A spatial model to quantify the mortality impact of service delivery in Sub-Saharan Africa: an ecological design utilizing data from South Africa.

Kurt Sartorius,Benn K D Sartorius

doi:10.1186/1476-072x-12-8

Kurt Sartorius, Benn K D Sartorius

Open Access

https://doi.org/10.1186/1476-072x-12-8

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Abstract

BackgroundSub Saharan Africa is confronted with a wide range of interlinked health and economic problems that include high levels of mortality and poor service delivery. The objective of the paper is to develop a spatial model for Sub-Saharan Africa that can quantify the mortality impact of (poor) service delivery at sub-district level in order to integrate related health and local level policy interventions. In this regard, an expanded composite service delivery index was developed, and the data were analysed using a Bayesian Poisson spatial model.ResultsThe results indicate significant differences in the risk of mortality and poor service delivery at sub-district level. In particular, the results indicate clusters of high mortality and poor service delivery in two of the bigger, poorer provinces with large rural communities. Conversely, two of the wealthier provinces have lower levels of mortality and higher levels of service delivery, but income inequality is more widespread. The bivariate and multivariate models, moreover, reflect significant positive linkages (p < 0.01) between increased mortality and poor service delivery after adjusting for HIV/AIDS, income inequality, population density and the protective influence of metropolitan areas. Finally, the hypothesized provision of a basket of services reduced the mortality rate in South Africa’s 248 sub-districts by an average of 5.3 (0.3-15.4) deaths per 1000.ConclusionThe results indicate that the model can accurately plot mortality and service delivery “hotspots’ at sub-district level, as well as explain their associations and causality. A mortality reduction index shows that mortality in the highest risk sub-districts can be reduced by as much as 15.4 deaths per 1000 by providing a range of basic services. The ability to use the model in a wider SSA context and elsewhere is also feasible given the innovative use of available databases. Finally, the paper illustrates the importance of developing policy in SSA that can simultaneously solve both economic and health problems.

Highlights

Sub Saharan Africa is confronted with a wide range of interlinked health and economic problems that include high levels of mortality and poor service delivery
These provinces consist of 52 districts (46 district municipalities and 6 metropolitans) that can be disaggregated to 248 local municipalities
The highest overall provincial mortality rate was observed in Free State followed by KwazuluNatal and Eastern Cape (Table 1), though the difference in mortality rates was not statistically significant when comparing the top four provinces

Summary

Introduction

Sub Saharan Africa is confronted with a wide range of interlinked health and economic problems that include high levels of mortality and poor service delivery. The objective of the paper is to develop a spatial model for Sub-Saharan Africa that can quantify the mortality impact of (poor) service delivery at sub-district level in order to integrate related health and local level policy interventions. The relationship between mortality and its social determinants has been widely reflected in the literature [8] In this regard, poverty and income inequality elevate the risk of disease and mortality because they promote differential access to limited services and facilities like water and sanitation that are often regarded as primary drivers of health [5,9,10]. Poor service delivery coupled with other household variables, has direct health and economic consequences (see Conceptual Framework) because a lack of basic services reduces productivity, it increases cost and makes households more susceptible to death and disease [1,12,13,14]

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