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. Findings: 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). Interpretation: 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. Funding: The Wellcome Trust, UK; University of the Witwatersrand, Medical Research Council, and Anglo American and De Beers Chairman's Fund, South Africa; the European Union; Andrew W Mellon Foundation, Henry J Kaiser Family Foundation, and National Institute on Aging, National Institutes of Health, USA. © 2008 Elsevier Ltd. All rights reserved.