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About the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and the Agincourt Health and socio Demographic Surveillance System (HDSS)
Summary
In 1992, research on health, demography and health systems was initiated in Agincourt, a rural subdistrict of Bushbuckridge, Limpopo Province, South Africa, close to the Mozambican border. In April 1998, the University Research Committee of the University of the Witwatersrand recognised the Agincourt Unit as a research programme of the University. This status was upgraded to that of a University Research Unit in 2000 (Agincourt Health and Population Unit - AHPU). In 2002, the unit achieved additional recognition as the Medical Research Council/ University of the Witwatersrand Rural Public Health and Health Transitions Research Unit (Agincourt).
There was an absence of vital registration in the Agincourt area; thus, a demographic and health surveillance system was introduced in 1992. The Agincourt HDSS includes annual census and special events updates (systematic recording of all births, deaths and migrations). Over the 1992-1996 period the research focused on decentralised health systems development. From 1997, the work transitioned from an emphasis on health systems research and development to a primary research focus on health, population, and social transitions. Currently work focuses on health and social trends and transitions as well as study training. The seventeenth census update was completed in 2011.
In 2000, Agincourt was one of the founding members of the INDEPTH Network (International Network for the Demographic Evaluation of Populations and Their Health in developing countries). The vision of INDEPTH is to harness the collective potential of the world s community-based longitudinal demographic surveillance initiatives in resource constrained countries. Collective work will provide a better, empirical understanding of health and social issues, and enable scientists to apply this understanding to alleviate the most severe health and social challenges.
Unit goal and aims
The Unit’s goal / mandate is:
To better understand the dynamics of health, population and social transitions in rural South (and southern) Africa in order to mount a more effective public health, public sector and social response.
The Unit has established a critical research platform for a programme structured to elucidate causal pathways and test interventions informed by prior studies. This programme will support advanced research training, develop systems to render data more widely available and provide leadership to INDEPTH multi-site initiatives.
Specific Aims
- To enhance capacity of the Agincourt research platform, including the Health and Socio-demographic Surveillance System (HDSS) and data management system, through:Applying strengthened measurement techniques to: cause-of-death estimation by validated verbal autopsy, full ‘reconciliation’ of in- and out-migration events, and recording of extra-household person-to-person social connections
- Instituting a standardized approach to each project, thus facilitating data management and linking of project datasets to the HDSS
- Establishing effective, individual-level links between population records and health facility registries in the sub-district (‘clinic-HDSS link’)
- Implementing effective policies and methods for requesting/releasing data to students, collaborators and other scientists, including accessible web-based mechanisms.
- To support an interdisciplinary research and intervention programme which will:
- Analyse trends describing health, population and social transitions; support simulation of populations affected by HIV/AIDS to predict the effects of interventions; and interpret divergences from contemporary transition theories
- Develop and test interventions targeting critical problems affecting the health and wellbeing of children and adults, under the research themes Child health and development; Adult health and wellbeing; HIV/AIDS and Chronic Care.
- Evaluate personal effects and population impacts of decentralised delivery of highly active anti-retroviral therapy (HAART)
- Investigate household responses to shocks and stresses
- Inform effective responses by the health sector and related development sectors such as education.
- A vigorous programme of research training focusing on doctoral and senior masters candidates nested within major research projects, with post-doctoral opportunities, and seeking promising scholars from South Africa and the region.
- Scientific leadership in multi-site collaborations involving the INDEPTH Network of HDSS sites, with emphasis on adult health and ageing, health consequences of migration and urbanisation, and trend analyses of mortality and cause of death. To strengthen collaborations with inter alia the Birth-to-Twenty cohort, Soweto, and three INDEPTH sites: the Africa Centre for Health and Population Studies in KwaZulu-Natal, the Dikgale HDSS in Limpopo Province, and the African Population and Health Research Centre, Nairobi.
Agincourt fieldsite (HDSS)
The Agincourt HDSS, and related baseline census, were first introduced in 1992 as part of a programme of decentralised health systems research and development that aimed to inform the rural efforts of a new South African Ministry of Health. The total population then numbered some 58,000 persons, rising to about 84,000 today in 14 500 households across 24 political villages (divided into 25 for research purposes) covering about 450 sq km. The Bushbuckridge Sub-District, where the Agincourt fieldsite is located, was part of the Gazankulu “homeland” during the pre-1994 apartheid era; post-1994, the area was politically contested. Although first incorporated against the wishes of local people in 1994 into the Limpopo Province, it was transferred in 2006 to the adjacent Mpumalanga Province. The presence of significant numbers of former Mozambican refugees, some 30% of the sub-district population, coupled with the area’s location alongside the western border of Mozambique, serves to render the setting not only a part of north-eastern South Africa but also a border region of rural southern Africa (see maps).
Work in Agincourt passed through several stages following a baseline census in 1992:
Decentralised Health Systems Development, 1992-96: Decentralised health systems development (1992-96) was closely aligned with, and contributed to, national and provincial Department of Health (DOH) strategies. These sought to establish primary health care oriented district-based health systems as the basis for an equity-sensitive national public health system. Work in this period provided a prototype for national policy in response to limited experience delivering rural services. Demographic surveillance, conducted approximately annually, was introduced in Agincourt through a baseline census in 1992 (pop. 58,000), just prior to South Africa’s first democratic election (1994), and as part of a university-linked initiative to inform policy and practice on the decentralisation of rural public health services. Working closely with district and provincial services, research and development efforts addressed planning and operational challenges in district systems development, quality of care, decentralised laboratory development, and evaluation of community programmes. Work also contributed to WHO efforts to strengthen district systems.
Strategic Review, 1996-97: By the mid-1990s it was apparent that the evidence base for public sector decentralisation and local development was inadequate. Limited knowledge of population structure and distribution, and ignorance of the cause-of-death profile were severe constraints that provoked a reconsideration of Agincourt directions. Following wide consultation with scientific colleagues and review of HDSS findings, work was reoriented to the research interface between the health and population sciences, with the goal of understanding health and population dynamics in rural South Africa in order to mount a more effective public health response. The period also saw concerted Agincourt technical support for start-up of the Dikgale DSS site of the University of the North, and preliminary discussions on a potential international network of DSS sites.
Health and Population Research, 1998-2004: As our work progressed, we became increasingly aware of major gaps in the population evidence base available - gaps which, in our view, can profoundly undermine DOH goals and programmes. Thus, by the late 1990s, the Agincourt programme of health systems R&D evolved towards the research portfolio that now constitutes this MRC Unit. Critical to the current phase is effectively institutionalising a high-functioning HDSS platform among Agincourt communities: ensuring its acceptance, securing office accommodation and associated infrastructure, strengthening and regularising field operations, consolidating data management and assuring quality, investing in the field, supervisory and managerial staff necessary, and demonstrating timely production of datasets for analysis and collaborations. Establishing a field-based research and training programme linked with Witwatersrand University (2003 onwards) that is central to an interdisciplinary university initiative termed ‘Population, Health and Society’.
Health Transitions Research and Training, 2005 onwards: The HDSS now provides an exceptional platform to study the dynamic patterns of infectious and non-communicable disease in southern Africa, including their social causes and consequences. Furthermore, it will enable us to train a cadre of young scientists to take this research agenda forward, including the development of critical interventions, into the 21st century.
Research portfolio
Work in Agincourt is founded on a research model that seeks to partner a strong, in-house scientific core with exceptional national and international health and population scientists. Achieving a compelling research portfolio requires productive interdisciplinary partnerships, attuned to Southern African priorities, and capable of generating the research investments necessary. Several such collaborations have been formed; prospects over the coming period are most promising with key project lines having entered the field during 2010/11.
The figure above provides the framework for the Unit’s research programme, indicating major research themes and their links. Every project is linked to the HDSS, relies on its data management system during field and analytic phases, and will ultimately contribute new datasets to the research platform thus extending and enriching it. To avoid overburdening study participants, HDSS management monitors selection of samples to limit participation in multiple studies. Project funding is sourced separately.
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