Global health faces a number of unprecedented challenges that cannot be approached effectively from the perspective of a single discipline, nor by concentrating on one country or region in isolation. These challenges are global in the full sense of the word and in urgent need of innovative research and fresh thinking. They present a unique opportunity for scholars from different parts of the world, and in particular for cooperation between Swedish and South African/African researchers. A special feature of this field is that it is constantly evolving.
The concept of “health transition”
Nowhere are the above challenges more visible than in Africa, where the impacts of HIV and AIDS interact with rapidly growing epidemics of chronic disease of the middle-aged and the unfinished agenda of infection and malnutrition mainly affecting children. This results in an increasingly weakened generation subject to what is often labelled a multiple and polarized burden.
During the 20th century, Sweden, like many European countries, underwent a transition from predominantly infectious causes to non-communicable diseases, with major implications for health services, social support and longevity. This transition was partly fuelled by socio-economic development, as well as by specific medical innovations. Many of the world’s poorer countries are still in the process of similar transitions, and currently at different stages. This has only been explored by researchers to a limited extent, despite the availability of long-term population statistics.
The concept of “transition” has been used to describe the above dynamics and labeled with different prefixes depending on disciplinary perspective. The early concept was labeled “demographic” and it mainly involved mortality and fertility and their consequences for population changes. When later using “epidemiological” as a prefix, the focus has shifted to the complex patterning of health and disease and their demographic, socio-economic and biological determinants while, during the last two decades, the wider framework of “health transition” has been used, including population change and the way societies and their health systems respond to changing health situations as a result of cultural, social and behavioral determinants.
One of the greatest challenges for international public health research is the gap in health information between rich and poor countries. Births and deaths are often not routinely recorded and most deaths are not medically attended or certified as to cause. This constitutes a major and longstanding constraint to the articulation of effective policies and programs aimed at improving the health of the poor. Scandinavia exemplifies the importance of health data for health policies and prevention activities.
A major challenge for international public health research thus lies in bridging the wide gap between countries of availability of timely health information. Swedish and African researchers have been involved with the INDEPTH network, now encompassing more than 40 health and demographic surveillance field sites in more than 20 countries, since its foundation in 1998. INDEPTH harnesses the collective potential of these initiatives to provide a better empirical understanding of health and social issues and to apply this understanding to alleviate the most severe health and social challenges.
Health transition in sub-Saharan Africa
Sub-Saharan Africa remains the only major area in the world where the burden of infectious disease still outweighs the burden of non-communicable disease and injuries. The health transition in Sub-Saharan Africa involves trends in health, disease, and mortality marked by discontinuities and abrupt changes that reflect the fragility and instability of its countries and the vulnerabilities of its individuals and populations. Specifically, the research demonstrates declines in infant mortality and increases in life expectancy throughout the continent from the 1950s through the 1990s, a period during which communicable diseases were responsible for most deaths in Africa but growing rates of adult mortality since the 1990s, mostly ascribed to HIV/AIDS and its co-morbidities which have played a major role in reversing the mortality trend and improvements in life expectancy, and reversing gender differences in life expectancies in several countries. Finally, wars have played a major role in reversing the trends in under-five mortality decline in sub-Saharan countries in the 1990s and beyond.
Health transition in South Africa
South Africa is by no means unique among a number of transitional countries in having insufficient detailed health information for its health service planning. South Africa is severely affected by the HIV/AIDS pandemic, while non-communicable diseases are becoming increasingly important causes of morbidity and mortality. However, information on these emerging conditions is incomplete and inadequate for effective health policy and planning.
It is clear that the projections of the World Bank and WHO of NCDs being the major causes of death in the developing countries have already been met and especially so for South Africa. The challenge for the health services of a country with the multiple burden of diseases is to complete the unfinished task of managing the diseases of poverty while simultaneously initiating prevention and cost-effective care of patients with NCDs.
Health is increasingly recognized as a driver of economic and social development, and not merely affected by it. Despite explicit equity goals of the South African Health and Welfare Department, lack of information on the poorest sectors of the population makes appropriate planning and resource allocation to address equity gaps a major challenge.
A tentative research agenda
The general theme “Health in Transition” can be approached from two perspectives and be investigated under two subthemes, “Prevention” or “Health Care”. Against this background, STIAS welcomes research proposals aimed at exploring various aspects of these subthemes. The following are topics of particular interest:
- Surveying and assessing existing data and research
- Emerging trends
- Major unmet challenges
- Universal health care
- The balance between prevention and care
- Health promotion (including social and economic factors)
- A critical examination of existing health systems
- Medical education
- Medical communication
- Implementation (especially middle management)
- Comparative data on success/failure of medical interventions
- Global mental health
- Changing behavior
- Health equity (equal access to health care)
- Medical dimensions of dealing with violence
- Affordable health care/health economics