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  • br Over the past decade global

    2019-04-22


    Over the past decade, global concern about the disproportionate burden of disease and mortality in low-income countries, especially in sub-Saharan Africa, has led to a substantial influx of funding for research by many donor and research agencies. This investment has energised in-country research; advanced the discovery and the use of new treatments for HIV/AIDS, tuberculosis, and malaria; and stimulated new research strategies for the prevention and control of these and other diseases. Questions have been raised about whether these international efforts could be better coordinated to increase efficiency and improve outcomes, while ensuring that research institutions and universities are supported with these funds. Financial support has been uneven; health ministries in some sub-Saharan African countries have been overwhelmed with many donors seeking to fund research activities, whereas neighbouring countries with an equally large burden of diseases have a paucity of funding.
    In sub-Saharan Africa, South Africa is at the forefront in the use of fiscal and legislative instruments to manage oxidative phosphorylation health. Mandatory regulations passed in March, 2013, to begin in 2016, will affect the salt content of processed food and will be a key weapon in the fight against the rising burden of hypertension. A first for Africa, the regulations could potentially affect population health regionally, as relaxation of tariff agreements enables South African retail chains to sell processed foods across the continent. At the UN Non-Communicable Diseases summit in 2011, the South African Minister of Health, Aaron Motsoaledi, noted: “We have been very ambitious in our targets…we cannot afford to let people die early”. Just beginning to turn around its life expectancy, with increasing numbers of patients with HIV now taking antiretrovirals, South Africa has a mounting burden of disease, with 40% of the population aged 35–44 years hypertensive. Salt consumption in South Africa is close to double the WHO-recommended maximum of 5 mg per day, with the major source of non-discretionary dietary salt from bread, a staple food. The process of academic engagement with the South African Government about salt regulations could potentially avert premature deaths from other chronic disorders. Experience suggests that three features were key in this engagement process. First, engagement with policy makers at the beginning of the short, 18 month research process was crucial to our understanding of the cost evidence needed. South African research had been mounting for some decades on the feasibility of implementation and the effect of salt reduction. This research formed the basis of our work and provided a starting point for policy makers. Second, communication of results as they emerged was constructive. The Minister of Health began publicly using data about the burden averted, the resources consumed, and the costs, before promulgating the draft legislation. Finally, although information from other countries is useful, context-specific, domestic costs and outcome indicators proved crucial. Population-level prevention of high-burden disorders can have a substantial effect. Most South African people with hypertension are not diagnosed; of those who are, medication adherence is not optimal. As a consequence, a third of cases result in premature death or disability, and two-thirds of stroke victims are permanently disabled. The resulting poverty spiral is substantial, so prevention of deaths and disability can potentially secure livelihoods and provide sizable economic savings. Our research suggests that by decreasing daily salt intake by 0·85 g per person, mostly by reducing salt in bread, South Africa could avert 7400 cardiovascular deaths (2900 from stroke) and save 4300 lives from non-fatal stroke. The savings from reduced numbers of hospital admissions of patients with non-fatal strokes alone could save ZAR300 million per year. Some momentum for passing the salt regulations was related to timing and the fact that the policy makers were able to leverage the global context to bolster their case, exploiting international examples as motivational evidence. By 2011, strong evidence, including both voluntary and mandatory regulation, was already in place in 37 countries worldwide. The synergy between political will, clear dietary guidelines, product reformulations, and effective communication to consumers can change behaviour. Changes in salt consumption have now been reported in five countries that are part of the Organisation for Economic Co-operation and Development, resulting from broad salt reduction initiatives. International champions and advisers to South Africa included the director of World Action on Salt and Health. Evidence also came from country campaigns including the UK Consensus Consumer Action on Salt and Health. The UN summit stimulated intense interest within South Africa, and created an opportunity to prepare its own goals.