Health in Transition

The concept of “health transition”

Nowhere are the above challenges more visible than in Africa, where the impacts of HIV and AIDS interact with rapidly growing epidemics of chronic disease of the middle-aged and the unfinished agenda of infection and malnutrition mainly affecting children. This results in an increasingly weakened generation subject to what is often labelled a multiple and polarized burden.

During the 20^th century, Sweden, like many European countries, underwent a transition from predominantly infectious causes to non-communicable diseases, with major implications for health services, social support and longevity. This transition was partly fuelled by socio-economic development, as well as by specific medical innovations. Many of the world’s poorer countries are still in the process of similar transitions, and currently at different stages. This has only been explored by researchers to a limited extent, despite the availability of long-term population statistics.

The concept of “transition” has been used to describe the above dynamics and labeled with different prefixes depending on disciplinary perspective. The early concept was labeled “demographic” and it mainly involved mortality and fertility and their consequences for population changes. When later using “epidemiological” as a prefix, the focus has shifted to the complex patterning of health and disease and their demographic, socio-economic and biological determinants while, during the last two decades, the wider framework of “health transition” has been used, including population change and the way societies and their health systems respond to changing health situations as a result of cultural, social and behavioral determinants.

One of the greatest challenges for international public health research is the gap in health information between rich and poor countries. Births and deaths are often not routinely recorded and most deaths are not medically attended or certified as to cause. This constitutes a major and longstanding constraint to the articulation of effective policies and programs aimed at improving the health of the poor. Scandinavia exemplifies the importance of health data for health policies and prevention activities.

A major challenge for international public health research thus lies in bridging the wide gap between countries of availability of timely health information. Swedish and African researchers have been involved with the INDEPTH network (www.indepth-network.org), now encompassing more than 40 health and demographic surveillance field sites in more than 20 countries, since its foundation in 1998. INDEPTH harnesses the collective potential of these initiatives to provide a better empirical understanding of health and social issues and to apply this understanding to alleviate the most severe health and social challenges.

Health transition in sub-Saharan Africa

Sub-Saharan Africa remains the only major area in the world where the burden of infectious disease still outweighs the burden of non-communicable disease and injuries. In a project initiated by the US National Academy of Sciences (The National Academies Press, Washington D.C (2012) the health transition in Sub-Saharan Africa is overviewed. The project’s aim is to strengthen the scientific basis for policy making through evidence-based research on the continuing and evolving epidemiological transition in Sub-Saharan Africa. As part of this work, Defo proposed a new conceptual framework for analyzing African countries, one that he calls an “eco-epidemiologic life-course framework” for understanding the patterns of health and disease in human populations (Defo BK (2011) Changing contexts of the health, disease and mortality nexus in African countries and regions; University of the Witwatersrand, Johannesburg, South Africa, October 20-22, 2011). Defo´s analysis of 60 years of data indicates that trends in health, disease, and mortality are marked by discontinuities and abrupt changes that reflect the fragility and instability of its countries and the vulnerabilities of its individuals and populations. Specifically, the research demonstrates declines in infant mortality and increases in life expectancy—throughout the continent from the 1950s through the 1990s, a period during which communicable diseases were responsible for most deaths in Africa but growing rates of adult mortality since the 1990s, mostly ascribed to HIV/AIDS and its co-morbidities and which have played a major role in reversing the mortality trend and improvements in life expectancy, and reversing gender differences in life expectancies in several countries because of HIV/AID´s disproportionate impact on women. Finally, wars have played a major role in reversing the trends in under-five mortality decline in sub-Saharan countries in the 1990s and beyond, and particularly so in middle Africa and Eastern Africa.

Health transition in South Africa

South Africa is by no means unique among a number of transitional countries in having insufficient detailed health information for its health service planning. South Africa is severely affected by the HIV/AIDS pandemic, while non-communicable diseases are becoming increasingly important causes of morbidity and mortality.   However, information on these emerging conditions is incomplete and inadequate for effective health policy and planning. What are the main cardiovascular risk factors in rural South Africans? How do these differ from established risk factors based on research in industrialised settings? What are the gender differentials in risk factors, if any?

It is clear that the projections of the World Bank and WHO of NCDs being the major causes of death in the developing countries have already been met and especially so for South Africa. The challenge for the health services of a country with the multiple burden of diseases is to complete the unfinished task of managing the diseases of poverty while simultaneously initiating prevention and cost-effective care of patients with NCDs.

Health is increasingly recognized as a driver of economic and social development, and not merely affected by it. Despite explicit equity goals of the South African Health and Welfare Department, lack of information on the poorest sectors of the population makes appropriate planning and resource allocation to address equity gaps a major challenge.

A tentative research agenda

The structure below is a tentative research agenda relating to the theme of the concept of the emerging health transition in sub-Saharan Africa and in South Africa in particular:

Health transitions do not follow the pattern observed in industrialised countries.

• What are the dynamics of demographic and epidemiological transition – mortality and fertility trends, patterns of risk and causes of death, changes in population composition and life-expectancy – within and across countries? What drives these changes, what is comparable and what is different across settings, and to what extent can future trends be predicted?
• How do these changes differ by age, sex, social group, rural and urban setting, and amongst the poorest? Are health and social inequalities between groups narrowing or widening? How do these inequalities interrelate?

The complex patterns of health transition have profound implications for the well-being of individuals and families, and poorly understood consequences for health systems.

• Who is most vulnerable or resilient? At what ages – childhood, adolescence, working-age, older people – shaped by which risk factors and social conditions?
• How can health systems, currently specialized to provide acute care, be reshaped to address the growing burden of chronic infectious and non-communicable diseases? What approaches can support the growing number of older persons?

The general theme “Health in Transition” can be approached from two perspectives and be investigated under two subthemes, “Prevention” or “Health Care”. Against this background, STIAS welcomes research proposals aimed at exploring various aspects of these subthemes. The following are topics of particular interest and may include aspects of both health prevention and/or health care:

• Surveying and assessing existing data and research
• Emerging trends
• Major unmet challenges
• Universal health care
• The balance between prevention and care
• Health promotion (including social and economic factors)
• A critical examination of existing health systems
• Medical education
• Medical communication
• Implementation (especially middle management)
• Comparative data on success/failure of medical interventions
• Global mental health
• Changing behavior
• Health equity (equal access to health care)Medical dimensions of dealing with violence (for instance rape)
• Affordable health care/health economics (including the power dimensions involved and the respective interests of the health industry, the health profession and political decision makers)
• Critical assessment of forecasting methods (for instance, scenario building rather than prediction)

The research topics listed under the seven long term theme projects are not meant to be exhaustive, but are intended as examples of where further research is needed. Researchers are welcome to indicate gaps and omissions and propose additional or alternative research projects in these fields.

Current projects under this theme

Aspects of major unmet challenges, a critical examination of existing health systems, changing behaviour, health equity, medical dimensions of dealing with violence and affordable health care/health economics are dealt with in the project Future bodies: preventing organ trafficking and focusing on consequences and alternatives to organ shortage.

Cutting across issues of (injury) care and prevention, and universal health care, health promotion, implementation, health equity, and affordable health care is the project Health transition and injury care and prevention.