Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance study.
BACKGROUND
In southern Africa, a substantial health transition is underway, with the heavy burden of chronic infectious illness (HIV/AIDS and tuberculosis) paralleled by the growing threat of non-communicable diseases. We investigated the extent and nature of this health transition and considered the implications for primary health care.


METHODS
Health and sociodemographic surveillance started in the Agincourt subdistrict, rural South Africa, in 1992. In a population of 70 000, deaths (n=6153) were rigorously monitored with a validated verbal autopsy instrument to establish probable cause. We used age-standardised analyses to investigate the dynamics of the mortality transition by comparing the period 2002-05 with 1992-94.


RESULTS
Mortality from chronic non-communicable disease ranked highest in adults aged 50 years and older in 1992-94 (41% of deaths [123/298]), whereas acute diarrhoea and malnutrition accounted for 37% of deaths (59/158) in children younger than 5 years. Since then, all-cause mortality increased substantially (risk ratio 1.87 [95% CI 1.73-2.03]; p<0.0001) because of a six-fold rise in deaths from infectious disease affecting most age and sex groups (5.98 [4.85-7.38]; p<0.0001), and a modest increase in deaths from non-communicable disease (1.15 [0.99-1.33]; p=0.066). The change in female risk of death from HIV and tuberculosis (15.06 [8.88-27.76]; p<0.0001) was almost double that of the change in male risk (8.13 [5.55-12.36]; p<0.0001). The burden of disorders requiring chronic care increased disproportionately compared with that requiring acute care (2.63 [2.30-3.01]; p<0.0001 vs 1.31 [1.12-1.55]; p=0.0003).


CONCLUSIONS
Mortality from non-communicable disease remains prominent despite the sustained increase in deaths from chronic infectious disease. The implications for primary health-care systems are substantial, with integrated chronic care based on scaled-up delivery of antiretroviral therapy needed to address this expanding burden.
Tollman
Stephen M
SM
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Kahn
Kathleen
K
Sartorius
Benn
B
Collinson
Mark A
MA
Clark
Samuel J
SJ
Garenne
Michel L
ML
D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D002423:Cause of Death / Q000639:trends*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008017:Life Expectancy / Q000639:trends*; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods*; D011320:Primary Health Care / Q000706:statistics & numerical data* / Q000639:trends; D012423:Rural Health / Q000706:statistics & numerical data* / Q000639:trends; D017678:Sex Distribution; D013019:South Africa / Q000453:epidemiology
Circulation. 2001 Nov 27;104(22):2746-53
11723030
Bull World Health Organ. 2004 Jul;82(7):503-8
15500283
J Hypertens. 2000 Feb;18(2):145-52
10694181
Lancet. 2008 May 10;371(9624):1603-11
18468544
Lancet. 2008 Mar 15;371(9616):915-22
18342686
Qual Saf Health Care. 2004 Aug;13(4):299-305
15289634
Lancet. 2001 Aug 4;358(9279):404-9
11502340
Lancet. 2000 May 13;355(9216):1684-7
10905244
Circulation. 2005 Dec 6;112(23):3554-61
16330696
Scand J Public Health Suppl. 2007 Aug;69:68-76
17676506
Scand J Public Health Suppl. 2007 Aug;69:8-20
17676498
Trop Med Int Health. 2000 Nov;5(11):824-31
11123832
Lancet. 2006 Sep 9;368(9539):954-61
16962886
Eur J Cardiovasc Prev Rehabil. 2006 Dec;13(6):964-9
17143129
Bull World Health Organ. 2006 Mar;84(3):181-8
16583076
Scand J Public Health Suppl. 2007 Aug;69:35-44
17676501
Stroke. 2004 Mar;35(3):627-32
14963282
Lancet. 2005 Nov 5;366(9497):1667-71
16271649
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003318
16625576
Am J Trop Med Hyg. 2004 Aug;71(2 Suppl):147-55
15331831
BMC Public Health. 2007 Nov 13;7:326
17999764
Stroke. 1997 Oct;28(10):1898-902
9341692
Lancet. 2004 Sep 4-10;364(9437):900-6
15351199
Int J Tuberc Lung Dis. 2004 Jun;8(6):796-9
15182153
AIDS. 1999 Jun 18;13(9):1091-7
10397540
Int J Tuberc Lung Dis. 2001 Jul;5(7):619-27
11467368
Am J Public Health. 2004 Mar;94(3):384-8
14998800
Bull World Health Organ. 2007 Nov;85(11):880-5
18038079
Hypertension. 2004 May;43(5):1017-22
15037552
Scand J Public Health Suppl. 2007 Aug;69:77-84
17676507
Lancet Neurol. 2007 Mar;6(3):269-78
17303533
Stroke. 2003 Jul;34(7):1604-9
12817107
J Hum Hypertens. 2007 Jan;21(1):28-37
17066088
Scand J Public Health Suppl. 2007 Aug;69:26-34
17676500
S Afr Med J. 2008 Jan;98(1):17-8
18270632
J Biosoc Sci. 2004 Jul;36(4):433-43
15293385