NCD mortality
In 2016 Mauritius sustained a total of 10 022 deaths from all causes [2]. About 8,893 (88.7%) were from NCDs; 647 (6.5%) from communicable, maternal, perinatal and nutritional conditions; and 481 (4.8%) from injuries [2]. Figure 2 shows number of deaths caused by various NCDs in 2016. About 37.5% of NCD deaths resulted from cardiovascular diseases; 26.7% from diabetes mellitus; 13.8% from malignant neoplasms (cancers); 10% from respiratory diseases; 4.1% from digestive diseases; 2.4% from genitourinary diseases; 1.8% from neurological conditions; 0.9% from endocrine, blood, immune disorders; 0.7% from mental and substance use disorders; 0.7% from congenital anomalies; 0.7% from other neoplasms; 0.6% from skin disease; 0.2% from musculoskeletal diseases; 0.03% from oral conditions; and 0.01% from sudden infant death syndrome. Thus, cardiovascular diseases, diabetes mellitus, malignant neoplasms (cancers) and respiratory diseases accounted for 88% of NCD-related deaths.
Figure 3 depicts trend of age-standardized death rate per 100 000 by cause in Mauritius. Between 2005 and 2016 mortality rates due to cardiovascular diseases, diabetes, malignant neoplasms and respiratory diseases increased by 9.58%, 31.54%, 40.54% and 16.13% respectively. The probability of dying between ages 30 and 70 years from any of the 4 main NCDs (cardiovascular diseases, cancer, diabetes, chronic respiratory diseases) was 22.5% in Mauritius in 2015 compared to around 10% in developed countries like Australia, France, Singapore and UK [54].
NCD morbidity and risk factors
In 2015, the standardized prevalence of type 2 diabetes in Mauritian population aged 20–74 years was 20.5% with a slightly higher proportion among women (21.3%) compared to men (19.6%). New cases of cancer increased from 1,800 (729 males and 1,071 females) in 2011 to 2,607 (1,058 males and 1,549 females) in 2016, representing an increase of 44.8% in 5 years. The prevalence of asthma in adults was 8.9%, that is 8.0% in men and 9.7% in women. Albuminuria, an index of kidney disease, was detected in 6.8% (7.1% of men and 6.6% of women) of the 2015 population survey compared to 12.4% in 2009 [55,56].
Risk factors
According to WHO [42] majority of NCDs emanate from four specific behaviours (harmful use of alcohol, tobacco use, physical inactivity, and unhealthy diet) that lead to four key metabolic/physiological changes (raised cholesterol, raised blood pressure, overweight/obesity and raised blood glucose). Figure 4 shows the trends of raised blood pressure (SBP> = 140 OR DBP> = 90), raised fasting blood glucose (> = 7.0 mmol/L or on medication), overweight (BMI = >25) among adults aged 18 years and above, and overweight (BMI = >25) among children and adolescents aged five to nine years.
Metabolic/physiological factors
Hypertension: The percentage of people aged 18 years and above with raised blood pressure decreased slightly from 26.4% in 2000 to 25% in 2015 [57].
Lipids: In 2015, the overall prevalence of elevated serum total cholesterol (≥ 5.2 mmol/L) was 44.1 % (47.1% for men and 41.8% for women), compared to 34.7% in 2009 [55].
Fasting blood glucose: The population of adults aged 18 years and above with raised fasting blood glucose increased from 11.4% in 2000 to 13% in 2014 [58–61].
Overweight: The World Health Organization defines overweight in adults as a body mass index (BMI) greater than or equal to 25, and obesity as a BMI greater than or equal to 30. In 2016, 32.3% (24.3% male and 39.8
% female) aged 18 years and above were overweight compared to 26% (19.9% male and 31.5% female) in 2000 [59]. A study conducted among 841 school children aged 9–10 years found 17.4% were overweight, 5.0% obese, and 12.7% thin [60]. The prevalence of overweight (BMI > +1 standard deviations above the median) among children and adolescents increased from 8.1% in 2000 to 14.6% in 2016, accounting for an 80.2% increase [61].
Behavioural risk factors
Harmful use of alcohol: In 2016 total pure alcohol consumption per person aged 15 years and older was equal to 3.6 litres (male 6.3 litres and female 1 litre) compared to 3.8 litres (male 6.6 litres and female 1.1 litre) in 2010. About 54% of persons aged 15 years and older consume beer, 31% spirits and 15% wine. Drinkers only consumed an average of 11.5 litres of pure alcohol in 2016 [62].
Tobacco use: Figure 5 shows trends in tobacco smoking among persons aged 15 years and above in Mauritius. Age-standardized prevalence of current tobacco smoking among persons aged 15 years and older in 2015 was 21.2% in Mauritius compared to African Region average of 13.9% [63,64]. The current tobacco smoking among males aged 15 years and over was 12.5 fold that of females in 2015. The current tobacco smoking for both sexes decreased by 17.8% between 2000 and 2015.
Salt/Sodium Intake: The age-standardized mean population salt intake (sodium chloride) was 14 grams per day in Mauritians aged 18 years and older in 2010 [65]. This is almost three times the WHO recommended daily salt intake of 5 grams per person [42]. A high level of salt intake is associated with high blood pressure and a greater risk of cardiovascular diseases [66].
Physical inactivity: In 2016, 29.8% (male = 27.6% and female = 31.8%) of adults aged 18 years and above were insufficiently physically active in Mauritius compared to African Region average of 22.1% (male = 18.4% and female = 25.6%) and European Region average of 29.4% (male = 26.2% and female = 32.4%) [67].
Coverage of core population and individual NCD interventions and services in Mauritius
Table 4 summarizes the assessment team’s evaluation (on a three-point scale, extensive, moderate or limited as per criteria given in the WHO assessment guide) of 24 core population-based interventions geared towards tackling the four main risk factors for NCDs, that is tobacco smoking, harmful alcohol use, unhealthy diet and physical inactivity.
[Insert Table 4 here]
About 4 (16.7%) of the interventions were rated extensive, 9 (37.5%) moderate and 11 (45.8%) limited. Out of the six antismoking interventions, two were rated extensive and four moderate. Out of the six interventions to prevent harmful alcohol use, one was rated extensive, one moderate and four limited. Of the six interventions to improve diet, one was rated extensive, two moderate and three limited. Of the six interventions to promote physical activity, none was rated extensive, two were rated moderate and four were rated limited. According to the assessment team’s rating Mauritius still needs to invest more in scaling up the coverage of population NCD control interventions to the extensive level.
Table 5 encapsulates the assessment team’s evaluation (on a three-point scale, as extensive, moderate or limited based on criteria given in the WHO Assessment guide) of the 15 core individual services for controlling cardiovascular diseases (CVD), diabetes and cancer.
[Insert Table 5 here]
Three (20%), eight (53%) and four (27%) of the 15 individual NCD services were rated extensive, moderate and limited respectively. With regard to CVD, effective primary prevention in high-risk groups and secondary prevention after AMI (including acetylsalicylic acid) were rated extensive; effective detection and management of hypertension, and rapid response and secondary care after AMI and stroke were rated moderate; and risk stratification in primary health care was rated limited. All the individual services for diabetes (detection and general follow-up, patient education, hypertension management and prevention of complications) were rated moderate. In the case of cancer first line services, prevention of liver cancer through hepatitis B immunization was rated extensive, and screening for cervical cancer and treatment of precancerous lesions were rated moderate. About the four cancer second line services, only vaccination against human papilloma virus was rated extensive; with the early case-finding for breast cancer and timely treatment of all stages, population-based colorectal cancer screening, and oral cancer screening coverage rated limited.
Health system opportunities to scale up core NCD interventions and services
In this subsection we present an analysis of the 15 health system features contained in Table 3.
Political commitment to NCDs, explicit priority-setting approaches and interagency cooperation: The Mauritius Government’s political commitment to continually improve the level and distribution of health is clearly expressed in Mauritius Vision 2030 [16], Government Programme 2015–2019 [68], MOHQL vision and mission statement [69] and health sector strategy 2017–2021 [20]. The MOHQL mission is to create a modern high-performing quality health system that is patient centred, accessible, equitable, efficient (uses available human, financial and physical resources without waste) and innovative (using the full potential of information and communications technology) [20].
The main objective of the health sector strategy is “to ensure the enhancement of health sector development in the Republic of Mauritius, including Rodrigues and the Outer Islands, in order to attain positive health outcomes for the individual, the family, the community and the economy at large” (p.21) [20]. In relation to NCDs and health promotion, Mauritius strategic objective is to reduce the burden of premature morbidity, mortality and disability associated with NCDs and their risk factors [20].
The Government has enacted various public health legislations targeting various NCD risk factors. For instance, the 2008 public health regulations which prohibit advertisement, sponsorship and sale and consumption of alcoholic drinks in public places [70]. Another set of public health regulations that came into force in March 2009 imposed restrictions on tobacco products; and was reinforced by the June 2018 Mauritius accession to the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products [71]. The Minister of Health and Quality of Life published the Government Gazette of Mauritius No. 74 of 15 August 2009 entitled “Food (Sale of Food on Premises of Educational Institutions) Regulations 2009”, which specifies the types of food which may be sold on the premises of educational institutions (pre-school, primary school, secondary school or pre-vocational school) [72].
In terms of priority-setting, current budget allocation to the MOHQL is divided into five major subheads: general, curative services, primary health care and public health, treatment and prevention of HIV and AIDS, and prevention of noncommunicable diseases and promotion of quality of life (see Table 6). Budget allocation is based on the proposal estimates from the MOHQL through an existing Committee chaired by the focal point of the Ministry of Finance and Economic Development in the MOHQL.
[Insert Table 6 here]
Between 2016/17 and 2019/20 total government expenditure increased from Rs 10.9 to 12.3 billion, representing a 13% increase. During the same period expenditure on prevention of NCDs and promotion of quality of life grew from Rs 106.8 million to Rs 137.3 million, accounting for a 29% increase. The country has undertaken a number of national health accounts (NHA) studies [10,37] and is currently institutionalizing NHA to facilitate tracking of health expenditures over time. The information is useful in determining whether allocation of financial resources reflects the stated health priorities.
The MOHQL recognizes that multi-sectoral action and partnerships are crucial for core interventions and services to have the greatest impact on NCD outcomes; the MOHQL is forming close partnerships with other sectoral ministries and national institutions; and with UN agencies, diplomatic missions, and civil society organizations including NGOs, the media and other relevant stakeholders [20]. For example, the Ministry of Education and Human Resources, Tertiary Education and Scientific Research has been an important partner in the prevention strategies which include health education, screenings and referrals, sale of healthy food items in school canteens, human papilloma virus (HPV) vaccination, etc.; the Ministry of Social Security, National Solidarity and Environment and Sustainable Development has been a partner particularly in providing preventive, promotive, curative and rehabilitative services to older people and people with disabilities; the Ministry of Agro Industry and Food Security is also collaborating with the MOHQL to ensure food security and safety and to encourage consumers to change their eating habits; the Ministry of Youth and Sports is promoting physical activities by providing incentives for purchase of sports equipment, increasing accessibility of sports infrastructure to the general public and allocation of grants to sports clubs; the Ministry of Gender Equality, Child Development and Family Welfare is organizing regular talks and sensitization campaigns on healthy eating habits, physical activities and cancer through the network of women centres in the island.
Regarding civil participation, several NGOs active in the health sector wish to have closer cooperation, better communication and more exchange with the MOHQL and create more synergy through joint government/NGO efforts. Furthermore, the MOHQL holds consultations with UN agencies on effective policy development, implementation, and service delivery regarding NCDs.
Coordination across providers, effective model of service delivery and effective management: The coordination across providers at the different levels of care in Mauritius such as home care, primary health care, and emergency care, regional and specialized hospitals is patient-focused with a referral system addressing the needs of NCD patients. Multidisciplinary cooperation is good and effective at facility level, and patients attending primary health-care (PHC) centres are seen by a multidisciplinary team of health professionals which includes community physicians, medical and health officers, nutritionists, diabetes specialized nurses and health-care assistants, amongst others. In principle, patients visit a primary health-care provider at a community health centre/area health centre for non-emergencies, and if necessary, are referred for specialist care. It is the responsibility of the community physician to make the link between PHC and hospital settings. These cases are referred back to primary care for follow-up once the conditions of the patients are stabilized and each patient has an NCD case sheet whereby the personal data, family history, personal history and life style such as smoking and alcohol habits are recorded. In terms of effective management, a performance management system is the only performance-based system for promotional and incremental incentives and a scoring system focusing on various key tasks which is filled out every year.
Regionalization and access to quality medicines:The overall public health-care system is well structured with three distinct levels of care, namely primary, secondary and tertiary. Effective regionalization of care has been achieved with a regional hospital and an extensive PHC network in each of the five health regions with a defined catchment population [73]. There are no wide variations in availability and quality of services within regions [74]. Tertiary care hospitals are accessible within reasonable driving distance. There is also a 24-hour free public emergency ambulance service manned by doctors and nurses with specialized training in emergency medicine. Concerning access to quality of medicines, based on the WHO concept of Essential Drugs [75], the MOHQL has developed its own medicine list covering all pharmacological classes including specialized items [76]. The list is reviewed every two to three years by the Drug Formulary Committee to assess its adequacy and the list approved serves as a guide for medical officers at public health facilities for prescription of medicines using their generic names and for drugs that are not on the essential list on a case-by-case basis. The Hospital Drugs Committee set up at regional level evaluates such requests and advises on the purchase of drugs needed for specific cases. In addition, monitoring of prices of pharmaceutical products is carried out by relevant authorities. So far, no cases of malpractices have been found in this respect and a national pharmacovigilance committee has been set up under the aegis of MOHQL to collect and analyze data on any adverse drug reactions in relation to the prescription and use of drugs in the treatment and control of disease and reporting of suspected quality issues. Finally, public procurement of medicines is highly efficient in terms of procuring medicine at competitive prices and is able to reap the benefits of economies of scale.
Integration of evidence into practice and adequate information solutions
Research, surveys [55,56] and other databases on NCDs have been useful in providing local evidence for identifying more effective actions for combating NCDs. For example, the vaccination strategy against cervical cancer for young girls which started in 2016 was finalized after studies on HPV subtype prevalence done by the Central Health Laboratory and the Mauritius National Cancer Registry (MNCR) [77,78]. The Virtual Health Library (VHL) in Mauritius which was set up in 2015 by the MIH provides all public health professionals electronic access to scientific knowledge on health [79].
Research is complemented by other adequate information solutions, for instance, the civil registration systems. Morbidity conditions and mortality causes are coded according to the 10th Revision of the WHO International Classification of Diseases [80]. The Health Statistics Report published annually also contains information on population and vital statistics, infrastructure and personnel, morbidity, mortality and the activities of almost all health services pertaining to the Republic of Mauritius. Most importantly, NCD Surveys that have been regularly carried out during the last 30 years provide trends in the prevalence of NCDs and their risk factors and measure impact of actions taken previously [55,56]. Other surveys conducted periodically or on an ad hoc basis such as surveys on nutrition [81], salt intake [66,82], tobacco control [40,63,65,83,84], household out-of-pocket expenditure [36], risky behaviours in children [85] and adolescents [86,87] also provide key information that cannot be obtained from routine sources. Annual and four-year reports are published regularly from the National Cancer Registry [78]. Since 2015, Mauritius has been conducting NHA and it has since been institutionalized [10,37].
Distribution and mix of human resources, incentive systems and managing change: The key roles of the health workforce have been recognized by the MOHQL and recruitment and retention of qualified health personnel have always been a priority. The numbers in all categories of health professionals per 100 000 people, such as doctors, dentists, pharmacists, nurses have increased over time and human resources for health remunerations account for a high proportion of the budget (73%) assigned to the health sector [10]. To improve the skills of health workers, continuing professional development (CPD) has become mandatory for doctors; and creation of the Mauritius Institute of Health (MIH) has availed opportunities for continuing education for other health workforce cadres. In terms of incentives, health professionals receive their salaries and allowances based on recommendations—guided by position levels, years of service and complexity of responsibilities assigned—from the Pay Research Bureau (PRB), an institution responsible for reviewing the pay and grading structures and conditions of service in the public sector [88]. Mauritius is also promoting innovative and comprehensive reforms, for example several changes have been introduced successfully at PHC and hospital levels with a view to improving health services delivery, including the introduction of preventive measures for modifying behaviour and mitigating health risks.
Population empowerment and financial access and protection provision: Increasing health literacy is one of the priorities of the MOHQL for community empowerment and it has gone up over the last decade as reflected in increased awareness of potential health risks associated with smoking, alcohol consumption, unhealthy diet and physical inactivity. A Health Literacy Framework was developed by MOHQL in 2013; it incorporated the strengthening of the health literacy components of the different national action plans being implemented to reduce risk factors and premature mortality as well as a strategy to guide actions to improve health literacy across the life course [89]. In relation to access to health services and financial protection, all government health-care services including medicines and laboratory tests are free to users and are fully tax-funded. Given that public health services are provided free of charge to all, there are no formal or informal payments which deter utilization of core NCD services in government health institutions including diagnostics and follow-up. Financial burden does not currently constitute any barrier to scaling up core NCD interventions. However, according to the WHO World Health Statistics 2018, Mauritius has a universal coverage index of 64%, implying that there are other factors at play that account for suboptimal coverage of essential health services (including reproductive, maternal, newborn and child health, infectious diseases, and NCD health services) [6].