COPD in Africa in the Post-COVID Era: A GBD 2023 Analysis of Trends, Demographic Drivers and Health-System Performance

Introduction

Chronic Obstructive Pulmonary Disease (COPD) remains a paramount public health challenge and the third leading cause of mortality globally, disproportionately affecting low- and middle-income countries (LMICs).^1,2 While historically characterized as a disease of affluence driven by tobacco smoking, the epidemiological epicenter of COPD has progressively shifted towards the African continent.³ Unlike the etiology observed in high-income nations, the burden of COPD in Africa is driven by a complex “double exposure”: the rising prevalence of smoking concomitant with pervasive exposure to household air pollution (HAP) from biomass fuel combustion, occupational hazards, and a high background of post-tuberculosis lung impairment.^4–6 Despite this escalating threat, chronic respiratory diseases in Africa have long been overshadowed by the prioritization of infectious diseases, leading to systemic under-diagnosis and inadequate management.⁷

The period from 2019 to 2023 represents a critical juncture in global health, demarcated by the profound disruptions of the COVID-19 pandemic. The interaction between SARS-CoV-2—a pathogen primarily targeting the respiratory system—and chronic lung conditions constitutes a “syndemic” that may have fundamentally altered the trajectory of COPD burden.⁸ On one hand, the pandemic severely disrupted essential health services, potentially leading to missed diagnoses, interrupted medication supply chains, and reduced access to pulmonary rehabilitation across Africa.⁹ On the other hand, pandemic-related lockdowns and behavioral changes may have transiently altered exposure to environmental risk factors. However, the net impact of these opposing forces on COPD incidence, mortality, and disability during this volatile recovery phase remains poorly understood, particularly in resource-limited settings where health systems were pushed to their brink.

Prior epidemiological assessments of COPD in Africa have largely relied on data from the Global Burden of Disease (GBD) 2019 or 2021 studies.^2,10–12 While foundational, these studies either predate the pandemic or capture only its acute phase, failing to delineate the complete epidemiological landscape of the “post-pandemic” era (up to 2023). Furthermore, existing literature often treats the African continent as a monolith, neglecting the substantial heterogeneity in demographic transitions, urbanization rates, and health system resilience across its 54 nations. With the recent release of the GBD 2023 estimates, there is a timely and imperative opportunity to re-evaluate the spatiotemporal trends of COPD using the most current and granular data available.

To address these critical knowledge gaps, this study leverages the newly released GBD 2023 dataset to provide a comprehensive analysis of the COPD burden across 52 African countries from 2019 to 2023. Beyond describing the magnitude of the burden, this study employs advanced metrics—including Estimated Annual Percentage Change (EAPC), decomposition analysis, and frontier analysis—to disentangle the drivers of epidemiological changes, distinguishing between demographic shifts (population growth and aging) and changes in age-specific rates. By illuminating the post-pandemic trajectory of COPD and identifying high-risk regions, this study aims to provide evidence-based insights for recalibrating national health strategies and advancing the African Union’s health agenda.

Methods

Study Design and Data Source

This study utilized the most recent estimates from the Global Burden of Disease (GBD) Study 2023, which provides comprehensive epidemiological data on 371 diseases and injuries across 204 countries and territories.¹³ We specifically extracted data for Chronic Obstructive Pulmonary Disease (COPD) across 52 African countries covering the period from 2019 to 2023. This timeframe was selected to capture the epidemiological trajectory of COPD in the immediate post-pandemic era, allowing for an assessment of disease burden following the initial disruptions of COVID-19.

Details regarding the GBD 2023 hierarchy, data input sources (eg, vital registration, verbal autopsy, and household surveys), and modeling strategies (eg, DisMod-MR 2.1) have been described extensively elsewhere^14,15 We adhered to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement for this analysis.¹⁶

Case Definition and Metrics

COPD was defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, specifically as an airflow limitation characterized by a post-bronchodilator FEV1/FVC ratio of less than 0.70.¹⁷ We analyzed four core metrics to comprehensively assess the disease burden: incidence, prevalence, mortality, and disability-adjusted life years (DALYs).

To control for differences in population age structures across African nations and allow for cross-country comparisons, we calculated age-standardized rates (ASR) per 100,000 population using the GBD world standard population. The Socio-demographic Index (SDI)—a composite indicator based on lag-distributed income per capita, average years of schooling, and total fertility rate—was used to stratify countries by development level.

Statistical Analysis

Temporal Trend Analysis (EAPC)

To quantify the temporal trends in COPD burden from 2019 to 2023, we calculated the Estimated Annual Percentage Change (EAPC).¹⁸ A trend was considered statistically significant if the 95% CI did not overlap with zero. Forest plots were generated to visually synthesize the EAPC results and heterogeneity across different African regions.

Decomposition Analysis

To disentangle the drivers behind the changes in absolute COPD burden (DALY counts) between 2019 and 2023, we conducted a decomposition analysis based on the Das Gupta method.^19,20 This approach partitioned the net change in DALYs into three additive components:

1. Population growth: changes attributable to the increase in total population size;
2. Population aging: changes attributable to shifts in the population age structure;
3. Epidemiological change: changes attributable to variations in age-specific DALY rates (reflecting changes in risk factor exposure or management).

Frontier Analysis

To benchmark the performance of African countries in managing COPD relative to their development status, we performed a frontier analysis. We plotted age-standardized DALY rates (2023) against SDI values for all 52 countries. A data envelopment analysis (DEA) approach using a loess regression (span = 0.8) was applied to estimate the “efficiency frontier”—the curve representing the lowest achievable burden for a given level of SDI. Countries were categorized as over-performers (observed/expected ratio <0.80), as expected (0.80–1.20), or under-performers (>1.20) based on their distance from the frontier.²¹

Health Inequality Analysis (SII)

To assess socioeconomic inequalities in COPD burden, we calculated the Slope Index of Inequality (SII). Countries were ranked by their SDI from lowest to highest, and a cumulative population fraction (relative rank) was assigned to each. We then performed a weighted linear regression of age-standardized DALY rates on this relative rank. The slope of the regression line (SII) represents the absolute difference in disease burden between the hypothetical “highest” (most developed) and “lowest” (least developed) ends of the socioeconomic spectrum. A negative SII indicates a pro-poor inequality (burden concentrated in lower-SDI countries), while a positive SII indicates a pro-rich inequality.²²

All statistical analyses were performed using R software (version 4.3.1). A p-value of <0.05 was considered statistically significant.

Ethics Approval and Consent to Participate

This study used publicly accessible, de-identified, aggregated estimates from the Global Burden of Disease (GBD) Study 2023 and did not involve collection of any individual-level identifiable information. The Ethics Committee of Harbin Medical University Cancer Hospital determined that this study was exempt from ethical review (decision date: November 11, 2025). Informed consent was not applicable.

Results

Across the 52 African countries included, the overall COPD burden increased in absolute terms between the pre-pandemic year 2019 and the post-pandemic year 2023, while age-standardised disability and mortality burdens generally declined.

In 2019, the total number of incident COPD cases in Africa was 751,091, rising to 871,054 in 2023, corresponding to a 16.0% increase. Over the same period, prevalent COPD cases increased from 10.99 million to 12.70 million (+15.6%). Total COPD-related DALYs increased from 3.56 million in 2019 to 3.86 million in 2023 (+8.5%), and deaths rose from 119,371 to 125,680 (+5.3%). At the country level, the median age-standardised incidence rate (ASR) was 95.4 (IQR 63.6–137.2) per 100,000 in 2019 and 98.1 (64.7–135.2) per 100,000 in 2023. Median age-standardised prevalence increased from 1439.6 (978.9–1852.8) to 1488.5 (998.3–1868.6) per 100,000. In contrast, median DALY ASRs declined from 579.6 (392.1–760.8) to 540.6 (369.9–711.1) per 100,000, and median mortality ASRs decreased from 23.2 (14.5–33.2) to 21.2 (13.5–29.7) per 100,000 between 2019 and 2023.

Substantial between-country heterogeneity was observed. In both 2019 and 2023, Ethiopia had the lowest incidence ASR (26.9 and 28.5 per 100,000, respectively), whereas Lesotho had the highest (189.7 and 188.1 per 100,000). For prevalence, ASRs ranged from 513.2 to 2546.2 per 100,000 in 2019 and from 540.8 to 2617.9 per 100,000 in 2023, with Ethiopia consistently at the lower end and Sudan at the upper end of the distribution. DALY ASRs were lowest in Djibouti (186.8 and 183.9 per 100,000 in 2019 and 2023, respectively) and highest in Lesotho (1338.0 and 1319.9 per 100,000). Mortality ASRs in 2019 ranged from 6.0 per 100,000 in Djibouti to 63.0 per 100,000 in the Democratic Republic of the Congo, and from 5.6 per 100,000 in Djibouti to 60.9 per 100,000 in the Central African Republic in 2023.

Regional patterns were consistent across indicators. North Africa had the highest median incidence ASR in 2023 (175.9 per 100,000), followed by Southern Africa (142.7), Central Africa (111.3), Western Africa (94.9) and Eastern Africa (56.7). A similar gradient was observed for prevalence ASRs, which in 2023 ranged from 906.6 per 100,000 in Eastern Africa to 2510.2 per 100,000 in North Africa; Central and Western Africa had intermediate medians (1578.1 and 1497.6 per 100,000, respectively), while Southern Africa remained high (2018.7 per 100,000). In terms of severity, Central and Southern Africa carried the greatest disability burden, with 2023 median DALY ASRs of 895.8 and 801.2 per 100,000, respectively, compared with 573.8 per 100,000 in Western Africa, 490.8 per 100,000 in North Africa and 304.4 per 100,000 in Eastern Africa. Mortality ASRs showed a similar pattern, being highest in Central Africa (median 42.2 per 100,000) and Southern Africa (30.6 per 100,000) and lowest in Eastern Africa (10.7 per 100,000) in 2023 (Figures 1, 2 and Table S1).

Figure 1 Trends in age-standardized COPD burden in Africa and subregions, 2019–2023, stratified by sex. Panels show age-standardized prevalence rate (ASPR), incidence rate (ASIR), death rate (ASDR), and DALY rate per 100,000 population for the African Union and five subregions.

Figure 2 Geographical distribution of COPD burden across 52 African countries in 2023. Choropleth maps show age-standardized rates per 100,000 population for incidence, prevalence, deaths, and DALYs.

Between 2019 and 2023, most countries experienced increasing incidence and prevalence ASRs but decreasing DALY and mortality ASRs. Age-standardised incidence rates increased in 44 (84.6%) of 52 countries and decreased in 8 (15.4%), with a median relative increase of 2.6%. The largest relative increases in incidence ASR were observed in Ethiopia (+5.9%), Senegal (+5.6%) and Djibouti (+5.3%), whereas South Africa (−3.1%), São Tomé and Príncipe (−2.6%) and Namibia (−1.8%) showed modest declines. Age-standardised prevalence increased in 48 (92.3%) countries and decreased in 4 (7.7%), with the steepest rises in Djibouti (+5.6%), Ethiopia (+5.4%) and Comoros (+5.3%) and the largest declines in South Africa (−3.1%), Botswana (−0.9%) and Namibia (−0.8%). In contrast, DALY ASRs decreased in 46 (88.5%) countries and increased in only 6 (11.5%). The most pronounced declines in DALY ASR were recorded in Egypt (−11.5%), Morocco (−10.5%) and Senegal (−10.3%), while a small subset of countries, including Sudan and Benin, showed modest increases. Similarly, mortality ASRs fell in 48 (92.3%) countries and rose in only 4 (7.7%); the largest reductions were in Egypt (−15.4%), Morocco (−14.7%) and Libya (−14.6%), whereas Sudan (+6.3%), Benin (+3.8%) and Algeria (+2.0%) exhibited moderate increases (Figures 1, 2 and Table S1).

Trend analyses based on estimated annual percentage change (EAPC) were concordant with these patterns. Median EAPCs in age-standardised incidence and prevalence were +0.62% (IQR 0.34% to 0.83%) and +0.68% (0.43% to 0.88%) per year, respectively, with positive EAPCs in 42 (80.8%) and 46 (88.5%) countries. Conversely, the median EAPCs for DALY and mortality ASRs were −0.95% (−1.43% to −0.30%) and −1.51% (−2.21% to −0.70%) per year, and 44 (84.6%) and 47 (90.4%) countries, respectively, showed declining age-standardised disability and death rates over the study period. Collectively, these findings indicate that while COPD incidence and prevalence continued to rise across most African countries after the COVID-19 pandemic, age-standardised disability and mortality burdens tended to improve, with marked geographic heterogeneity in both baseline levels and temporal trends (Figure 3, Table S1 and Supplementary Figure 1).

Figure 3 Trends in COPD prevalence across 52 African countries, 2019–2023. Estimated annual percentage change (EAPC) with 95% confidence intervals is shown, grouped by subregion; colors indicate significant increase, significant decrease, or non-significant change.

In both 2019 and 2023, the age–sex distribution of COPD burden in Africa showed a clear and consistent male excess across all indicators. COPD was virtually absent in childhood, with age-specific incidence, prevalence and DALY rates close to 0 per 100,000 in both sexes below 15 years of age. From adolescence onwards, incidence, prevalence, DALYs and deaths increased monotonically with age in both men and women, but were consistently higher in men at every adult age group (Figure 4 and Supplementary Figure 2).

Figure 4 Age–sex patterns of COPD burden in Africa in 2023. Age–sex pyramids show age-specific rates per 100,000 population for (A) incidence, (B) prevalence, (C) deaths, and (D) DALYs.

In 2023, sex differences in incidence and prevalence were moderate but highly consistent. Across adults (≥15 years), male age-specific incidence rates were on average about 19% higher than in females (mean male–female ratio ≈1.19; range 1.08–1.37). For example, incidence was 82.9 vs 65.8 per 100,000 at ages 40–44 years (ratio 1.26) and 210.4 vs 172.0 per 100,000 at 50–54 years (ratio 1.22) in men and women, respectively. Prevalence showed a similar pattern: male rates were on average 12% higher (mean ratio ≈1.12; range 1.09–1.18), reaching 2583.0 vs 2186.7 per 100,000 at 50–54 years (ratio 1.18) and 4679.1 vs 4087.2 per 100,000 at 60–64 years (ratio 1.14).

Sex disparities were larger for severity and fatal outcomes. Age-specific DALY rates were on average 54% higher in men (mean ratio ≈1.54; range ~1.09–1.84), rising from 304.1 vs 183.6 per 100,000 at 40–44 years (ratio 1.66) to 2193.8 vs 1248.9 per 100,000 at 60–64 years (ratio 1.76), and peaking at 5061.1 vs 2753.9 per 100,000 at 70–74 years (ratio 1.84). The mortality gap was even greater: male COPD death rates were on average 72% higher (mean ratio ≈1.72), with 3.9 vs 1.7 per 100,000 at 40–44 years (ratio 2.26), 59.6 vs 29.5 per 100,000 at 60–64 years (ratio 2.02) and 215.4 vs 105.4 per 100,000 at 70–74 years (ratio 2.04). Even at 80–84 years, mortality remained substantially higher in men (501.0 vs 281.8 per 100,000; ratio 1.78).

The 2019 profiles closely mirrored those observed in 2023. Among adults, male incidence rates were on average 21% higher than female rates (mean ratio 1.21; range 1.09–1.40), with 82.9 vs 64.6 per 100,000 at ages 40–44 years (ratio 1.28) and 280.4 vs 240.4 per 100,000 at 60–64 years (ratio 1.17). Male prevalence rates were on average 14% higher (mean ratio 1.14; range 1.10–1.20), reaching 2572.9 vs 2142.9 per 100,000 at 50–54 years (ratio 1.20) and 7400.1 vs 6543.6 per 100,000 at 70–74 years (ratio 1.13).

Gender gaps were again largest for DALYs and mortality in 2019. DALY rates were on average 64% higher in men (mean ratio 1.64; range 1.13–1.96), rising from 305.1 vs 179.5 per 100,000 at 40–44 years (ratio 1.70) to 2366.7 vs 1278.4 per 100,000 at 60–64 years (ratio 1.85), and 5547.9 vs 2824.9 per 100,000 at 70–74 years (ratio 1.96). Male COPD mortality was on average 86% higher (mean ratio 1.86; range 1.08–2.38), from 0.7 vs 0.4 per 100,000 at 15–19 years (ratio 1.85) to 3.9 vs 1.6 per 100,000 at 40–44 years (ratio 2.38), 65.8 vs 30.8 per 100,000 at 60–64 years (ratio 2.13), and 241.0 vs 110.4 per 100,000 at 70–74 years (ratio 2.18). (Figure 4 and Supplementary Figure 2)

Overall, both 2019 and 2023 show a stable pattern: men in Africa have slightly higher age-specific incidence and prevalence of COPD than women, but a disproportionately greater burden of disability and a markedly higher risk of COPD-related death once the disease is established.

Between 2019 and 2023, total COPD DALYs across the 52 African countries increased by approximately 303,100. Decomposition analysis showed that this net increase was overwhelmingly driven by demographic forces: population growth added about 413,200 DALYs (136.3% of the net change) and population aging a further 71,200 DALYs (23.5%), while improvements in COPD epidemiology—reflected in declining age-specific DALY rates—offset roughly 181,400 DALYs (−59.8% of the net change).

At the country level, 51 of 52 countries experienced an increase in COPD DALYs, with only Cabo Verde showing a small net reduction because favourable epidemiologic change more than compensated for demographic pressures. Population growth contributed positively to DALYs in all countries (median +4023 DALYs; IQR 1312–8036), whereas the effect of aging was smaller and more heterogeneous (median +61 DALYs; IQR −202 to +935), being positive in 30 (57.7%) and negative in 22 (42.3%) countries. In contrast, epidemiologic change was protective in most settings: 46 (88.5%) countries showed negative epidemiologic effects (median −777 DALYs; IQR −2087 to −239), while only six countries—Algeria, Sudan, Ghana, Cameroon, Benin and Comoros—had adverse epidemiologic shifts that increased COPD DALYs despite concurrent demographic drivers.

Substantial regional heterogeneity was evident. Western Africa accounted for the largest share of the net increase (≈97,300 DALYs; 32.1%), followed by Central Africa (≈71,600; 23.6%), North Africa (≈61,400; 20.3%), Eastern Africa (≈54,300; 17.9%) and Southern Africa (≈18,500; 6.1%). In all five subregions, population growth was the dominant positive driver, particularly in Western Africa, where it added about 140,600 DALYs. Population aging substantially amplified COPD burden in North and Southern Africa (≈54,700 and 17,100 DALYs, respectively), but slightly reduced DALYs in Western Africa. Epidemiologic change reduced COPD DALYs in every subregion, most notably in North (≈−51,900 DALYs) and Southern Africa (≈−41,600 DALYs), partially counteracting the strong demographic forces. Collectively, these findings indicate that the post-pandemic rise in COPD DALYs in Africa is primarily a consequence of rapid population growth and aging, with widespread but insufficient epidemiologic gains to fully offset demographic pressure (Figure 5).

Figure 5 Decomposition of the change in total COPD DALYs between 2019 and 2023. The net change in DALYs is partitioned into contributions from population growth, population aging, and epidemiologic change (changes in age-specific DALY rates) using the Das Gupta method.

In 2023, frontier analysis benchmarking observed against SDI-expected COPD burden revealed marked heterogeneity across the 52 African countries. Age-standardised DALY rates (ASDRs) ranged from 183.9 to 1319.9 per 100,000 (median 540.6; IQR 369.9–711.1), while SDI-based expected ASDRs ranged from 435.5 to 767.4 per 100,000 (median 567.0; IQR 510.8–650.6). The median observed-to-expected ratio was 0.96 (IQR 0.65–1.25), indicating that, on average, COPD DALYs were close to the frontier level but with substantial between-country variation.

Using the observed-to-expected ratio, 19 countries (36.5%) were classified as over-performers with low burden (ratio <0.80), 17 (32.7%) as performing as expected (0.80–1.20), and 16 (30.8%) as under-performers with high burden (>1.20). Over-performers had substantially lower COPD DALYs than predicted for their SDI, with a mean ratio of 0.58 and median ASDR 325.2 versus 541.5 per 100,000 expected. In five countries—Djibouti, Comoros, Somalia, Kenya and Ethiopia—observed ASDRs were less than half of expected levels; Djibouti, for example, had 183.9 versus 550.9 DALYs per 100,000 (ratio 0.33). Countries classified as “as expected” had ratios tightly clustered around unity (median 1.00), with median observed and expected ASDRs of 560.4 and 589.8 per 100,000, respectively.

By contrast, under-performers showed a pronounced COPD excess relative to their SDI. In this group, observed ASDRs were on average 55% higher than expected (mean ratio 1.55; median 1.33), with a median observed rate of 827.7 versus 564.0 per 100,000 expected. Five countries—Democratic Republic of the Congo, Lesotho, Sao Tome and Principe, Central African Republic and Angola—had observed ASDRs at least 60% above expected, exceeding twice the frontier level in several cases (eg Democratic Republic of the Congo: 1248.8 vs 494.6 per 100,000; ratio 2.52; Lesotho: 1319.9 vs 569.1 per 100,000; ratio 2.32). Overall, roughly one-third of African countries already achieve COPD DALY levels at or well below those expected for their development level, whereas nearly one-third bear COPD burdens at least 20% above the SDI frontier, indicating considerable scope for DALY reduction even at current socio-demographic conditions (Figure 6).

Figure 6 Frontier and inequality analyses of COPD DALYs in Africa in 2023. Frontier analysis benchmarking observed age-standardized DALY rates against SDI-expected values; countries are categorized by performance status based on observed-to-expected ratios.

In 2023, the Slope Index of Inequality (SII) for COPD in Africa showed only a modest socio-economic gradient in DALY burden across the 52 countries. Using population-weighted regression of age-standardised COPD DALY rates on the relative SDI rank, the SII was +63.5 DALYs per 100,000 (95% CI −168.3 to 295.3; p = 0.59). This corresponds to predicted DALY rates of 501.2 per 100,000 at the lowest SDI level and 564.6 per 100,000 at the highest SDI level, an absolute difference of about 12% relative to the continental mean (532.9 per 100,000). The very low explained variance (R² ≈ 0.01) indicates that, at the country level, COPD DALY rates in Africa in 2023 do not follow a strong, systematic gradient by SDI; instead, COPD burden is distributed relatively evenly across the development spectrum, with only a weak and statistically uncertain tendency toward higher DALY rates in higher-SDI countries (Supplementary Figure 3).

Discussion

This continent-wide analysis using GBD 2023 estimates through 2023 provides an updated, country-resolved picture of COPD in Africa during the transition from the pre-pandemic baseline (2019) to the early post-pandemic period (2023). Three findings are particularly policy-relevant. First, we document a consistent pattern of rising absolute burden but improving age-standardised severity, with increases in incident and prevalent cases and total DALYs and deaths, alongside declines in age-standardised DALY and mortality rates in nearly 90% of countries. This “more patients, lower per-capita severity” profile has not been quantified at 52-country resolution using the latest GBD cycle. Second, by decomposing DALY changes, we show that the net rise in COPD DALYs is driven predominantly by population growth and ageing, while improvements in age-specific DALY rates partially offset demographic pressure—an important distinction for planning, because demographic momentum implies that absolute COPD burden will continue to expand even if per-capita rates improve. Third, our frontier benchmarking highlights actionable heterogeneity: at similar SDI levels, roughly one-third of countries achieve DALY rates at or below the frontier, whereas another third remain ≥20% above SDI-expected values, indicating substantial avoidable burden not explained by socio-demographic development alone.

Comparison with and Added Value Over Existing Evidence

Our findings are broadly consistent with global GBD 2019 analyses, which reported that chronic respiratory diseases (CRDs) are now the third leading cause of death worldwide and that, despite rising absolute deaths and cases, age-standardised CRD and COPD mortality and DALY rates have declined over recent decades. However, previous work has largely relied on GBD 2019 or 2021 estimates, stopping before or during the acute COVID-19 phase and often aggregating Africa into broad regional groupings.^23–28 In contrast, our study is, to our knowledge, the first to use GBD 2023 to track COPD burden across 52 African countries through 2023, explicitly capturing the early post-pandemic period and quantifying how demographic and epidemiologic forces interact in this setting.

Interpreting Post-Pandemic Trends

The simultaneous rise in incidence and prevalence with declining age-standardised DALY and mortality rates mirrors global CRD patterns, where the number of patients and deaths has grown but per-capita risk has fallen over the past three decades.²⁹ In Africa, the increase in absolute cases is unsurprising given rapid population growth, demographic ageing and persistent or rising exposure to key risk factors—most notably tobacco smoking, household air pollution from biomass and kerosene, occupational dust and fumes, and post-tuberculosis lung damage.^30,31

The observed decline in age-standardised DALY and death rates suggests that, conditional on having COPD, African patients may now experience slightly less disability and lower fatality than in 2019. Several mechanisms are plausible.^32,33 First, gradual strengthening of NCD programmes and better access to essential respiratory medicines in some countries may be improving long-term disease control. Second, COVID-19 prompted major investments in oxygen systems and respiratory care capacity in many low- and middle-income countries; although coverage remains uneven, these improvements could yield spill-over benefits for COPD management and for survival from acute exacerbations. Third, pandemic-related changes—including reduced circulation of some respiratory viruses, mask use and heightened health awareness—may have temporarily reduced severe exacerbations in certain settings.^7,34

Our decomposition results highlight, however, that epidemiologic improvements have been insufficient to fully counterbalance demographic pressure: COPD DALYs still increased by ~300,000 between 2019 and 2023, and 51 of 52 countries saw net growth in burden. Without further reductions in smoking, household air pollution and occupational exposures, and without strengthened chronic care platforms, the absolute COPD burden will likely continue to rise for decades, as predicted for other NCDs under GBD 2023.²¹

Regional Heterogeneity, Health-System Performance and Inequality

The marked regional gradients we observed—high incidence and prevalence in North and Southern Africa, and particularly high DALY and mortality rates in Central and Southern Africa—are consistent with region-specific risk environments and health-system capacities.^35,36 North Africa combines relatively high smoking prevalence and urbanisation with comparatively better access to diagnostic services and pharmacotherapy, which may increase measured incidence and prevalence while improving survival.³⁷ Central and Southern Africa, by contrast, face a “triple exposure” to mining-related dust, biomass smoke and post-infectious lung disease in the context of fragile health systems and limited access to spirometry and specialist care.³⁸

Frontier analysis provides an important nuance: at similar levels of SDI, some countries (eg Djibouti, Ethiopia, Kenya) have COPD DALY rates less than half of their SDI-expected values, whereas others (eg Democratic Republic of the Congo, Lesotho, Central African Republic, Angola) have DALY rates more than 50% above expected. Since SDI partially captures the impact of income, education and fertility, these outliers likely reflect differences in tobacco control, clean-cooking transitions, occupational regulation, TB control, and the strength of primary care and referral networks—factors also emphasised in recent reviews on CRDs in LMICs.^39–41

The very modest and statistically non-significant SII confirms that, at least at the country level, COPD DALYs are not concentrated solely in the poorest African settings. This pattern differs from that seen for maternal disorders or sepsis, where sharp pro-poor gradients have been documented, and underlines that COPD in Africa is shaped by a complex interplay of environmental, behavioural, and policy determinants that SDI alone cannot capture.

Persistent Male Disadvantage

Across 2019 and 2023, men experienced only moderately higher incidence and prevalence than women (≈12–21% excess) but far higher DALY and mortality rates (≈50–80% excess), indicating that male COPD is both slightly more common and substantially more severe and fatal. This pattern aligns with global data showing higher COPD prevalence and mortality in men, particularly in settings where tobacco use and high-risk occupations remain male-dominated. In Africa, however, the persistence of large male–female gaps despite intense female exposure to biomass smoke suggests important gendered differences in cumulative tobacco exposure, occupational hazards, health-seeking behaviour, comorbidity profiles and access to diagnosis and long-term treatment.

From a policy perspective, these findings argue for gender-sensitive strategies: scaling up tobacco taxation and cessation support and enforcing occupational protections for men, while simultaneously accelerating clean-cooking interventions that disproportionately benefit women and children.⁴²

Strengths

This study has several notable strengths. First, it leverages the most recent GBD 2023 estimates, which incorporate updated data sources, refined demographic inputs and improved modelling strategies, thereby providing the most current picture of COPD in Africa. Second, it is, to our knowledge, the first analysis to focus specifically on the 2019–2023 interval across 52 African countries, capturing both the immediate pre-COVID baseline and the early post-pandemic trajectory. Third, by combining EAPC, decomposition analysis, frontier benchmarking and the SII, we move beyond simple trend descriptions to disentangle demographic versus epidemiologic drivers, quantify health-system “efficiency” at given SDI levels, and interrogate cross-country inequality. Fourth, detailed age–sex disaggregation allows us to document and quantify persistent male disadvantage in COPD burden, a dimension often under-reported in African respiratory epidemiology.⁴³

Limitations

Several limitations should be considered. First, our study is constrained by the usual caveats of GBD modelling. In many African countries, COPD case detection is hampered by limited spirometry, weak primary care systems and incomplete vital registration.^44,45 As a result, GBD must rely on sparse or indirect data sources, covariate-based imputation and model assumptions, which may lead to uncertainty or systematic bias in country-specific estimates. Second, the 2019–2023 window is relatively short for robust assessment of long-term trends; EAPC estimates over five years may be sensitive to year-to-year fluctuations and to evolving GBD input data and methods. Third, our decomposition analysis is ecological and cannot attribute epidemiologic improvements to specific risk-factor trends (eg tobacco, household air pollution, TB control) or to particular interventions (eg oxygen scale-up, essential NCD packages).

Policy Implications and Future Directions

Despite these limitations, our findings have several important implications. First, demographic momentum means that COPD burden in Africa will continue to grow in absolute terms even if age-specific rates stabilise or fall. National NCD strategies and universal health coverage packages should explicitly integrate COPD, with investments in spirometry, task-sharing for diagnosis and management, affordable inhaled therapies, and robust oxygen and acute care systems. Second, the wide spread of performance at similar SDI levels suggests that substantial reductions in COPD DALYs are achievable with currently available tools. Policymakers in under-performing countries could learn from the policy and health-system configurations of African over-performers—such as Djibouti, Ethiopia and Kenya—where COPD burden is far below SDI-expected levels.⁴⁵

Third, the pronounced and stable male disadvantage highlights the need for targeted interventions for men, including aggressive tobacco control, occupational health programmes and early-detection strategies, while not neglecting women’s exposure to household air pollution. Finally, future research should extend this work by (i) incorporating risk-factor-specific attribution for COPD DALYs under GBD 2023; (ii) adding subnational analyses to capture within-country inequalities; and (iii) projecting COPD burden to 2030 and beyond under alternative intervention scenarios, building on the decomposition and frontier frameworks used here and in other recent GBD 2023 applications.

Conclusion

Across 52 African countries, COPD burden increased in absolute terms from 2019 to 2023, while age-standardised DALY and mortality rates generally declined, indicating a post-pandemic pattern of “more patients but lower per-capita severity”. Decomposition analyses suggest that population growth and ageing were the main drivers of rising total DALYs, whereas improvements in age-specific DALY rates partially offset demographic pressure. Marked cross-country heterogeneity and substantial performance gaps at similar SDI levels were identified by frontier analysis, and the SDI gradient in DALY rates was weak and not statistically significant. The persistent male disadvantage in COPD disability and mortality highlights the need for gender-sensitive strategies. Strengthening tobacco control, accelerating clean-energy transitions, and improving access to diagnosis and long-term chronic respiratory care—especially in under-performing countries—could yield meaningful reductions in COPD burden even at current levels of socio-demographic development.