1. Burden of disease: Concepts and applications

2. Session Aims 1.to introduce the concept “burden of disease” 2.to examine patterns and trends in mortality in Southern African settings 3.to discuss and evaluate the concept of “health transition” 4.to introduce the concept of “priority setting” and its relation to burden of disease studies 5.to examine the implications of South African mortality patterns for the provision of health care in the country.

3. Data to measure burden of disease Industrialised versus developing settings National data eg census, vital registration Health facilities Surveys eg household surveys: DHS Sentinel site data eg India, China, HDSS, verbal autopsy Models

4. The disability-adjusted life year (DALY) A single measure of disease burden Expresses years of life lost due to premature death and years lived with a disability (ie years of healthy life lost due to poor health)

5. DALY: Values and methods How “long” should people live? Is a year of healthy life now worth more than in 30 years’ time? Are we – all people – equal? How to compare years of life lost due to premature death, and years lived with disabilities of differing severities?

6. Trends in life expectancy Agincourt 1992-2003

7. Relative increase in mortality, Agincourt 2002-2003 compared to baseline 1992-1993

8. Trends in under-five mortality

9. Trends in adult mortality Age 20-34

10. Trends in cause specific mortality: Infectious & parasitic disease

11. Trends in adult mortality Age 50-64

12. Trends in cause specific mortality: Women 50-64, broad categories

13. Age-standardised death rates, broad cause and broad health care categories, Agincourt 1992-2005

14. Top five causes of death, 50-64 years Agincourt 1992-2005

15. Top five causes of death, children and older adults, Agincourt 1992-2005

16. Prevalence of stroke survivors: South Africa, Tanzania, New Zealand

17. Sub-district services based on network of clinics staffed by primary care nurses with limited support drug supply irregular medical supervision sporadic Poor capacity to manage chronic illness No functional system secondary prevention 103 stroke survivors – only 1 on aspirin 85 hypertensives – 8 on treatment; only 1 controlled General pop ≥ 35 – 43% hypertension; 24% of these treated in past week; half with BP controlled Missed diagnoses Majority of deaths with active TB had previously presented to clinic 2/3 TB patients seen at a clinic self-referred to hospital Care-seeking pluralistic – allopathic, traditional, faith-based most first visits to local clinics = pivotal role Managing chronic NCDs in Agincourt

18. Age-standardised death rates by health care categories, Agincourt sub-district 1992-2005

19. PHC in Practice: Integrating HAART & chronic NCD care

21. Age-specific death rates by nationality of household head

22. Reasons given for non-consultation: no money, ineffective care 25% 18% 26% 7% Household survey data No money

23. Implications of mortality patterns for health system Shift orientation of service provision: chronic, long-term care as well as acute, episodic care Tackle (prevent/control) increasing burden of non- communicable disease and risk Strengthen HIV/AIDS (and TB) prevention, treatment and care Simultaneously maintain and improve on gains in child and maternal health Strengthen primary care provision + referral system Address differential access to care

24. Epidemiological Transition Epidemiologic transition theory: 3 stages Pestilence and famine Receding pandemics Man-made or degenerative disease Critique Not same direction: reversals in mortality “counter transition” Not sequential: stages may overlap, co-existence different diseases “prolonged/protracted transition” Too general: insufficient attention to subgroup differences “epidemiologic polarisation”

25. Rethinking epidemiologic transition: mortality patterns in rural South Africa Counter transition Mortality increasing in children and young adults Protracted or prolonged transition Simultaneous emergence of HIV/AIDS together with increasing non-communicable disease Epidemiologic polarisation Poorest experience highest burden of mortality

26. Why is burden of disease information necessary? “priority setting” and its relation to burden of disease Programme planning Programme evaluation