9

Future Research Directions

The presentations and discussions in the workshop highlighted the importance of improving our understanding of the status and effects of the epidemiological transition in sub-Saharan Africa. The importance and immediacy of the issue was framed by Barthélémy Kuate Defo, who pointed out at the offset of the workshop that (a) since the 1960s, when most countries in sub-Saharan Africa achieved their independence, many contextual changes have affected the epidemiological landscape of the continent and the sub-Saharan African region; (b) urbanization, gross domestic product per capita, improved sanitation and water access, improved per capita agricultural production, improved telecommunications, increases in the number of physicians per 1,000 inhabitants, medical advances, and improved nutrition and living standards are major changes that have taken place in sub-Saharan Africa which have led to improvements in survival rates and substantial gains in life expectancy at birth, paving the way for the ongoing epidemiological transition in sub-Saharan African countries; (c) prospects for durable reductions in mortality are hampered by the high prevalence of communicable and preventable diseases; and (d) the data needed to understand the changes in the epidemiological landscape are thin in most countries in the region.

In the discussion on future directions it was pointed out that the importance of the issue and the paucity of data in sub-Saharan Africa lead to a situation in which estimates of population health parameters must be made but they tend to be made using whatever data are available as inputs to the increasingly sophisticated models that have been developed. These available data are usually at the global level, and the consequence is that national estimates for countries in sub-Saharan Africa tend to derived from global estimates. As better data become available, national estimates should contribute to the global estimates rather than vice versa, as is now the case.

The presentations and discussions at the workshop identified a need to help countries strengthen their health-information systems so that within-country data become the source of information and country figures can be fed into global estimates. In the face of health transitions it is necessary to measure not only health status but also rates of change, implying that within-country data cycles need to be put into operation on an ongoing basis. This is a prerequisite for ensuring a continuous supply of timely health information, rather than forcing analysts to rely on a series of random snapshots.

In the discussion on the national and local-area data needed to capture the epidemiological transition in African countries, workshop participants emphasized the importance of obtaining complete and timely registration of all births and deaths at the national level, including medical certification of the cause of death. However, for both logistical and economic reasons, it is unlikely that near-complete individual registration of births and deaths will be widely implemented in sub-Saharan African countries any



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9 Future Research Directions The presentations and discussions in the workshop highlighted the importance of improving our understanding of the status and effects of the epidemiological transition in sub-Saharan Africa. The importance and immediacy of the issue was framed by Barthlmy Kuate Defo, who pointed out at the offset of the workshop that (a) since the 1960s, when most countries in sub-Saharan Africa achieved their independence, many contextual changes have affected the epidemiological landscape of the continent and the sub-Saharan African region; (b) urbanization, gross domestic product per capita, improved sanitation and water access, improved per capita agricultural production, improved telecommunications, increases in the number of physicians per 1,000 inhabitants, medical advances, and improved nutrition and living standards are major changes that have taken place in sub-Saharan Africa which have led to improvements in survival rates and substantial gains in life expectancy at birth, paving the way for the ongoing epidemiological transition in sub-Saharan African countries; (c) prospects for durable reductions in mortality are hampered by the high prevalence of communicable and preventable diseases; and (d) the data needed to understand the changes in the epidemiological landscape are thin in most countries in the region. In the discussion on future directions it was pointed out that the importance of the issue and the paucity of data in sub-Saharan Africa lead to a situation in which estimates of population health parameters must be made but they tend to be made using whatever data are available as inputs to the increasingly sophisticated models that have been developed. These available data are usually at the global level, and the consequence is that national estimates for countries in sub-Saharan Africa tend to derived from global estimates. As better data become available, national estimates should contribute to the global estimates rather than vice versa, as is now the case. The presentations and discussions at the workshop identified a need to help countries strengthen their health-information systems so that within-country data become the source of information and country figures can be fed into global estimates. In the face of health transitions it is necessary to measure not only health status but also rates of change, implying that within-country data cycles need to be put into operation on an ongoing basis. This is a prerequisite for ensuring a continuous supply of timely health information, rather than forcing analysts to rely on a series of random snapshots. In the discussion on the national and local-area data needed to capture the epidemiological transition in African countries, workshop participants emphasized the importance of obtaining complete and timely registration of all births and deaths at the national level, including medical certification of the cause of death. However, for both logistical and economic reasons, it is unlikely that near-complete individual registration of births and deaths will be widely implemented in sub-Saharan African countries any 19

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time in the near future. Thus it will be important to consider what Alan Lopez and others referred to as the "best-buy" strategies for health data in sub-Saharan Africa. Discussing the choice of data sources, the conferees concluded that it would be useful to combine a variety of sources with different strengths. Such an approach will require research on the quality of various data sources in order to understand which sources are complementary and which are viable in a particular national context and over time. In evaluating the data sources researchers should consider such factors as the size and diversity of a country; the nature and coverage of the country's health system; the local costs of relevant items such as wages, travel, and communications; and which data strategies have been more or less successful in a particular locality. One particularly useful resource for informing the design of data-gathering systems for tracking epidemiological transition is AusAID's Health Information Systems Knowledge Hub (HISHUB; http://www.uq.edu.au/hishub/) at the University of Queensland. Although this system was designed primarily for Asian and Pacific countries, the principles it lays out should translate well to sub-Saharan Africa. According to HISHUB, the minimum data set for understanding epidemiological transitions in order to inform health transitions includes: 1. Reliable unbiased documentation of age- and sex-specific mortality, including the major causes of deaths in the population (civil registration with vital statistics and sentinel or sample mortality surveillance systems with verbal autopsy). Several sources of data on causes of death should be considered. Research should focus on means for obtaining physician-certified coverage of all deaths (at least 90 percent) in a country with cause-of-death coding of reasonable quality; the establishment of systems to collect such data has proved elusive for low-income countries as well as for many middle-income countries and will potentially require decades to achieve. In the meantime, the use of the World Health Organization Health Metrics Network and others interim data sources should be explored. Such interim data sources could include sentinel (urban and rural) demographic surveillance sites and, where possible, statistically representative sample registration sites with verbal autopsy on all deaths. It was suggested that designing, funding, and implementing these interim measures within one to two years would be an attainable goal. 2. Periodic documentation of exposure to the top 10 major risk factors of mortality by age and sex (via periodic population-based surveys). Concerning this issue, it was noted that there are standard adapted survey instruments for each risk factor (smoking, nutrition, high blood pressure, obesity, HIV sero- status, solid fuel smoke exposure, etc.) but that these are rarely assembled into an omnibus national sample survey. Future research strategies should include an extension of the Health Metrics Network and the Household Survey Network in order to promote greater integration and more strategic scheduling of national household surveys. 3. Periodic documentation of the effective coverage of key preventive and curative health interventions aimed at the aboce causes and risk factors 20

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(via periodic health facility surveys or routine health statistics). Information sources for these important measures remain undeveloped. Research is needed to determine a simple methodology that district health managers can apply to understand the annual reach and coverage of their services. Innovative combinations of epidemiological and demographic information would help provide annual estimates at the district level. Health status in low-income countries is changing more rapidly now than at in any prior time in human history. To track and, eventually, to steer these population health dynamics and to understand what such transitions imply for health systems and policies will require radical changes in and a strengthening of national health-information systems so as to provide essential information. In their summary of the issues, Byass, de Savigny, and Lopez (2011) suggested that strengthening the information systems will require concerted investments on three fronts: 1. Interim investments in sentinel or sample registration systems that provide timely and high-quality longitudinal data on deaths and causes of deaths, combined with a concurrent development of effective civil registration systems for vital statistics; 2. Periodic national cross-sectional omnibus sample surveys of the top 10 major risk factors for the major causes of death; and 3. Annual sub-national sample surveys or routine statistics on effective coverage of the essential health interventions relevant to these causes of death. The workshop highlighted the need for countries in sub-Saharan Africa and their international funding partners to prioritize these three dimensions of their national strategies for strengthening health systems. 21