The Indirect Cost of Disability Adjusted Life Years Lost among the Elderly in Kenya

Background: As Kenya accelerates the momentum to attain the Sustainable Development Goals (SDG) 3 on health and 13 on combatting impacts of climate change, it is critically important not to overlook their impacts on the elderly, i.e. people aged 60 years and above (elderly). The objective of this study was to estimate the indirect cost (productivity losses) of disability-adjusted life years (DALYs) lost among the elderly in Kenya in 2015.


Background
Kenya is one of the five East African Community (EAC) countries.In 2015 it had an estimated population of 46,034,000 people; which was about 4% of Africa's population.About 1,921,000 (4%) of Kenya's population was 60 years and above, i.e. the elderly [1].Sixty-five percent of the elderly were aged 60 to 69 years and the remaining 35% were aged 70 years and above.Sixty-seven and 33% of the elderly were female and male respectively.The World Health Organization (WHO) projects that the number of people aged 60 years (or over) in Africa will increase by 3.2 fold between 2015 and 2050; meaning that Kenya will have approximately 6.2 million elderly people by 2050.
During the same year there occurred a total of 317,173 deaths from all causes in Kenya; which was 3% of deaths borne by Africa [2].Approximately 93,693 (30%) of Kenya's deaths were among the elderly; 33% among 60-60 year olds and 67% among 70 years and above.Fifty-one percent of the deaths were female.
Kenya incurred a total loss of 21,854,898 disability-adjusted life years (DALYs) from all causes in 2015, i.e. 3.1% of Africa's loss [1].About 2,238,004 (10.2%) of the DALY loss occurred among the elderly; of which half were among those aged 60-69 years and other half among 70 years and above.Again almost 51% of the DALY loss was incurred by females.
The disability-adjusted life years (DALYs) losses are attributable to three very broad causes [1].First, 656,637 (29.3%) of the DALY lost in 2015 were cau-sed by communicable, maternal, perinatal and nutritional conditions.Second, 1,434,494 (64.1%) were from non-communicable diseases.Lastly, 146,873 (6.6%) were from intentional and unintentional injuries.Thus, it is clear that majority of health problems of elderly persons are inextricably linked to chronic non-communicable diseases.
According to WHO most of the chronic NCD conditions can be prevented or delayed by healthy behaviours, including physical activity, stoppage of substance abuse (including alcohol and tobacco consumption), and good nutrition.WHO adds that if declines in functional capacities are detected early, supportive environments can ensure that concerned elderly persons can enjoy dignified lives and continued personal growth [3].
The Kenya National Commission on Human Rights report entitled 'Growing old in Kenya: making it a positive experience' alluded in 2009 that: "There is no adequate recognition within government policies and practices of growing old as a process that has to be factored in both planning and resource allocation; and policies in critical sectors such as health, housing, employment and social protection are not old age focused (p.viii)" [4].
The 2010 Kenya Constitution article 57 stipulates that "The State shall take measures to ensure the rights of older persons (a) to fully participate in the affairs of society; (b) to pursue their personal development; (c) to live in dignity and respect and be free from abuse; and (d) to receive reasonable care and assistance from their family and the State" [5].In 2014, the current Kenya Government Conclusions: Kenya incurs every year substantive productivity losses due to morbidity and premature mortality among the elderly.Therefore, there is need for increased government, private sector and development partner's investments into health and wellbeing of the elderly to prolong their intrinsic and functional capacities.published a national policy on older persons and ageing with 10 thematic areas: older persons and the Law; poverty and sustainable livelihood; health, HIV and AIDS: family; community and culture; food security and nutrition; infrastructure; housing and recreational facilities; education, training and ICT; employment and income security; social protection and services and cross cutting issues [6].The Government is rolling out a social protection fund which was envisaged in its 2030 vision [7].The 2014 national health policy makes a commitment to define a health service package and delivery system for elderly (60 years and over), among others [7].
In 2007 the Government of Kenya started Older Persons Cash Transfer (OPCT) programme targeting poor households with at least one member above the age of 65 years.In the Financial Year 2015/2016, the total number of beneficiaries were 325,000 and received Ksh.2,000 per household every two months [8].They were also registered with National Hospital Insurance Fund (NHIF).The cash transfers and the health insurance are expected to cushion the recipient from vagaries of nutrition related deficiencies, and thus, improve quality of their lives.Inspite of these recent positive steps by the Kenyan government, there still exists large unmet need for social and financial protection among the elderly in Kenya.
The ushering of the United Nations Sustainable Development (SDG) Goal 3 -To ensure healthy lives and promote wellbeing for all at all ages through universal health coverage including financial risk protection -provides a good opportunity for Kenya to mount a comprehensive multi-sectoral action to create enabling healthy ageing policies in all sectors; food, nutrition, education (life-long learning), health and economic security systems, and physically secure and healthy living environments that will enable elderly citizens to restore, sustain and/or improve their intrinsic capacities and functional abilities [9,10].
There is urgent need for information on the productivity losses associated with DALYs lost among the elderly for use by relevant government Ministries and civil society organizations to advocate strongly with the Ministry of Finance and development partners for increased investments into health and general socioeconomic welfare of the elderly.
This paper answers the question: What is the indirect cost of DALYs lost from all diseases and health conditions among the elderly in Kenya?The objective was to estimate the indirect cost of DALYs lost among the elderly people in Kenya in 2015.

Methods
Framework for Estimating Indirect Cost Associated with 2015 DALYs Lost from all causes among the elderly According to WHO, DALY is a summary measure which combines years of life lost (YLL) through premature death and years of life lived with disability (YLD).The methodological details on calculations of DALYs and data sources are contained in WHO technical paper [11].
The non-health GDP loss ( ) associated with DALYs lost from j th disease (or health condition) in Kenya is the sum of the potential nonhealth GDP loss due to DALYs lost from j th disease among those aged 60-69 and those aged 70 years and above .The non-health GDP loss associated with j th disease (or health condition) DALYs lost among persons in the two age groups is the product of the per capita non-health GDP in purchasing power parity (PPP) and the total j th disease (or health condition) DALYs lost in a specific age group.Kenya's discounted total non-health GDP loss attributable to j th disease (or health condition) DALYs was estimated using the equations (1) to (3) below.Where: is per capita non-health GDP in purchasing power parity (PPP), which is obtained by subtracting per capita total health expenditure ( ) from per capita GDP ( ); is the total DALYs lost to j th disease (or health condition) between the age of 60-69 years in country i in 2015; and is the total DALYs lost to j th disease (or health condition) between the age of 70 years and above in country i in 2015.The non-health GDP per capita in purchasing power parity for Kenya is the difference between per capita GDP and per capita total health expenditure.
The year 2015 was used as the base year for all the calculations because it marks the end of the MDG era and serves as the baseline for the SDGs [9].The DALY estimates published by WHO in the Global Health Observatory are already discounted at a 3% discount rate.Therefore, any attempt to introduce discount factor in the equations (1) to (3) would be double discounting.

Data Sources
The data on the indicators contained in Table 1 were solely obtained from WHO and IMF databases.Those indicators were used in the study to estimate the productivity losses incurred by Kenya.
The DALYs lost in 2015 for Kenya's elderly by cause were obtained from the WHO Global Health Observatory [1].Methods and data sources for global burden of disease 2000-2015 are reported in WHO technical paper [11].
The 2015 Per capita GDP in International Dollars (Int$) or Purchasing Power Parity (PPP) for each country was obtained from the IMF World Economic Outlook database [12].
The per capita total expenditure on health for 2015 was not available.Therefore, projections for 2015 were calculated using 2013 and 2014 per capita total expenditure on health for each country from the WHO Global Health Observatory [13].
The issues of sampling and sample size were not relevant for the current study.This is because we analysed DALYs from all causes that exists within the WHO Global Health Observatory [1].

Ethical Clearance
No ethical clearance was required from the Meru University of Science and Technology (MUST) Institutional Research Ethics Review Committee (MIRERC) because the study relied completely on analysis of WHO [1].
Health SDG Targets

Expenditure on health in 2015
Projected 2015 total expenditure on health (THE) per person per country in Africa (projected using 2013 and 2014 THE data).Assumed constant growth.
publicly available secondary data in the WHO and IMF databases.

Results
The total indirect cost of DALYs lost from all causes among the elderly in Kenya was Int$ 7,088,274,986.
The losses were evenly distributed between the 60-69 years and 70 years and above age brackets.The females and males bore Int$ 3,609,997,094 (50.9%) and Int$ 3,478,277,848 (49.1%) of the indirect cost respectively.3).Third, Int$ 1,150,801 (0.1%) of the CON indirect cost resulted from maternal conditions.Fourth, Int$ 5,216,980 (0.3%) of the CON indirect costs were related to neonatal conditions.

Communicable diseases and nutritional conditions indirect costs As shown in
Lastly, nutritional deficiencies led to a loss of 55,164 DALYs which resulted into an indirect cost of Int$ 174,718,675, i.e. 8.4% of the CON.Proteinenergy malnutrition and iron-deficiency anaemia were responsible for 95.5% of this loss.

Indirect costs of non-communicable diseases
As portrayed in Table 4, about Int$ 4,543,372,566 (64.1%) of the total indirect costs from all causes were from non-communicable diseases (NCD) cluster.The economic losses attributable to NCD cluster emanated from fifteen broad causes.Firstly, the malignant neoplasms (cancers) were responsible for a loss of 368,272 DALY which translated to an indirect cost of Int$1,166,403,036 (25.7%).About Int$ 540,944,576 (46%) of this economic loss resulted from oesophagus cancer, stomach cancer, breast cancer, cervix uteri cancer and prostate cancer.Secondly, other neoplasms accounted for Int$22,568,469 (0.5%) of NCD indirect cost (Table 5).Thirdly, diabetes mellitus was responsible for Int$241,215,813 (5.3%) of the loss.Fourthly, Int$41,865,425 (0.9%) of the NCD economic losses were from endocrine, blood, and immune disorders.
Fifthly, mental and substance abuse disorders among elderly in Kenya led to 49,976 DALY losses; which were equivalent to Int$ 158,285,962 (3.5%) of the NCD indirect costs (Table 6).About 70% of economic loss resulted from depressive disorders and anxiety disorders.
Sixth, the neurological conditions caused a loss of 54,774 DALYs; which was equivalent to an indirect cost of Int$ 173,481,335 (3.8% of NCDs losses) (Table 7).Alzheimer disease and other dementias accounted for about 77% of the indirect costs from neurological conditions.Table 5 provides the distribution of DALYs and indirect costs by individual neurological conditions among the elderly in Kenya in 2015.
Seventh, the sensory organ diseases were responsible for a loss of 111,390 DALYs, which were equivalent to indirect cost of Int$ 352,796,856, i.e. 7.8% of NCD economic losses.A majority of 61.2% of the economic losses resulted from hearing losses and uncorrected refractive errors in vision.Tenth, the digestive diseases led to a loss of 139,229 DALYs among the elderly.This was equivalent to an indirect cost of Int$ 440,971,945, i.e. 9.7% of NCD productivity losses.Peptic ulcer disease, cirrhosis of the liver, gastritis and duodenitis, and paralytic ileus and intestinal obstruction were responsible for 80% of losses in digestive diseases related DALY losses and indirect costs.Fourteenth, congenital anomalies led to a loss of 3,140 DALYs which were equivalent to Int$ i.e. 0.2% of the NCD indirect costs.About 2.2% of the congenital anomalies indirect costs were from neural tube defects; 0.1 from cleft lip and cleft palate; 6% from down syndrome; 13.4% from congenital heart anomalies; 5.6% from other chromosomal anomalies; and 72.7% from other congenital anomalies.
Fifteenth, oral conditions caused a loss of 8,350 DALYs which translated to Int$26,445,416, i.e. 0.6% of the NCD total productivity losses.Out of that loss, 3% was from dental caries, 55.5% from periodontal disease, 25.2% from edentulism, and 16.3% from other oral disorders.

Indirect cost of injuries
In 2015 the injuries cluster accounted for a loss of 146,873 DALYs which resulted in total indirect cost of Int$ 465,181,291, which was equivalent to 6.6% of the total country's loss from all causes.About 128,884 DALY losses were from unintentional injuries causing an indirect cost of Int$ 408,206,456 (87.85%).Unintentional injuries resulted from the eight causes listed in Table 12.About 60.4% of unintentional injuries indirect costs resulted from road injuries and falls.

Discussion
There were a number of key findings.First, the elderly in Kenya are confronted with a triple burden of disease -including communicable diseases and nutritional deficiencies, non-communicable diseases, and injuries.Second, top 20 diseases in Table 13 were responsible for 62% of the DALY losses and indirect costs incurred by the elderly in Kenya.Three, NCDs (stroke, cardiovascular diseases, dia-betes, cancer and hearing loss) were the cause of majority of the losses in intrinsic and functional capacities of the elderly, and hence, indirect costs in Kenya.Four, diarrhoea diseases, lower respiratory infections, tuberculosis, and iron-deficiency were among the top 20 causes of DALY losses and indirect costs.Fifth, road injuries and falls were among the top twenty.
In September 2015, the United Nations General Assembly adopted resolution A/RES/70/1 with 17 Sustainable Development Goals (SDGs) [9].The SDG 3 is about ensuring healthy lives and promoting well-being for all at all ages including the elderly.SDG target 3.c requires Kenya (among others) to substantially increase health financing and health workforce within the national and county health systems, including those services that specifically address the health needs of the elderly.SDG target 3.8 calls upon all countries to ensure universal health coverage.In the context of the current study, this includes ensuring that all the elderly in need have financial risk protection, and unfettered access to safe, effective, and quality essential health-care services (including essential medicines and vaccines).
Adequately resourced national and county health systems and other systems that assure elderly's universal access to basic needs (food, shelter, clothing, water and sanitation, education) may enable Kenya to achieve the following SDG targets: • 3. Various WHO strategies, strategic plans and action plans provide clear guidance to countries on the proven cost-effective interventions related to the various health SDG targets.In order to achieve the communicable diseases target SDG 3.3, the Seventieth World Health Assembly (WHA) adopted a resolution on global vector control response 2017-2030 aimed at reducing the burden and threat of vector-borne diseases through effective locally adapted sustainable vector control [14].That resolution provides extra guidance and impetus for accelerated implementation of the global technical strategy and targets for malaria [15].WHO also developed a framework detailing strategies and interventions for malaria elimination [16].The Sixty-Ninth WHA adopted global health sector strategies for combatting HIV [17], sexually transmitted infections [18] and hepatitis [19].
In order realize SDG target 3.4 for the elderly, Kenya needs to accelerate the implementation of the actions contained in the WHO the global strategy and action plan for the prevention and control of NCDs [20,21].The country also needs to fully implement the actions proposed in the WHO mental health action plan to prevent and/or delay temporal decline in elderly's intrinsic and functional capacities [22].
With a view to giving impetus for Member States push towards SDG target 3.6, the Sixty-Ninth WHA adopted two pertinent resolutions.Resolution WHA 69.5 adopted the WHO global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence [23] and WHA69.7 on addressing the challenges of the UN Decade of Action for Road Safety [24].The latter calls upon Member States (including Kenya) to implement the Brasília Declaration on Road Safety [25]; to renew commitment to the UN Decade of Action for Road Safety 2011-2020; to implement the Global Plan for the Decade of Action for Road Safety 2011-2020 [26]; and to implement the recommendations contained in the WHO Global Status Report on Road Safety [27].The latter report recommends to countries to enforce road safety laws (e.g.those related to reducing speed, increasing motorcycle helmet use, reducing drinkdriving, increasing seat-belt use, reducing drugdriving, reducing distracted driving, e.g.talking on phone while driving) and take appropriate actions to ensure safer roads and vehicles.
The Sixty-Ninth WHA resolution WHA69.3 calls upon Member States to implement the proposed actions in the Global strategy and action plan on ageing and health through a multisectoral approach [28].It also urges international, intergovernmental and nongovernmental organizations, as well as selfhelp and other relevant organizations to support and contribute to the accomplishment of the Global strategy and action plan on ageing and health [29].
There exists political will at the global and continental level to tackle the triple burden of disease.In 2011, the UN General Assembly (UNGA) adopted a Political Declaration on the Prevention and Control of NCDs [30].
In September 2016, the UNGA adopted resolution A/RES/70/300 encouraging Member States to consolidate gains and accelerate efforts to control and eliminate malaria in developing countries, particularly in Africa, by 2030 [31].In 2001 the UNGA adopted resolution A/RES/S-26/2 declaring commitment on HIV/AIDS [32]; and resolution A/ RES/60/262 entitled political declaration on HIV/ AIDS [33].In June 2011 and 2000 the UN Security Council adopted resolutions S/RES/1983 (2011) and S/RES/1308 (2000) on HIV/AIDS [34].
In March 2010, the UNGA resolution 64/255 proclaimed 2011-2020 the Decade of Action for road safety, with a global goal of stabilizing and then reducing the forecasted level of global road fatalities by increasing activities conducted at national, regional and global levels [35].In the follow-up, the UNGA adopted resolutions 66/260 of 19 April 2012, 68/268 of April 2014 and 70/260 of April 2015 on improving global road safety [36,37].

Conclusion
This study demonstrates that morbidity and premature mortality among the elderly results in sizeable GDP losses in Kenya.The finding is even of greater significance when one recalls that our study focussed only on productivity losses, and did not take into account the direct costs incurred by the national health system and communities.We did not include other non-monetary contributions made by the elderly to the society, including guidance and counselling of younger people in communities, caring for the orphaned children, brokering of peace in families, transmission of indigenous knowledge and cultural values.
Thus, there are three arguments for increased government and partner investments into health and wellbeing of the elderly: (a) the elderly have a human right to health; (b) the elderly have made in the past, and continue to make, a substantive contribution to Kenya's economic development; and (c) the elderly make a significant non-monetary contribution to societal wellbeing.

Table 2
, approximately Int$ 2,079,721,129 (29.3%) of the total indirect costs from all causes resulted from communicable and nutritional (CON) conditions.The indirect costs attributable to CON cluster resulted from five broad causes.First, 445,894 DALYs equivalent to Int$ 1,412,249,484

Table 2 .
Indirect cost of DALY lost from infectious and parasitic diseases among the Kenya's elderly (Int$ or Purchasing Power Parity).

Table 3 .
Indirect cost of DALY lost from respiratory infections, maternal and neonatal conditions, and nutritional deficiencies among the Kenya's elderly (Int$ or Purchasing Power Parity).

Table 4 .
DALY losses and indirect cost of malignant neoplasms (cancers) among elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 6 .
DALY losses and indirect cost of mental and substance abuse disorders among elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 5 .
DALY losses and indirect cost of other neoplasms, diabetes mellitus and endocrine, blood and immune disorders among elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 8
presents the distribution of DALY losses and indirect cost by individual sense organ diseases among the elderly in Kenya in 2015.
Eighth, cardiovascular diseases (CVD) led to 415,793 DALY losses, which translated to total indi-

Table 7 .
DALY losses and indirect cost of neurological conditions among elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 8 .
DALY losses and indirect cost of sense organ diseases among the elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 9 .
DALY losses and indirect cost of cardiovascular diseases among the elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 10 .
DALY losses and indirect cost of digestive diseases among the elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 11 .
DALY losses and indirect cost of genitourinary diseases among the elderly in Kenya in 2015 (Int$ or Purchasing Power Parity).

Table 10 pro
vides distribution of DALYs lost and indirect costs by individual digestive diseases.Eleventh, genitourinary diseases were responsible for 35,880 DALYs lost, which was equivalent to Int$ 113,639,424, i.e. 2.5% of the NCD productivity losses.About 66% of the genitourinary diseases DALY and indirect costs emanated from kidney diseases and benign prostatic hyperplasia.Table 11 provides distribution of DALYs lost and indirect costs by individual genitourinary diseases.Twelfth, skin diseases led to a loss of 11,922 DALYs which was equivalent to Int$ 37,758,337 of indirect costs, i.e. 0.8% of the total NCD productivity losses.Thirteenth, musculoskeletal diseases accounted for a loss of 60,112 DALYs which was equivalent to Int$ 190,389,627 indirect cost, i.e. 4.2% of the

Table 12 .
DALY losses and indirect cost of injuries among the elderly in Kenya in 2015 (Int$ or Purchasing Power Parity.

Table 13 .
Top 20 causes of DALY loss and indirect costs among the elderly in Kenya.