ADDRESSING THE IMPACT OF NONCOMMUNICABLE DISEASES AND INJURIES IN ETHIOPIA: FINDINGS AND RECOMMENDATIONS FROM THE NONCOMMUNICABLE DISEASES AND INJURIES (NCDI) COMMISSION OF ETHIOPIA A Collaboration with the Global Lancet Commission on Reframing NCDIs for the Poorest Billion Full Report Addis Ababa November 2018 Ethiopia NCDI Commission Report, November 2018 Page 0 Ethiopia NCDI Commission Report, November 2018 Page 1 TABLE OF CONTENTS FOREWORD ............................................................................................................................. 5 ETHIOPIA NONCOMMUNICABLE DISEASES AND INJURIES (NCDI) COMMISSION .................................................................................................................................................... 7 ACKNOWLEDGEMENTS ..................................................................................................... 11 ACRONYMS ........................................................................................................................... 13 EXECUTIVE SUMMARY ..................................................................................................... 15 SECTION 1: BACKGROUND AND POLICY CONTEXT................................................... 19 BACKGROUND ................................................................................................................ 19 POLICY CONTEXT ......................................................................................................... 21 SECTION 2: EPIDEMIOLOGY OF NON-COMMUNICABLE DISEASES AND INJURIES AND THEIR RISK FACTORS IN ETHIOPIA ...................................................................... 26 INTRODUCTION ............................................................................................................. 26 MATERIALS AND METHODS ...................................................................................... 26 RESULTS ........................................................................................................................... 27 1. BURDEN OF NON-COMMUNICABLE DISEASES AND INJURIES (NCDI) IN ETHIOPIA ....................................................................................................................... 28 2. PREVALENCE OF RISK FACTORS FOR NCDIs ................................................... 32 3. PREVALENCE OF MAJOR NCDIs IN ETHIOPIA .................................................. 38 DISCUSSION AND CONCLUSIONS ........................................................................... 51 SECTION 3: EXISTING SERVICES FOR NONCOMMUNICABLE DISEASES AND INJURIES ................................................................................................................................ 57 SECTION 4: ESSENTIAL INTERVENTIONS FOR NON-COMMUNICABLE DISEASES AND INJURIES....................................................................................................................... 63 NUTS AND BOLTS OF THE NATIONAL PRIORITY SETTING PROCESS IN THE COMMISSION ......................................................................................................... 63 PRIORITY SETTING FRAMEWORK .......................................................................... 64 THE PRIORITY SETTING PROCESS .......................................................................... 65 RESULTS OF THE PRIORITY SETTING PROCESS (STEP 1-3) ............................ 69 ESTIMATED IMPACT OF NCDI INTERVENTIONS ON LIFE EXPECTANCY AND DEATHS AVERTED ............................................................................................... 77 SECTION 5: INTEGRATION OF NCDI SERVICES INTO THE EXISTING HEALTH CARE SYSTEM ...................................................................................................................... 80 INTRODUCTION ............................................................................................................. 80 HEALTH SYSTEM STRENGTHENING IS KEY FOR ENSURING UHC FOR NCDS AND INJURIES IN ETHIOPIA ........................................................................... 80 SECTION 6: FISCAL SPACE, RESOURCE GENERATION AND MOBILIZATION, FINANCING............................................................................................................................ 92 FISCAL SPACE AND BUDGET EXPANSION............................................................. 92 Ethiopia NCDI Commission Report, November 2018 Page 2 BUDGETARY ROOM FOR EXPANDING TOTAL HEALTH EXPENDITURE .... 92 BUDGETARY ROOM FOR EXPANDING HEALTH EXPENDITURE FOR NCDIS SERVICES ......................................................................................................................... 95 RESOURCE GENERATION AND MOBILIZATION ................................................. 97 SECTION 7: KEY FINDINGS AND RECOMMENDATIONS ............................................ 99 KEY FINDINGS: ............................................................................................................... 99 RECOMMENDATIONS: ............................................................................................... 102 REFERENCES ...................................................................................................................... 105 LIST OF TABLES TABLE 1: NCDI RELATED MORTALITY BY AREA OF RESIDENCE ...............................................................................................29 TABLE 2: PREVALENCE OF RISK FACTORS FOR NCDS IN ETHIOPIA BY GENDER, AREA OF RESIDENCE AND WEALTH STATUS.................33 TABLE 3: PREVALENCE OF NCDS IN ETHIOPIA. ..................................................................................................................41 TABLE 4 : AGE-STANDARDIZED INCIDENCE RATES (ASIR) PER 100,000 POPULATION AND ESTIMATED NUMBER OF CASES IN 2015 FOR THE MOST COMMON CANCER TYPES IN ETHIOPIA IN ADULTS (15+) .............................................................................43 TABLE 5: ESTIMATED NUMBER OF CHILDHOOD CANCER CASES NATIONALLY IN 2015 IN ETHIOPIA. ..............................................43 TABLE 6 : PREVALENCE OF ASTHMA AND ASTHMA SYMPTOMS IN ETHIOPIA ............................................................................47 TABLE 7 : DISTRIBUTION OF TYPES OF INJURIES IN ETHIOPIA: HOSPITAL-BASED DATA ................................................................48 TABLE 8 : ACCESS AND READINESS OF HEALTH FACILITIES FOR NCDIS SERVICES IN ETHIOPIA ......................................................59 TABLE 9: INCREMENTAL COST OF SCALING UP CANCER INTERVENTIONS AND THEIR COST EFFECTIVENESS, LISTED BY DELIVERY PLATFORM, 2019-2023.....................................................................................................................................70 TABLE 10: INCREMENTAL COST OF SCALING UP INTERVENTIONS FOR DIABETES, CARDIOVASCULAR AND CHRONIC RESPIRATORY DISEASES AND THEIR COST EFFECTIVENESS LISTED BY DELIVERY PLATFORM, 2019-2023. ..............................................................71 TABLE 11: INCREMENTAL COST OF SCALING UP INTERVENTIONS FOR MENTAL, NEUROLOGICAL, AND SUBSTANCE USE DISORDERS AND THEIR COST EFFECTIVENESS LISTED BY DELIVERY PLATFORM, 2019-2023. ....................................................................72 TABLE 12: INCREMENTAL COST OF SCALING UP ESSENTIAL SURGICAL INTERVENTIONS AND THEIR COST EFFECTIVENESS LISTED BY DELIVERY PLATFORM, 2019-2023. ......................................................................................................................73 TABLE 13: MULTI-SECTORAL AND POLICY INTERVENTIONS FOR THE PREVENTION OF NONCOMMUNICABLE DISEASES AND INJURIES ..73 TABLE 14: INCREMENTAL COSTS BY MAJOR CATEGORY, 2019-2023. COSTS ARE REPORTED IN $1,000 USD. .............................76 TABLE 15: ESTIMATED IMPACT OF NCDI SERVICES ON LIFE EXPECTANCY AND DEATHS AVERTED .................................................78 TABLE 16: NCDI SERVICES THAT COULD BE DELIVERED AT COMMUNITY LEVEL BY HEALTH EXTENSION WORKERS. ...........................88 TABLE 17: NCDI SERVICES THAT COULD BE DELIVERED AT HEALTH CENTERS ...........................................................................88 TABLE 18: NCDI SERVICES THAT COULD BE DELIVERED AT PRIMARY HOSPITALS .......................................................................90 TABLE 19: NCDI SERVICES THAT COULD BE DELIVERED AT REFERRAL AND SPECIALIZED HOSPITALS...............................................91 TABLE 20:ASSUMPTIONS FOR HEALTH EXPENDITURE PROJECTIONS .......................................................................................94 TABLE 21: POSSIBLE BUDGET EXPANSION FOR NCDIS (US$ PER CAPITA) FOR THE FIRST FIVE YEARS (2019-23) AND UP TO 2030. ..97 LIST OF FIGURES FIGURE 1: PARTIAL VIEW OF THE FIRST MEETING OF THE NATIONAL NCDI COMMISSION OF ETHIOPIA, AUGUST 9, 2016. .............. 8 FIGURE 2: MEMBERS OF THE NATIONAL NCDI COMMISSION OF ETHIOPIA, AUGUST 9, 2016 ..................................................10 FIGURE 3: FLOW DIAGRAM OF STUDIES REVIEWED, SCREENED AND INCLUDED. .....................................................28 FIGURE 4: CAUSES OF DEATH IN ETHIOPIA 2016, ALL AGES AND BOTH SEXES(N=677,269) (SOURCE: IHME) .............................29 FIGURE 5:DISTRIBUTION OF MORTALITY AND INJURIES IN ETHIOPIA 2016, ALL AGES AND BOTH SEXES (SOURCE: IHME) ...............30 FIGURE 6: MORTALITY DISTRIBUTION BY CAUSE AND AGE IN ETHIOPIA, 2016 (SOURCE: IHME): ...............................................30 FIGURE 7: DISEASE BURDEN (DEATHS AND DISABILITY COMBINED = DALYS) FOR ALL MAJOR