Hidden in Plain Sight: Africa’s Multimorbidity Crisis

PLOS Global Public Health is delighted to share a new collection of papers curated by representatives of the Africa Multimorbidity Alliance. Below the authors draw out key characteristics of Africa’s multimorbidity crisis from the Collection’s papers and the challenge it presents both for, and to, global health.

Introduction

Multimorbidity – commonly defined as the co-occurrence of two-or-more long-term conditions in one person – is rising globally, reflecting both increased longevity and persistent health inequalities.(1) How to recognise, prevent, and manage the diverse range of multimorbidity is a major challenge. The health systems of low- and middle-income countries, including in Africa, are particularly unprepared.(2) Such systems remain under-resourced, dependent on increasingly undependable global health funding – as recent aid cuts have made all too clear – and oriented ‘vertically’ toward single infectious diseases. This has obfuscated the syndemic interactions of persisting chronic infectious and rapidly rising non-communicable diseases (NCDs) and the complex health and social burdens these engender.(3,4)

Agenda-setting initiatives have identified urgent research needs for responding to multimorbidity in a global context, including specifically in sub-Saharan Africa.(5) We need context-specific concepts and models; better data about its burden and determinants; integrated treatment and prevention approaches; and the restructuring of health systems. Cross-disciplinary research shows that multimorbidity in Africa manifests differently in many respects – epidemiologically, socially, and structurally – from the global North. This research also makes clear the profound challenge multimorbidity poses both for, and to, global health. The tendency of global health actors to tackle diseases one-at-a-time through undependable, unsustainable vertical models has directly impeded the ability of health systems to recognise and respond to the emerging multimorbidity crisis.(6,7) Those seeking to make multimorbidity visible and actionable face entrenched hierarchies and divisions between disciplines and diseases and unidirectional North-to-South knowledge flows. Whilst interest in multimorbidity research is growing, there is a lack of prioritisation by many funders, and opportunities to place knowledge, experience, and best practice into conversation are relatively few, limiting opportunities for collective learning.

This Collection in PLOS Global Public Health brings together original research seeking to conceptualise, make visible, and advocate for urgent action to confront the multimorbidity crisis in Africa. Several pieces come from partners within the Africa Multimorbidity Alliance, a cross-disciplinary community of practice to support learning about multimorbidity across African contexts. A common thread running through many of the articles is the commitment to decolonising concepts and framings of multimorbidity. This means not only recognising that multimorbidity manifests differently in African contexts from high-income settings in the global North,(8) but decentring diseases altogether and placing the values, needs, and lived realities of those affected by multimorbidity at the concept’s theoretical centre. The articles are grouped into four main themes: expanding the multimorbidity concept; multimorbidity epidemiology; burden of treatment and inaccessibility; and health systems and service integration. Within these themes, some articles are grouped as dialectic ‘pairs’, comparing and contrasting findings from different settings to optimise cross-country learning. Key messages across the articles are presented in Box 1.

Expanding the multimorbidity concept

The first article in the Collection represents the most substantial collaborative initiative by the Alliance. Dixon et al. developed an expanded conceptual model of multimorbidity that expands the predominant focus on disease clustering and interactions to capture its wider complexity, bio-social determinants, and common consequences for people living with multimorbidity (PLWMM) (Fig 1). Drawing from the syndemic framework,(4) complexity theory,(9) and burden of treatment theory,(10) the model is dynamic and relational, highlighting how biological, social, health systems, and broader structural factors intersect to co-produce multimorbidity. Here multimorbidity interactions are non-linear: on the one hand PLWMM are often pushed past ‘tipping points’ towards severe and complex multimorbidity, with wide-reaching impacts across their social network and wider health system; equally even modest, well-placed changes in social context can make multimorbidity more manageable. One implication of the model is that engaging multimorbidity requires integration of multiple disciplines and perspectives –  including epidemiology, social science, health systems research, and, of course, voices of affected communities.

Fig 1. An expanded conceptual model of multimorbidity (from Dixon et al.)

Multimorbidity epidemiology

The next group of articles present novel approaches to understanding multimorbidity clusters, as well as their burden and determinants, in a diversity of African settings. The first pair of articles demonstrate the potentials and challenges of describing the epidemiology of multimorbidity in settings where data are scarce, unstandardised, and often single disease focused. Combining cohort datasets from Malawi (urban and rural), Uganda (rural), and The Gambia (rural), Price et al. investigated a range of long-term communicable and NCD condition clusters. Multimorbidity was strongly associated with ageing in all settings, although highest in Malawian women, and with higher educational attainment in Malawi and Uganda. A key limitation of these analyses is that many morbidities, such as mental health conditions, are not being collected as part of routine cohort data. The authors conclude the need for robust population-level data capturing a wide variety of long-term conditions, ensuring diversity and proportionate representation from men and women and urban and rural areas. The second article by Nkoka et al. presents findings from a cross-sectional study in urban and rural Malawi, demonstrating a significant association between physical health multimorbidity and depression and anxiety. These results underscore the importance of integrating mental health into the broader management of multimorbidity to enhance overall health outcomes. By including often-overlooked components of multimorbidity, such as mental health and chronic pain, this research provides a more comprehensive understanding of how multimorbidity impacts quality of life (QoL). 

The next pair of articles more explicitly attend to QoL. In a multi-facility study in Ethiopia, Eyowas et al. found that a third  of study participants had poor QoL. Advanced age, obesity and multimorbidity were associated with poor QoL. Conversely, perceived social support and satisfaction with care were associated with better QoL across different condition clusters. Otieno et al., meanwhile, studied the association between different cardiometabolic multimorbidity combinations with healthcare utilization and QoL in Ghana. Similar to Eyowas et al., they found that multimorbidity was associated with higher rates of healthcare utilization and lower QoL, with the cluster of ‘cardiopulmonary disease and depression’, associated with the most frequent outpatient attendances, lowest QoL, and highest risk of hospitalization compared to other clusters. Both articles show that multimorbidity has considerable impacts on QoL and, echoing Nkoka et al., that mental health is an important component of multimorbidity and driver of poor QoL.

The final article in this theme by Calderwood et al. showed that multimorbidity is common not only within the wider population, but particularly in working age people (in this case, healthcare workers). Using data from an occupational health intervention during COVID-19 that included screening for chronic conditions, the authors described the epidemiology of multimorbidity among health workers of multiple cadres in Zimbabwe. Half of healthcare workers screened were living with a chronic condition, and one in seven of these had multimorbidity. Perhaps surprisingly given their healthcare employment, most conditions other than HIV were either undiagnosed or untreated. The authors concluded that multisectoral action to implement contextually relevant chronic disease services in Africa is urgently needed; along with specific attention to health workers to protect and retain this critical workforce.

Burden of treatment and its inaccessibility

The next pairing of articles used qualitative methods including in-depth interviews and ethnographic fieldwork to gain insights into the lived experience of multimorbidity from the perspective of patients and carers. Chikumbu et al. investigated the burden of treatment faced by PLWMM in urban and rural Malawi. They highlight many experiences of multimorbidity that elude other quantitative methodologies: coming to terms with and gaining an understanding of life with multimorbidity; dealing with disruptions to family life; the work of seeking family and community support; navigating fragmented care systems; coping with lack of continuity of care; enacting self-management advice; negotiating medical advice; appraising treatments; and importantly, dealing with the burden of lack of treatments. The paradoxical burden of lack rarely appears in conceptualisation of treatment burden but is one of the most important in extremely low-resource settings.

The second article by Van Pinxteren et al. demonstrates that the roles of, and burden placed on, informal carers are crucial to consider within our framings of multimorbidity. Focusing on urban and rural South Africa, the authors explored how informal caregiving networks impact the capacity of PLWMM to manage their conditions. Informal carers, they found, provide a variety of roles that increase ‘self’-management capacity, including emotional, logistical, health services, and informational support. Additional support networks, access to grants or financial security, and feeling a duty to care eased the perceived carer burden while a lack of social support, financial hardship and insufficient information decreased their capacity to support others. The authors conclude the importance of interventions that actively support informal caregivers, which may enable the development of solutions that optimize the role of informal care networks and ensure sustainability, with a view to improving the health outcomes of PLWMM in South Africa and other sub-Saharan African contexts. 

Image credit: Participant explains the challenges of obtaining multiple medicines from a private pharmacy due to frequent stockouts in their local public clinic. Taken by Fionah Mundoga For the Wellcome Trust funded KnowM study, Zimbabwe

Health systems and service integration

The final collection of papers tackles the health system implications of multimorbidity. The first by Karanja et al. examines the case of post-TB care, against the backdrop of a historic emphasis in TB management on disease contagion and control at the expense of sequela including lung damage and co-morbidities. Using stakeholder mapping and in-depth interviews, the authors identified the importance of providing holistic care for TB patients addressing both TB comorbidities and sequelae. Challenges to holistic post-TB care include uncertainty around the burden of post-TB morbidity, leadership of post-TB services, funding constraints, staff and equipment limitations, and the need for improved integration between national TB and NCD programmes for care provision and oversight. They conclude the need for pilot studies of models of integrated TB care and for cross-learning between countries and from albeit fledgling HIV-NCD services. The study highlights the value of a multimorbidity lens for challenging boundaries between communicable and non-communicable which have shaped the way services have evolved.

Similarly seeking to expand health system capacities for chronic care from HIV and TB towards NCDs, the next pair of papers present qualitative research in the context of some of the most established programmes in integrated chronic care in Africa. Naanyu et al. consider the Primary Health Integrated Care for Four Chronic Conditions (PIC4C) model in Kenya, examining the extent to which the programme’s goals to provide decentralised, integrated care for hypertension, diabetes, breast and cervical cancer supported people living with these conditions. They highlight the role of inter-related social and economic contextual factors in shaping interactions with services and show that the intervention helped to facilitate linkage to care and reduce costs. However, retention and adherence were affected by the wider system context, including inconsistencies in medication availability and financial constraints for patients. Some challenges were mitigated through tailored advice from health care workers, who could be better supported to adopt flexible, contextually responsive approaches. Also highlighting the real-world implementation challenges of integrated chronic care, Bukenya et al. evaluated the Management of Chronic Conditions in Africa (MOCCA) programme in Uganda which provided integrated chronic care for HIV, diabetes, and hypertension rather than typically ‘vertical’ services. Observed benefits including reduced transport costs by avoiding multiple clinic visits, reduced stigma from HIV, and better access to medicines, while sustaining the provision of ART services. However, NCD medicines supplies were buffered during the study period, warning that these challenges, as in Kenya, remain. Both papers demonstrate the potential benefits of integrated chronic care; however, sustaining these models in practice will require addressing demand-side socio-economic challenges and wider systemic disparities, especially in NCD medicine supply chains.

The final article by Dixon et al. shifts the focus to the wider health system and global health context that shapes possibilities for integrated chronic care. Using ethnographic research in Zimbabwe, they show how fragmented, unevenly-resourced chronic care reflects wider systemic siloes and hierarchies, from vertical, externally-driven funding and policy; to parallel research, health information, and monitoring and evaluation (M&E) systems; to single disease clinical training, guidelines, and service delivery models. Multimorbidity is invisible in structures of upward reporting beyond a couple of specific HIV-related comorbidities, while ground-level voices remain sidelined in decision-making. Stakeholders recommended a more decisive push to integrate and expand services beyond the current emphasis on integrating NCDs into HIV. To avoid reproducing unsustainable vertical programme models, there is need to build a more integrated, domestically-driven learning environment for the development of new integrated care models, feeding in a wider variety of knowledge than typically recognised in evidence-based global health. Multimorbidity is complex and evolving, requiring dynamic, adaptive health systems. There is a danger in adopting interventions to address multimorbidity without concurrently addressing the wider vertical structures that multimorbidity has shown has reached its limit.

Image credit: In Zimbabwe, HIV is managed in dedicated “OI” clinics. Patients with HIV and NCD(s) must attend the OI clinic and outpatient department separately, leading to long waiting times and lack of coordinated care. Taken by Fionah Mundoga for the Wellcome Trust funded KnowM study, Zimbabwe

Conclusions

Rising to the multimorbidity crisis in Africa requires not only attentiveness to differential manifestations in this setting relative to the global North, but reflexive critique of the politics and practices of global health that have obfuscated multimorbidity and made it so challenging to recognise and respond to. At this critical moment of rupture in global health funding, the articles here represent a small Collection of ongoing efforts to confront entrenched legacies of vertical programming across disciplines, funders, and sectors and to make multimorbidity visible to our systems of research, decision-making, and service delivery. Multimorbidity is complex, evolving and requires health systems that are equal to it; this can be supported by the kind of research presented in this Collection that embraces complexity and helps those working within low-resource health systems to overcome legacies and drive change.

Collection curators:

Edna Bosire (Aga Khan University, University of the Witwatersrand)

Amelia C. Crampin (Malawi Epidemiology and Intervention Research Unit, University of Glasgow, London School of Hygiene & Tropical Medicine)

Justin Dixon* (Biomedical Research and Training Institute, London School of Hygiene & Tropical Medicine)

Rashida A. Ferrand (Biomedical Research and Training Institute, London School of Hygiene & Tropical Medicine)

Celia L. Gregson (Biomedical Research and Training Institute, University of Bristol)

Felix Limbani* (Malawi-Liverpool-Wellcome Trust Clinical Research Programme)

Emily Mendenhall (Edmund A. Walsh School of Foreign Service at Georgetown University)

Ben Morton (Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine)

Mosa Moshabela (University of KwaZulu Natal)

Mandikudza Tembo (Biomedical Research and Training Institute, London School of Hygiene & Tropical Medicine)

*Correspondence to be addressed to Justin Dixon (justin.dixon@lshtm.ac.uk) or Felix Limbani (flimbani@mlw.mw)

References

1.       Chowdhury SR, Chandra Das D, Sunna TC, Beyene J, Hossain A. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. EClinicalMedicine. 2023;57: 101860.

2.       Basto-Abreu A, Barrientos-Gutierrez T, Wade AN, Melo DO De, Souza ASS De, Nunes BP. Multimorbidity matters in low and middle-income countries. Journal of Multimorbidity and Comorbidity. 2022;12:1–10.

3.       Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet. 2017;389(10072):951–63.

4.       Dixon J, Mendenhall E. Syndemic thinking to address multimorbidity and its structural determinants. Nature Reviews Disease Primers. Nature Research; 2023;9

5.       Academy of Medical Sciences, Academy of Science of South Africa. Improving the prevention and management of multimorbidity in sub-Saharan Africa: Workshop report. 2019. Available from: https://acmedsci.ac.uk/file-download/22652130

6.       Dixon J, Mendenhall E, Bosire EN, Limbani F, Ferrand RA, Chandler CIR. Making Morbidity Multiple: History, Legacies, and Possibilities for Global Health. Journal of Multimorbidity and Comorbidity. 2023;13:1–2

7.       Blarikom E Van, Fudge N, Swinglehurst D. The emergence of multimorbidity as a matter of concern : a critical review. Biosocieties. 2023;18:614–631.

8.       Roomaney RA, Van Wyk B, Wyk VP Van. Decolonising multimorbidity? research gaps in low and middle-income countries. Pan African Medical Journal. African Field Epidemiology Network; 2022;41:140

9.       Sturmberg JP, Getz LO, Stange KC, Upshur REG, Mercer SW. Beyond multimorbidity: What can we learn from complexity science? J Eval Clin Pract. 2022;27(5):1187–93.

10.      May CR, Eton DT, Boehmer K, Gallacher K, Hunt K, MacDonald S, et al. Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness. BMC Health Serv Res. 2014;14:281

Collection papers: