Who Counts? Understanding and enabling synergies between routine mortality data and data systems inform and rural primary health systems in South Africa
Described as the single most critical development failure of the past 30 years, in Africa and Asia the majority of births, deaths, and causes of deaths are never recorded. Each year, 50 million new-borns are not registered, and half of all countries in Africa and Southeast Asia record no cause of death data. Civil registration and vital statistics are essential public goods that benefit individuals and societies. Official data on births, deaths, and cause of death are essential for planning services, and are the only means of establishing and protecting identities, citizenship, and property rights. Developing methods to record and report on all deaths in resource-constrained settings is therefore an important strategy for saving lives and improving human security. In lieu of functional civil registration, Verbal Autopsy (VA) has emerged a pragmatic alternative to population health data in settings where medical certification is weak or absent. Applied in over 45 low and middle-income countries, VA collects information on medical signs, symptoms and circumstances from witnesses of a death and assigns probable medical causes. Part of WHO’s normative global role is to develop and update standard protocols for VA interviews and cause of death reporting categories, of which the most recent version is the WHO 2016 instrument. Recently, international and regional shifts have supported the transition of VA from research settings into state systems of civil registration and vital statistics (CRVS). As VA shifts towards routine use, computerised methods to collect and interpret standardised VA data have also been developed, enabling new possibilities of scale.
The project will evaluate the impacts of new VA data and data processes in provincial and district policy and planning in rural northeast South Africa as part of the VAPAR (Verbal Autopsy with Participatory Action Research) programme. VAPAR is a health systems research initiative to strengthen mortality data, combine with local knowledge and interpret, plan and act in the health system. The student will be required to spend time at the School of Public Health, University of the Witwatersrand, which hosts the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) Health and Socio-Demographic Surveillance System (HDSS), where the majority of the fieldwork will take place. HDSSs are geographically defined areas representative of district populations that monitor population health. Established in 1992, Agincourt is the oldest and most developed HDSS in South Africa conducting annual updates collecting information on vital events including births, deaths, migration and socioeconomic status. The area is densely populated, with 116,000 people in 18,500 households in 31 villages covering 420 square kilometres; 30% of the population comprises former Mozambican refugees. The sub-district is bordered by Limpopo and is in close proximity to Mozambique. Infrastructure and population density are heterogeneous, ranging from fully serviced houses to isolated rural homesteads. There is little formal sanitation and electricity is available but affordable only to a minority. There is high unemployment and a limited economic base that results in labour migration. 84% of the population is below the poverty line and a significant number of households rely on social grants for survival.
The project will generate new data and insights from VA drawing on statistical methods to produce data on levels and causes of mortality in routine surveillance and to quantify critical limiting circumstances of those deaths. The project will also employ realist evaluation applying quantitative and qualitative methods, including narratives with community and health systems stakeholders, to develop understandings of the impacts of VA data, how they are produced, in which circumstances, leveraging which impacts, including in research and stakeholder engagement (e.g. with new VA data processes); cost savings in services (e.g. reorganising of existing services); policy and planning changes (e.g. changes to provincial performance plans); and health outcomes (e.g. HIV/AIDS-related mortality). Using mixed methods, participatory and coproduction approaches, the student will evaluate the practical utility of new VA data and data systems to understand whether and how impacts have been achieved, adopting a realist context-mechanism-outcome framework.
Please apply for Degree of Doctor of Philosophy in Applied Health Science, to ensure that your application is passed to the correct person for processing.
This project is for self-funded students only - there is no funding attached.
Candidates should have (or expect to achieve) a minimum of a 2.1 Honours degree in a relevant subject. Applicants with a minimum of a 2.2 Honours degree may be considered provided they have a Merit/Commendation/Distinction at Masters level.