Implications of forecasted disease burden on envisioning health strategies in Ethiopia; Findings from Global Burden of Disease 2017 Forecasting Study

Abstract

Background Universal health coverage is the main goal of the health sector in the coming decade for Ethiopia, in the county’s transitions to a middle-income state. We used GBD 2017 forecasting 2017–2040 results to support Ethiopia’s envisioning framework with baseline scenario and calibration targets

Methods We used GBD 2017 forecasting estimates for Ethiopia which modelled 250 causes and cause of death from 2017–2040. The data sources for Ethiopia include surveys, surveillance, case notifications, facility reports, sibling history, verbal autopsy and police records to estimate mortality and causes of death. We reported Life Expectancy (LE), death and premature mortality rates using GBD broader and detail categories with 95% uncertainty Intervals (UI).

Results Ethiopians average life expectancy will increase from 66.0 years (64.0-68.5) in 2017 to 73.8 years (70.3–77.3) in 2040. In 2040, the all-cause age-standardized death rate is 854 per 100,000 people of which NCDs caused 567.1 and CMNNDs caused 211.2 of the deaths. NCDs and injuries show a smaller reduction of 26% and 23% respectively between 2017 and 2040 compared to the 53% decrease for CMNNDs. Cardiovascular and neoplasm causes 224.7, 137.8 deaths/100,000 respectively. Diarrheal, lower respiratory infections, and other common infectious diseases combined caused 144.5 age-standardized deaths/100,000 in 2040. The combined age-standardized death rate for HIV/AIDs and tuberculosis is 35.2 deaths/100,000. The age-standardize premature mortality percentage contribution of CMNNDs declined from 62.4% in 1990, 45% in 2018 and 34% in 2040, whereas NCDs contribution increased from 25.2% in 1990, 46% in 2019 and 54% in 2040.

Conclusions Ethiopians average life expectancy is expected to increase. This major gain is expected to be attributed to further reductions in under-five child mortality and decline in burden of major communicable, maternal and nutritional diseases. Ethiopia is more likely to achieve the success of LMI countries in terms of life expectancy; neonatal, child and maternal mortality rates; eradicating malaria, tuberculosis and HIV/AIDS causes of mortality however less likely to achieve the success of UMICs by 2040. Non-communicable disease and injuries are expected to be leading causes of age-standardized death rate from 2007 through 2040.

Background Ethiopia has an estimated total population of 103 million in 2016, where half of them are dependent population (45% under the age of 15 years and 3% above the age of 65), and the sex ratio is almost equal (1). During the implementation of the 20-year Health Sector Development Plan (HSDPs) from 1997–2015, which also covers the MDG era, substantial decline has been recorded on under 5 morbidity and mortality, in maternal morbidity and mortality, in morbidities and mortalities due to HIV/AIDS, tuberculosis (TB) and malaria. Despite great progress over the past two decades, a huge burden of preventable mortality still persists in Ethiopia (2). The main contributors to this burden include child and maternal mortality, stillbirths, HIV/AIDS, TB, non-communicable diseases (NCDs) and injuries (3, 4). Ethiopia is currently experiencing double disease burden, that is communicable and non-communicable diseases, which was not recognized in the HSDP strategic plan of the country (2).

Background

Ethiopia has an estimated total population of 103 million in 2016, where half of them are dependent population  (45% under the age of 15 years and 3% above the age of 65), and the sex ratio is almost equal (1).  During the implementation of the 20-year Health Sector Development Plan (HSDPs) from 1997-2015, which also covers the MDG era, substantial decline has been recorded on under 5 morbidity and mortality, in maternal morbidity and mortality, in morbidities and mortalities due to HIV/AIDS, tuberculosis (TB) and malaria. Despite great progress over the past two decades, a huge burden of preventable mortality still persists in Ethiopia (2). The main contributors to this burden include child and maternal mortality, stillbirths, HIV/AIDS, TB, non-communicable diseases (NCDs) and injuries (3,4). Ethiopia is currently experiencing double disease burden, that is communicable and non-communicable diseases, which was not recognized in the HSDP strategic plan of the country (2).

In this sustainable development (SDG) era, Ethiopia is envisioning the future healthcare system to understand broadly long term development with particular emphasis to Primary Health Care (PHC) system. Universal health coverage (UHC) is the main goal of the health sector in the coming decade, in the county’s transitions to a middle-income state (5). Currently, Ethiopia is implementing the first phase of the second 20-year health sector strategy “Envisioning Ethiopia’s Path to Universal Health Care through strengthening of Primary Health Care” called a Health Sector Transformation Plan (HSTP), which covers the period 2015- 2020. The HSTP is in line with the country’s second growth and transformation plan (GTP-II) and Sustainable Development Goals (SDGs) (6). The envisioning plan has given particular emphasis to the PHC system not only to achieve  Universal Health Coverage (UHC) but also to respond to inequity in health care provision, scarcity of funds in the health sector and to address issues on sustainable financing (5). The PHC approach is considered as the core of Ethiopia's envisioning strategy to move to UHC for which UHC is assumed to guarantee access to essential services while providing protection against financial risk (7–9). However, lack of baseline evidence for specific strategic areas and targets is presented as a challenge to monitor progress and predict gains and resource need. Besides, understanding future disease burden and the nature of the epidemiologic transitions with its major drivers and determinates would be essential for priority setting and implementing high impact interventions to achieve UHC targets. Therefore, to fill this evidence gap this study used GBD 2017 forecasting results to support Ethiopia’s envisioning framework with baseline scenario and calibration targets for intervention that intends to guide the overall investment direction of the country in health.  Health planning, investments in health requires considerations of possible future trends in health and the corresponding drivers.

Methods

The methods used were described elsewhere (10), in brief GBD 2016 data was used and modelled 250 causes and cause of death groups organized by GBD hierarchical cause structure to forecast causes from 2017-2040. A three component model of cause-specific mortality were developed: a component explained by changes in behavioural, metabolic, and environmental risks, and selected interventions quantified in GBD; a component explained by income per person, educational attainment, and total fertility rate under 25 years(SDI), and time; and an autoregressive integrated moving average (ARIMA) to capture the unexplained component correlated over time (10). The model’s main component captured the prevalence for 65 risk factors reported in GBD 2016 and the relative risk (RRs) between levels of risk exposure and each GBD outcome. GBD 2016 reported RRs for each risk outcome pair based on meta-analysis of randomized trials and cohort studies. Interventions quantified in GBD currently include antiretroviral therapy (ART) for people living with HIV, met need for family planning with modern contraceptive methods, and vaccination coverage of diphtheria, tetanus, pertussis (three doses) and measles; pneumococcal conjugate vaccine, and vaccination coverage of rotavirus; and Haemophilus influenza type B. Risk factors, interventions and measures of development as independent drivers.  

For each independent drivers-65 risk factors, selected interventions, income per person, educational attainment, and total fertility rate under 25 years- reference forecasts through 2040 and two alternative scenarios; better health and worse health were developed. These scenarios corresponded with the relative effect of these drivers on health outcomes. A hypothetical future scenarios were constructed using annualized rates of changes observed across all years in the past for the better and worse scenarios to show what would happen if Ethiopia had that level of change in the future.

The data sources for Ethiopia include surveys, surveillance, case notifications, facility reports, sibling history, verbal autopsy and police records to estimate mortality and causes of death. We reported Life Expectancy (LE) compared with countries considered benchmark in Ethiopia’s envisioning strategy, death and premature mortality rates using GBD broader and detail categories with 95% uncertainty Intervals (UI). Years of life lost (YLLs) calculated as a measure of premature mortality by summing up the remaining life expectancy for people dying in each age group.

To identify LMIC and UMIC bench marking countries from low and middle income countries and upper and middle income countries, their health status; health care system resource and health care system performance and health status of the population were considered. There were 48 LMIC and 55 UMIC using world bank classification of GNI per capita. The team got GDP by years from 1960-2011 and their health profile from WHO’s World Health Statistics report (WHO). LMIC were countries with the best health profile, population of 10 million+ and were low income country in 1970’s; with MMR, UMR, Age-standardized mortality rates by cause per 100,000 populations for CD, NCD, Injuries), cause-specific mortality rate per 100, 000 populations for malaria, TB and HIV and life expectancy at birth. The average of health status and health care performance achievements of best countries selected by the above criteria were considered as a bench mark target for Ethiopia as a best case scenario (Average achievements of best LMIC for Ethiopia’s 2025 target as a best case scenario and average of achievements of best UMIC for Ethiopia’s 2035 targets as a best case scenario). The average of health status and health care performance achievements of all LMIC and UMIC countries are considered as a bench mark target for Ethiopia as a base case scenario (Average achievements of all LMIC for Ethiopia’s 2025 target as a base case scenario and average achievements of all UMIC for Ethiopia’s 2035 targets as a base case scenario).

Results

Life expectancy

In Ethiopian the average life expectancy will increase from 66.0 years (64.0-68.5) in 2017 to 73.8 years (70.3-77.3) in 2040. Average life expectancy for males increases from 65.4 years (62.3-68.4) in 2017 to 72.2 years (68.1-76.3) in 2040 and for female from 67.2 (64.3-69.9) in 2017 to 75.5 years (71.6-79) in 2040 (Figure 1).  

Crude death rates and percentage changes 

Crude death rates for broad groups of causes and the crude all-cause mortality rate are presented in Table 1. In 2017, Communicable, Maternal, Neonatal and Nutritional Diseases (CMNND) accounted for 47.9% (95% UI 43.2–53.4), NCDs accounted for 43.6% (95% UI:38.6–47.9) and injuries accounted for 8.5% (95% UI:7.4–9.8) of the total 686,800 deaths. In 2040, deaths due to NCDs accounts for 60.8% (95% UI:53.3–66.7), CMMND causes accounts for 28.1% (95% UI 22.2–36.0) and injuries accounts for 11.0% (95% UI:9.17%–13.2) of 784,400 deaths.

In 2017, 311.7 deaths per 100,000 were due to CMMNN disease while 283.1 deaths per 100,000 were due to NCDs, and 55.5 deaths per 100,000 were due to injuries. In 2040, non-communicable disease accounted 277.9 deaths per 100,000, 129.6 deaths per 100,000 were due to CMNN disease and injuries accounted 50.4 deaths per 100,000.

All-cause death will decline by 30%; from 650.3 death per 100,000 in 2017 to 457.9 deaths per 100,000 in 2040. The transition from high CMNN disease burden to high NCDs burden occurs in 2020. From 2038, deaths due to NCDs will be two times higher than CMNN disease. Mortality due to CMNN causes will show a 58.4% significant decline, while NCDs have a 1.8% decline and injuries a 9% decline between 2017 and 2040.

In 2017, diarrhea, lower respiratory infections and other common infectious disease collectively caused 149.0 (95% UI; 104.0-205.0) deaths per 100,000 people. HIV/AIDs and tuberculosis collectively caused 60.1 (95% UI; (48.3-73.4) deaths per 100,000 people. Neonatal disorders caused 57.9 (95% UI; 45.0-75) deaths per 100,000 people (Table 1). Cardiovascular diseases and neoplasms caused 118.6 (95% UI; 93.1-145.8), 63.1(95% UI; 50.3-75.8) per 100,000 people respectively and diabetes caused 27.8 (95% UI; 21.7-37.6) per 100,000 people. Transport injury, unintentional injuries, self-harm and interpersonal violence causes 29.3 (95% UI; 21.5-39.9), 31 (95% UI; 26.6-36) and 25.8 (95% UI; 18.2-36.9) deaths per 100,000 people respectively. Between 2017 and 2040, diarrhea, lower respiratory infections and other common infectious disease causes collectively decline by 47%, HIV/AIDS and tuberculosis collectively decline by 56%, neonatal disorder causes decrease by 80% while cardiovascular disease fall only 15%, unintentional injuries 28% and self-harm and interpersonal violence decrease 6%. Whereas mortality due to neoplasm and diabetes causes increase by 22% and 14% respectively and transport injury increased by 21%, between 2017 and 2040. 

Age-standardized death rates and the Epidemiologic transition

The CMNNDs were leading causes of age-standardized death rate since 1990, whereas non-communicable disease become leading causes of age-standardized death rate after 2007 through 2040 (Table 2). The epidemiologic transition from CMNNDs to NCDs and the burden of injuries in terms of age-standardized death rates for both sexes and all age groups, has shown in Figure 3. Overall, total mortality and age-standardized death rates for each of the broad groups of causes decreases between 2017 and 2040. In 2040, the all-cause age-standardized death rate is 854 (95% UI; 635.3-1168.7) per 100,000 people of which NCDs caused 567.1 (95% UI; 429.4-753.3) and CMNNDs caused 211.2 (95% UI; 132.8-331.9) of the deaths. NCDs and injuries show a smaller reduction of 26% and 23% respectively between 2017 and 2040 compared to the 53% decrease for CMNNDs (Table 2).

Diarrheal, lower respiratory infections, and other common infectious diseases combined caused 144.5 (95% UI; 72.4-253.2) age-standardized deaths per 100,000 populations in 2040. The combined age-standardized death rate for HIV/AIDs and tuberculosis is 35.2 (95% UI:22.2-53.5) deaths per 100,000 people (Table 2). Cardiovascular and neoplasm causes 224.7 (95% UI: 149.2-328.4), 137.8 (95% UI: 103.2-177.1) deaths per 100,000 people respectively. Transport and unintentional injuries causes 22.5 (95% UI: 16.3-30.8) and 34 (95% UI: 27.3-42.5) deaths per 100,000 people, respectively.

Between 2017 and 2040, except diarrheal, lower respiratory infections, and other common infectious diseases which decline by 42%, all CMNND level two categories of causes of death showed a 57% and above decline. The age-standardized death rates from cardiovascular diseases and neoplasms will have a 37% and 8% reduction, respectively, between 2017 and 2040. Age-standardized death rates due to unintentional injuries will also decline by 33% and due to transport injuries by 2% (Table 2).

The top 20 leading causes of deaths accounts for 72% of the total age-standardized deaths in 2040. Twelve of the 20 leading causes were NCDs and six of them were in the top 10 leading causes. The top five leading cause in 2040 are ischemic heart disease, lower respiratory infections, diarrheal disease, stroke and diabetes 96 (95% UI:47.3-167.6), 71.1 (95% UI:42.6-110.4), 57.5 (95% UI:12.1-148.1), 56.8 (95% UI:34.6-95, 39.9 (95% UI:23-69.8) deaths per 100,000 people, respectively (Table 2).

Transition in disease burden in the age-standardized death rate per 100,000 for the top 30 leading causes of death between 2017 and 2040 is shown in Figure 5. Significantly larger reductions, 50% and more occurs for diarrheal disease (50%), tuberculosis (76%), Meningitis (52%), protein-energy malnutrition (69%). Lower respiratory infection (28%) and HIV/AIDs (35%) also show declining. NCDs in the top 10 leading category show reductions; ischemic heart disease by 39%, stroke by 46%, diabetes by 3%, whereas prostate cancer increases by 18%.

Crude YLL rates and percentage changes

In 2040, the all-cause crude YLL rate was 14223.2 per 100,000 people (95% UI: 11000.3-18499.7) of which CMNNDs caused 28.1% (5524.9 per 100,000 people (95% UI: 3754-7866.6), NCDs caused 60.8% (6725.8

(95% UI: 5231.6-8461.8) per 100,000 people, injuries caused 11% (1972.5 per 100,000 people (95% UI: 1479.2-2568.1) (Table 3). The crude YLL per 100,000 people showed 70% reductions for CMNNDs,  12% and 23%, for NCD and injuries respectively. All CMNNDs level two causes showed 55 to 85% reduction in crude YLL rates. Cardiovascular disease and diabetes causes declines by 21 and 5%, respectively, while neoplasm increased by 12%, mental and substance use disorder by 17% and neurological disorders increases by 2% between 2017 and 2040. Unintentional injuries declines by 47%, however transport injury increased by 11% in the same period.

Age-standardized YLL rates and disease burden transitions

In 2040, the all-cause age-standardized YLL rate was 19023.2 (95% UI: 14223.8-25077.7), of which CMNNDs caused 6496.1 per 100,000 people (95% UI: 4322.6-9529.3), NCDs caused 10332.3 per 100,000 (95% UI: 7695-13683) and Injuries caused 2194.7 per 100,000 people (95% UI: 1647.3-2836.8) (Table 4). The age-standardize YLL percentage contribution of CMNNDs declined from 62.4% in 1990, 45% in 2018 and 34% in 2040, whereas NCDs contribution increased from 25.2% in 1990, 46% in 2019 and 54% in 2040 (Figure 4).  NCDs are the leading causes of age-standardized YLL rates between 2019 and 2040, as indicated in Figure 6).  The top 20 leading causes accounted 64% of the total age-standardized YLL rate in 2040 (Figure 5). In 2040, 10 of the 20 leading causes were NCDs. The top five leading causes were lower respiratory infections, Ischemic heart disease, diarrheal diseases, stroke, and road injuries causing 1665.6(95% UI: 921.9-2634.2), 1493.6(95% UI: 788-2482.6), 1211.5(95% UI: 334.3-2912.7), 951.3(95% UI: 560.8-1650.6), and 742.9(95% UI: 525-1032.7) per 100,000 people, respectively.

Discussions

Ethiopians average life expectancy is expected to increase significantly with females’ gaining more than male between 2017 and 2040. Mortality due to NCD and injuries are expected to show smaller reduction compared to CMNNDs. NCDs continue being the leading causes of age-standardized death rate from 2017 through 2040. Of the CMNNDs, the age-standardized deaths due to diarrheal disease, tuberculosis, meningitis and protein-energy malnutrition are expected to decline by half or more, whereas lower respiratory infections and HIV/AIDS showing one third or less decline from the rates in 2017 to 2040. During the same period, cardiovascular diseases declines by 37%, neoplasms by 8%, diabetes by 3%. In the contrary, prostate cancer is expected to increase by 18%. In 2040, twenty leading causes account for 72% of the total age-standardized death rates and six of 10 leading causes are NCDs. The five leading causes of age-standardized death rates are ischemic heart disease, lower respiratory infections, diarrheal disease, stroke and diabetes. In terms of premature mortality, NCDs are expected to be the leading causes of age-standardized rate from 2017 through 2040. Percentage contribution of CMNNDs to the total premature deaths will decline from 47% in 2017 to 34% in 2040. By contrast, the contribution of NCDs is expected to increase from 44% in 1990 and 54% in 2040. The top twenty leading causes accounts for two thirds of the total age-standardized premature mortality in 2040. In 2040, 10 of the 20 leading causes of premature mortality rate expected to be NCDs. The top five leading causes of premature mortality are lower respiratory infections, Ischemic heart disease, diarrheal diseases, stroke, and road injuries.

Policy Implications

Conclusions

Ethiopians average life expectancy is expected to increase. This major gain in life expectancy is expected to be attributed to further reductions in under-five child mortality and decline in burden of major communicable, maternal and nutritional diseases. However, more gains could be expected postponing death from non-communicable disease and injuries. Ethiopia is more likely to achieve the success of lower middle income countries in terms of life expectancy; neonatal, child and maternal mortality rates; eradicating malaria, tuberculosis and HIV/AIDS causes of mortality however less likely to achieve the success of UMICs by 2040.  Non-communicable disease and injuries are expected to show smaller reduction and expected to be leading causes of age-standardized death rate from 2007 through 2040. Ethiopia is using UHC approach to address health inequalities with different segments of the population and addressing the largest share of unmet health-care needs due to financial hardship. The cornerstone of these strategy would be having an equitable and effective primary health care system that provides free access to high-quality primary and secondary care for prevention and treatment, and uses regulation and economic tools for substantially reducing tobacco and harmful alcohol use. The health-care need to go beyond simply increasing the number of facilities and personnel, and should consider how and where care is delivered including considering a more integrated care provided in the community setting to reduce the double burden of communicable and non-communicable diseases.

Abbreviations

Declarations

Ethics approval and consent to participate

     Not Applicable

Consent for publication

    Not Applicable

Availability of data and material

  Not Applicable

Competing interests

 The authors declare that they have no competing interests

Funding

The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Authors' contributions

AM conceptualized, designed and wrote the manuscript and AH, SA, AW, SZ, MN, EA, CJ critically review the manuscript and provided significant intellectual contribution for the manuscript.

Acknowledgements

 Not Applicable

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Tables

Table 1: Crude Death Rates (CDR) per 100,000 for both sex and all age groups in 1990, 2007, 2017,2040

Table 2: Age-standardized death rates (ASDR) per 100,000 for both sex and all age groups with level one and two categories, 1990, 2005, 2017, 2040

Table 3: Crude YLL rates per 100,000 peoples for both sex and all age groups with level one and two categories, from 1990,2005,2017,2040

Table 4: Age-standardized YLL rates per 100,000 peoples for both sex and all age groups with level one and two categories, from 1990, 2005, 2017, 2040