers for nearly a decade.

Focusing on three different socio-economic and geographic areas of the country, the project has found that the burden of mortality from many familiar infectious diseases, including HIV and malaria, remains excessively high. Yet it also has shown that Tanzanians have a very high risk of dying from causes less familiar to poor countries: NCDs including heart disease, high blood pressure, asthma and diabetes. Age-specific death rates from NCDs such as stroke are several times higher than in parts of Western Europe.

Other major findings include:

• As many as 27 percent of all adult deaths at the district level are due to non-infectious causes.

• Up to 42 percent of the Tanzanian population live in absolute poverty, on less than $0.75 a day. Yet during the 1990s, the daily cost of insulin treatment for diabetes was $0.78.

• In 1992, treatment of adults with diabetes (who make up about 0.2 percent of the population) was equivalent to eight percent of total government health expenditure. A year's treatment for a person with diabetes far exceeds the annual per capita health budget.

• Obesity, a risk factor for high blood pressure and other NCDs, is common in poor and middle income urban areas.

• Cigarette smoking, another risk factor, is reported more frequently by poor people in AMMP areas. In Tanzania, single cigarettes are sold for a few shilling - affordable for even the very poor.

• Urban women are particularly at risk from stroke. High rates of stroke mortality may be due to under-detection of high blood pressure and poor management of those diagnosed with the disease.

Patients with NCDs are as likely to use formal health services during their final illness as those with infectious diseases.

This has long been suspected by health professionals and is true even in poorer rural areas. NCDs are not solely the concern of wealthy urban elites. However, the need to use public resources in the fight against NCDs in developing countries is often downplayed. Increasing risks and high levels of health service use mean it is time to rethink the current low priority of NCDs in health policy. Other implications include the need for:

• culturally appropriate and cost-effective programmes for prevention and management of NCDs

• national policy based on the overall context of the disease burden from both infectious and non-infectious causes

• public education about NCD risk factors, such as cigarette smoking, the costs of managing these diseases, and prevention strategies, such as regular exercise

• realistic and equitable policies to ensure the adequate supply of drugs and services for management of NCDs

• collaboration between public and private sectors to implement these policies for all, regardless of personal financial resources.

P. Setel, Y. Hemed, D. Whiting, H. Masanja, M. Lewanga, R. Mswia and H. Kitange for the AMMP team (in alphabetical order): Richard Amaro, Berlina Job, Gregory Kabadi, Judith Kahama, Joel Kalula, Ayoub Kibao, John Kissima, Regina Kutaga, Frederic Macha, Haroun Machibya, Mkamba Mashombo, Louisa Masayanyika, Godwill Massawe, Gabriel Masuki, Ali Mhina, Veronica Mkusa, Ades Moshy, Hamisi Mponezya, Deo Mtasiwa, Ferdinand Mugusi, Samuel Ngatunga, Mkay Nguluma, Peter Nkulila, Seif Rashid, JJ Rubona, Asha Sankole, and Daudi Simba.

Henry Kitange
AMMP
Ministry of Health
PO Box 65243
Dar es Salaam
Tanzania
T: +255 22 211 6145
F: +255 22 212 3289
ammp.dar@twiga.com
www.ncl.ac.uk/ammp

See also
Stroke mortality in urban and rural Tanzania, The Lancet 355 by R.Walker et al (2000)
Must diabetes be a fatal disease in Africa? Study of costs of treatment, British Medical Journal 304 by S. Chale et al (1992)