Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study.

Victoria Pillay-Van Wyk,Debbie Bradshaw,Nadine Nannan,Rob E Dorrington,Nontuthuzelo Somdyala,Edward Nicol,Ian Neethling,William Msemburi,Theo Vos,Nomfuneko Sithole,Tracy Glass,Megan Prinsloo,Pam Groenewald,Ria Laubscher,Jané D Joubert,Anastasia Rossouw,Richard Matzopoulos,Beatrice Nojilana,Nomonde Gwebushe

doi:10.1016/s2214-109x(16)30113-9

Abstract

The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality. We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison. All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence. This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data. South African Medical Research Council's Flagships Awards Project.

Highlights

Despite being an uppermiddle-income country,[3] South Africa has high mortality levels resulting from a unique quadruple disease burden, described in the first National Burden of Disease study in 2000.4 The 2009 Lancet Series on Health in South Africa[2,5] ascribed the poor health status to the country’s history of colonialism and apartheid, which resulted in every aspect of life being racially segregated, exploitation of the working class, high poverty and unemployment, and extreme wealth inequalities.[6]
The second National Burden of Disease (NBD) study, we describe the trends in mortality during a 16-year period and estimate deaths by specific causes and years of life lost to premature mortality nationally and provincially, after adjusting for these data inadequacies
In 2012, 43·4% of the deaths were attributed to noncommunicable diseases, 33·6% to HIV/AIDS and tuberculosis, 13·5% to other communicable diseases, perinatal conditions, maternal causes, and nutritional deficiencies, and 9·6% to injuries

Summary

Introduction

South Africa has poor health outcomes given its level of economic development.[1,2] Despite being an uppermiddle-income country,[3] South Africa has high mortality levels resulting from a unique quadruple disease burden, described in the first National Burden of Disease study in 2000.4 The 2009 Lancet Series on Health in South Africa[2,5] ascribed the poor health status to the country’s history of colonialism and apartheid, which resulted in every aspect of life being racially segregated, exploitation of the working class, high poverty and unemployment, and extreme wealth inequalities.[6]. The beginning of democracy in 1994 led to efforts to build a society with racial equality, postapartheid macroeconomic policies have focused more on economic growth than on wealth inequality.[2,6] The 2012 update of the Lancet Series[7] acknowledged improved access to water, sanitation, and electricity, and increased provision of social grants[6] but noted the large racial differentials in social determinants of health. The health service faces considerable challenges, including inefficiencies and inequities.[5,6] More than half of the country’s health-care financing, and more than 70% of the country’s doctors are employed in the private sector, serving about 20% of the population.[8]

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