Health Transition in sub-Saharan Africa

Abstract

The US National Academy of Sciences (NAS) National Research Council published a report on the effects of health programs on child mortality in sub-Saharan Africa which discusses the factors leading to the mortality decline that started around 1950 and continued throughout the 1980s and provides information on how to sustain this decline (but the report avoids far-reaching conclusions on the role of the health interventions). Child mortality (under age 5 years) has declined from about 290 to about 180 deaths/1000 live births from 1960 to 1985 but we do not know how much of this decline is attributable to biomedical causes to the Expanded Programme on Immunization to the Oral Rehydration Therapy program to the increased use of antibiotics to increased education to changes in nutrition or to improved water and sanitation. The NAS report presents the evidence of specific case studies on changes in mortality determinants but ignores the interventions of family planning and water and sanitation programs. Other ways to determine the effectiveness of interventions would be to analyze when health interventions were introduced and when they obtained substantial coverage and relate these dates to mortality decline or to compare demographic and health survey (DHS) data on key indicators between countries that are reasonably successful in delivering health interventions to those which are not; if the DHS data fail to support the success of the interventions then more effective interventions may be called for. A third method is to examine the mortality impact achieved in research projects. Important lessons from the NAS reports review of case studies (which takes national coverage levels into account to assess possible mortality impact) are 1) there is a dearth of information on integrated studies; 2) efficacy and effectiveness need to be distinguished; 3) lumping the results of a small number of longitudinal studies may not provide a picture applicable to most of the region; and 4) optimism about a single intervention based on a single study is often excessive. Although the NAS report fails to give age-specific mortality trends and differentials the attention they deserve it provides a useful and cautions review of the topic and suggests many avenues of needed research.