From Alma-Ata to Agincourt

On September 12, 2008, in Africa, global health, health systems, mortality, South Africa, by Karen Grepin

The focus of this week’s Lancet is all about reviving the focus on primary health. The MDGs are not going to be met, HIV/AIDS has highlighted the weaknesses of health systems (in particular in Africa), and health is not getting much better in low-income countries, so lets re-evaluate Alma-Ata and its focus on primary health care.

One of the research articles presented in these series is a interesting piece by Tollman and co-authors that documents the epidemiological transition, thought to be underway in most low-income countries, in a poor African population in South Africa. The article is especially important because its focus is actually on adult mortality, which is very poorly understood. While in general we know very little about overall mortality patterns in most low-income countries, adult mortality is particularly poorly understood. In fact, for the most part it is largely just made up in most of Africa. The reasons for this are numerous, but mainly because vital registration systems don’t really operate in these areas, and also it is very difficult to collect adult mortality data from household surveys (you have to be alive to answer questions).

The authors find pretty much what you would expect: children die mainly of infectious diseases, prime age adults have seen a significant increase in mortality from HIV/AIDS, and that older adults bear a large burden from chronic diseases, which are also on the rise.

While I have a few methodological issues with this paper (for example, is it possible that the all-cause mortality rate in this area was ~ 600/100,000 in 1992? This is a rate that is almost half the rate seen in most developed countries today), and while I think this article is significant in the contributions it makes, I wonder how the authors conclude on the implications of this work. Namely, the authors state that one of the main implications of their work should be that “..integrated chronic care [should be] based on scaled-up delivery of antiretroviral therapy..”.

The authors contribution was to document the rates of different types of mortality, which is very important, but do not provide any evidence about how these burdens should be addressed. Therefore, it strikes me as a major jump to come to this type of conclusion. My fear this article will now become the major article cited by advocates advocating further reliance on HIV/AIDS funding to strengthen health systems.

In my mind, we really don’t know how this should be done and what focus or priorities should be used to build up these systems. Please look before you cite.

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