Monitoring of non-communicable diseases such as hypertension in South Africa: Challenges for the post-2015 global development agenda

Background. Examining the non-communicable disease (NCD) profile for South Africa (SA) is crucial when developing health interventions that aim to reduce the burden of NCDs.Objective. To review NCD indicators in national data sources in order to describe the burden of NCDs in SA, using hypertension as an example.Methods. Age, gender, district of death and underlying cause of death data were obtained for 2008 and 2009 mortality unit records from Statistics SA and adjusted using STATA 11. Data for raised blood pressure were obtained from four national household surveys: the South African Demographic and Health Survey 1998, the Study on Global Ageing and Adult Health 2007, and the National Income Dynamics Study 2008 and 2010.Results. The proportion of years of life lost due to NCDs was highest in the metros and least-deprived districts, with all metros (especially Mangaung) showing high age-standardised mortality rates for ischaemic heart disease, cerebrovascular disease and hypertensive disease. The prevalence of hypertension has increased since 1998. National household surveys showed a measured hypertension prevalence of over 40% in adults aged ≥25 years in 2010. Treatment coverage was 35.7%. Only 36.4% of hypertensive cases (on treatment) were controlled.Conclusion. Further work is needed if NCD monitoring is to be enhanced. Priority targets for NCDs must be integrated into national health planning processes. Surveillance requires integration into national health information systems. Within primary healthcare, a larger focus on integrated chronic care is essential

The importance of identified cause-of-death information being available for public health surveillance, actions and research

An amendment to the South African Births and Deaths Registration Act has compromised efforts to strengthen local mortality surveillance to provide statistics for small areas and enable data linkage to provide information for public health actions. Internationally it has been recognised that a careful balance needs to be kept between protecting individual patient confidentiality and enabling effective public health intelligence to guide patient care and service delivery and prevent harmful exposures. This article describes the public health benefits of a local mortality surveillance system in the Western Cape Province, South Africa (SA), as well as its potential for improving the quality of vital statistics data with integration into the national civil registration and vital statistics system. It also identifies other important uses for identifiable cause-of-death data in SA that have been compromised by this legislation

Estimating the burden of disease attributable to physical inactivity in South Africa in 2000

Objectives. To quantify the burden of disease attributable to physical inactivity in persons 15 years or older, by age group and sex, in South Africa for 2000. Design. The global comparative risk assessment (CRA) methodology of the World Health Organization was followed to estimate the disease burden attributable to physical inactivity. Levels of physical activity for South Africa were obtained from the World Health Survey 2003. A theoretical minimum risk exposure of zero, associated outcomes, relative risks, and revised burden of disease estimates were used to calculate population-attributable fractions and the burden attributed to physical inactivity. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis. Setting. South Africa. Subjects. Adults ≥ 15 years. Outcome measures. Deaths and disability-adjusted life years (DALYs) from ischaemic heart disease, ischaemic stroke, breast cancer, colon cancer, and type 2 diabetes mellitus. Results. Overall in adults ≥ 15 years in 2000, 30% of ischaemic heart disease, 27% of colon cancer, 22% of ischaemic stroke, 20% of type 2 diabetes, and 17% of breast cancer were attributable to physical inactivity. Physical inactivity was estimated to have caused 17 037 (95% uncertainty interval 11 394 - 20 407), or 3.3% (95% uncertainty interval 2.2 - 3.9%) of all deaths in 2000, and 176 252 (95% uncertainty interval 133 733 - 203 628) DALYs, or 1.1% (95% uncertainty interval 0.8 - 1.3%) of all DALYs in 2000. Conclusions. Compared with other regions and the global average, South African adults have a particularly high prevalence of physical inactivity. In terms of attributable deaths, physical inactivity ranked 9th compared with other risk factors, and 12th in terms of DALYs. There is a clear need to assess why South Africans are particularly inactive, and to ensure that physical activity/inactivity is addressed as a national health priority

Quality of cause of death certification at an academic hospital: Cape Town, South Africa

Objectives: To investigate the quality of cause of death certification and to assess the level of under-reporting of HIV/AIDS as a cause of death at an academic hospital. Design: Cross-sectional descriptive retrospective review of death notification forms (DNFs) of deaths due to natural causes in an academic hospital in Cape Town during 2004. Errors in cause of death certification were assessed and ability to be coded according to International Statistical Classification of Diseases and Related Health Problems (ICD-10). The association between serious errors and age, gender, cause of death, and wards was analysed. A sample of DNFs (N=243) was assessed for level of underreporting of HIV/AIDS. Results: A total of 983 death certificates were evaluated. Almost every DNF had a minor error; serious errors were found in 32.2% (95% CI: 29.3-35.1). Errors increased with age, and cause of death was the most important factor associated with serious errors. Compared with neoplasms, which had the lowest error rate, the odds ratio for errors in endocrine and metabolic diseases and genitourinary diseases were 17.2 (95% CI: 8.7-34.0) and 17.3 (95% CI: 7.8-38.2) respectively. Based on the sub-sample, the minimum prevalence of HIV among the deceased patients was 15.7% (95% CI: 11.1-20.3) and the underreporting of deaths due to AIDS was 53.1% (95% CI: 35.8-70.4). Conclusion: This study demonstrates that in almost a third of the DNFs, the errors were serious enough to affect identification of underlying cause of death, confirming the need to improve the quality of medical certification

Trends and inequities in amenable mortality between 1997 and 2012 in South Africa

Background. Amenable mortality comprises causes of death that should not occur with timely and effective healthcare. It is commonly used to assess healthcare performance. It could also be used to assess the effectiveness of the pending National Health Insurance (NHI) in South Africa (SA), but to do this, the level and distribution of amenable mortality are required using a local list of amenable causes. Objectives. To establish an amenable cause-of-death list appropriate for SA and to determine the levels, trends, geographical distribution, population group differences and international comparisons of mortality amenable to healthcare. Methods. A local list of amenable causes of death was developed with input from public health and disease-specific medical experts. The Second SA National Burden of Disease estimates were reclassified into amenable mortality. Analyses of age-standardised death rates (ASDRs) and amenable mortality proportions were conducted by province and population group between 1997 and 2012. Excess mortality in relation to the best-performing province and population group was also analysed. ASDRs for SA were compared with those of European Union (EU) and Organisation for Economic Co-operation and Development (OECD) countries. Results. The local list of amenable conditions contained 45 causes of death. There were large disparities in amenable mortality between provinces and population groups, which did not attenuate over time. There was an average annual percentage increase in amenable ASDRs, but when HIV/AIDS was excluded from the analysis there was an average annual decrease of 1.12%. In the post-peak HIV/AIDS period between 2008 and 2012, an annual average of 207 810 amenable deaths could have been saved if all provinces had the same ASDR as the Western Cape. SA’s ASDR was 2.6 and 2.2 times higher than that of the worst-performing EU and OECD country, respectively. Conclusions. This is the first study known to the authors that has established a local amenable mortality list and described the epidemiology of amenable mortality in SA. Amenable mortality could be used as an indicator of the performance of the pending NHI over time and, in combination with other indicators, could identify areas of the health system that require improvement. Benchmarking could also quantify gaps in health system performance between geographical regions and indicate whether these are reduced with time

Medical certification of death in South Africa – moving forward

Despite improvements to the Death Notification Form (DNF) used in South Africa (SA), the quality of cause-of-death information remains suboptimal. To address these inadequacies, the government ran a train-the-trainer programme on completion of the DNF, targeting doctors in public sector hospitals. Training materials were developed and workshops were held in all provinces. This article reflects on the lessons learnt from the training and highlights issues that need to be addressed to improve medical certification and cause-of-death data in SA. The DNF should be completed truthfully and accurately, and confidentiality of the information on the form should be maintained. The underlying cause of death should be entered on the lowest completed line in the cause-of-death section, and if appropriate, HIV should be entered here. Exclusion clauses for HIV in life insurance policies with Association of Savings and Investments South Africa companies were scrapped in 2005. Interactive workshops provide a good learning environment, but are logistically challenging. More use should be made of online training resources, particularly with continuing professional development accreditation and helpline support. In addition, training in the completion of the DNF should become part of the curriculum in all medical schools, and part of the orientation of interns and community service doctors in all facilities

Where do children die and what are the causes? Under-5 deaths in the Metro West geographical service area of the Western Cape, South Africa, 2011

Background. Accurate child mortality data are essential to plan health interventions to reduce child deaths.Objectives. To review the deaths of children aged <5 years during 2011 in the Metro West geographical service area (GSA) of the Western Cape Province (WC), South Africa, from routine data sources.Methods. A retrospective study of under-5 deaths in the Metro West GSA was done using the WC Local Mortality Surveillance System (LMSS), the Child Healthcare Problem Identification Programme (Child PIP) and the Perinatal Problem Identification Programme (PPIP), and linking where possible.Results. The LMSS reported 700 under-5 deaths, Child PIP 99 and PPIP 252, with an under-5 mortality rate of 18 deaths per 1 000 live births. The leading causes of death were pneumonia (25%), gastroenteritis (10%), prematurity (9%) and injuries (9%). There were 316 in-hospital deaths (45%) and 384 out-of-hospital deaths (55%). Among children aged <1 year, there were significantly more pneumonia deaths out of hospital than in hospital (144 (49%) v. 16 (6%); p<0.001). Among children aged 1 - 4 years there were significantly more injury-related deaths out of hospital than in hospital (43 (47%) v. 4 (9%); p<0.001). In 56 (15%) of the cases of out-of-hospital death the child had visited a public healthcare facility within 1 week of death. Thirty-six (64%) of these children had died of pneumonia or gastroenteritis.Conclusions. Health interventions targeted at reducing under-5 deaths from pneumonia, gastroenteritis, prematurity and injuries need to be implemented across the service delivery platform in the Metro West GSA. It is important to consider all routine data sources in the evaluation of child mortality