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• Geographic Coverage of Surveillance systems: is the Sub Saharan Africa region being misrepresented?
  Gail C Menezes, Robyn Richmond
  Published on: 4 October 2018

• Published on: 4 October 2018

  Geographic Coverage of Surveillance systems: is the Sub Saharan Africa region being misrepresented?

  • Gail C Menezes, Student University of New South Wales
  • Other Contributors:
    • Robyn Richmond, Professor of Public Health/ Associate Dean

  Dear Editor,
  We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
  Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the resu...

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  Dear Editor,
  We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
  Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the results of this study may have more impact if the study had included all countries in SSA.
  The paper by Utazi et al mentions risk factors that influence under five mortality, these include the prevalence of preventable diseases, maternal risk factors, sanitation practices and prevalence of stunting (1). The protective factors mentioned in the paper include education of women, vaccination coverage and access to healthcare facilities (1). These authors discuss the similarities between Health and Demographic Surveillance Systems [HDSS] sites located in urban areas compared to rural areas (1). They determined that the urban areas had higher levels of protective factors and lower levels of risk factors (1). However, the level of infrastructure, urban-rural disparities and presence of intervention strategies in urban areas could be attributed to these findings (3, 4). As Urban areas are easily accessible and tend to have basic infrastructure in place (3), intervention strategies can be implemented with relative ease in urban areas. Similarities between countries in U5M rates in urban areas could be due to urban-rural disparities, infrastructure and accessibility of intervention strategies, which are common features in many low and middle income countries (3, 4).
  In our last point we consider political conflict in a region as a determinant of U5M rates (5). A study based in South Sudan discussed the effect of conflict-related health inequities and inequitable conditions of daily living on U5M (5). Healthcare service delivery becomes a challenge in regions where violence and conflict remain (5). Furthermore, in the region of South Sudan, where conflict and displacement persists, children in urban areas were at greater risk of dying before their fifth birthday, than those living in rural areas (5).

  We agree with the fact that HDSS sites are an important and comprehensive tool for monitoring child mortality and influencing policies related to child mortality. However, the geographical variation in the factors associated with mortality should not be confined to only risk and protective factors as highlighted in this paper (1). We suggest that the variations should also consider factors such as political conflict, displacement and urban rural disparities.
  The implications for future research point to the need for an inclusion of all countries in SSA rather than selected countries that cluster on the east and west of SSA. We have highlighted the importance of considering underlying determinants of conflict and disparities, when analysing the relationship between under five mortality rates and geospatial variables.

  Reference List:
  1. Utazi CE, Sahu SK, Atkinson PM, Tejedor-Garavito N, Lloyd CT, Tatem AJ. Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa. BMJ Global Health. 2018;3(2).
  2. Cooper RS, Osotimehin B, Kaufman JS, Forrester T. Disease burden in sub-Saharan Africa: what should we conclude in the absence of data? The Lancet. 1998;351(9097):208-10.
  3. Mulholland E, Smith L, Carneiro I, Becher H, Lehmann D. Equity and child-survival strategies. Bulletin of the World Health Organization. 2008;86:399-407.
  4. Beatriz ED, Molnar BE, Griffith JL, Salhi C. Urban-rural disparity and urban population growth: A multilevel analysis of under-5 mortality in 30 sub-Saharan African countries. Health & place. 2018;52:196-204.
  5. Mugo NS, Agho KE, Zwi AB, Damundu EY, Dibley MJ. Determinants of neonatal, infant and under-five mortality in a war-affected country: analysis of the 2010 Household Health Survey in South Sudan. BMJ Global Health. 2018;3(1).

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  Conflict of Interest:
  None declared.

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