About the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) and the Agincourt Health and Socio-Demographic Surveillance System (HDSS)

Much of the information on this page comes directly from an open access article: Profile: Agincourt Health and Socio-Demographic Surveillance System. Kahn et al. International Journal Of Epidemiology 2012;41:988–1001  that can be accessed on  http://ije.oxfordjournals.org/content/41/4/988.full.pdf+html

Main Agincourt office

Main Agincourt Field Offices

The Agincourt Health and Socio-Demographic Surveillance System (HDSS), located in rural northeast South Africa close to the Mozambique border, provides the foundation for the Rural Public Health and Health Transitions Research Unit of the Medical Research Council (MRC) and University of the Witwatersrand, South Africa (the MRC/Wits-Agincourt Unit). Its origins lie in the university’s ‘Health Systems Development Unit’ that in the early 1990s focused on district health systems development, sub-district health centre networks and referral systems and training of clinically oriented primary health care nurses.1–2

The Agincourt HDSS was a founding member of the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) (http://www.indepth-network.org/) and provides leadership to INDEPTH multi-centre initiatives in adult health and ageing3 and migration and health4. back to top

Agincourt HDSS in SA

Location of Agincourt HDSS research site in South Africa

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. back to top

Agincourt  Health and Socio-Demographic Surveillance System (Agincourt HDSS)
The Agincourt Health and Socio-Demographic Surveillance System (HDSS) provides the foundation for the MRC/Wits-Agincourt Unit.  An HDSS is a longitudinal population registration system that monitors demographic dynamics in a geographically defined population.

What is an HDSS

An HDSS monitors how a population changes in a geographically defined area

In 1992, a baseline census was conducted in 20 contiguous villages chosen for their rural living conditions, limited access to public sector services, underperforming primary care clinics and communities of Mozambican refugees displaced by the civil war.3,4 Three phases followed the baseline census:
Office sign in Agincourt1. Decentralised Health Systems Development, 1992-96: Decentralised health systems development (1992-96)1-6 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.  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 in 1994. 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. back to top

2. Deepening observational work:6,7,8  Several cohorts are nested within the population under surveillance and generally focus on subgroups at different stages along the life courseThe Agincourt HDSS contributes to evaluation of national policy at population, household and individual levels. Examples include the following:

i)   introduction of the Rotarix  and pneumococcal conjugate vaccines into the Expanded Programme on Immunization,
ii)   impact of social support grants (old age pension and child support grant) on the health and well-being of grant recipients and other household members, and
iii)   the population impact of decentralized delivery of highly active anti-retroviral therapy (HAART) through public and private health systems.

In addition, a portfolio of work examines household responses to shocks and stresses and the resulting pathways influencing child and adult health and well-being. This includes the care and support roles of older women, intra- and inter-household social connections, use of natural resources, and diverse migration and livelihood strategies. back to top

3. Extending a portfolio of intervention research (2004 onwards): An established university and MRC-linked field research and training programme supporting multiple investigations into the causes and consequences of critical findings from the HDSS.  Ongoing trials target critical problems affecting the health and well-being of children and adolescents. back to top

Who is covered by the HDSS and how often have they been followed up?
At baseline in 1992, some 57,600 people were recorded in 8,900 households in 20 villages;3 by 2006 the population had increased to about 70,000 people in 11,700 households.8 This increase is partly due to Mozambican in-migrants overlooked in the baseline survey; and to a new settlement established as part of the post-apartheid government’s Reconstruction and Development Programme. In 2007 the study area was extended to include the catchment area of a new privately supported community health centre established to provide HIV treatment prior to public sector roll-out of HAART. By mid 2011, the population under surveillance comprised some 90,000 people residing in 16,000 households in 27 villages. In the first quarter of 2013, another 4 villages were added making the number of research villages under surveillance 31, the population some 110 000 in 21 000 households.  Households are self-defined as “people who eat from the same pot of food”. Given sustained high levels of temporary labour migration in Southern Africa, we include temporary migrants resident for less than six months per year who retain close ties with their rural households. There have been 20 census and vital event update rounds, conducted strictly annually since 2000. Participation is virtually complete with only two households refusing in 2011. back to top

The Agincourt HDSS research site
The Agincourt HDSS research site is located in northeast South Africa close to the border with Mozambique, the boundary of the study site abutting on the Kruger National Park conservation area.

map of Agincourt HDSS research site













The Agincourt HDSS covers an area of 475 km2comprising a sub-district of 31 villages with traditional and elected leadership. Since the democratic transition in 1994, infrastructure development has proceeded but at a rate below expectations: electricity is available in all villages but the cost is too high for many households; few gravel roads have been tarred within the sub-district; a dam was constructed nearby but to-date there is no piped water to dwellings and sanitation is rudimentary. Every village has a primary school and most a high school, however the quality of education remains poor9; while almost all children enroll, progress is often delayed with few post-secondary opportunities.

The area is dry in winter (May to October) with soil more suited to game farming than agriculture. Households generally purchase maize and other foods, supplementing this with home-grown crops and collection of wild foods10. South Africa’s non-contributory social grant system is a vital source of household income, notably the old age pension11 and child support grant12,13. There are two health centres and six clinics within the sub-district, with three district hospitals 25 to 60 kms away. back to top

 MRC/Wits Agincourt Unit Organisational Framework
The Agincourt HDSS constitutes a platform for research programmes that elucidate causal pathways and test interventions across the life course. Figure 1 below outlines the organizational framework, indicating major research themes and links between them.

Theme framework
Figure 1
: MRC/Wits Agincourt Unit Organisational Framework

Critical questions relate to:

i)  the dynamics of rapidly evolving health, population and social transitions— including inequalities  between individuals and communities and social and biological explanations,
ii)  determinants of vulnerability and resilience along the life course and
(iii)  implications for policy, programmes and services.

Efforts have been made to deepen observational work, extend a portfolio of intervention research and enhance capacity of the platform to support research training with PhD, post-doctoral and selected masters projects nested within established research areas.

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 and various projects undertaken.

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. back to top

Enhancing capacity of the Agincourt research platform:
Efforts to ensure rigour and extend analytic possibilities include:

i) application of automated measurement techniques to cause-of-death estimation by verbal autopsy, 14-16
ii) full ‘reconciliation’ of in- and out-migrations, follow-up of migrants who depart the study area and iii) recording of extra-household social connections
iii) linkage of individual records in the HDSS with those from sub-district clinics  based on conventional identifiers (name, date of birth, village, ID, cell number and other household members).
iv) establishing cohorts

back to top

And if I want collaborate with the MRC/Wits Agincourt Unit, what do I need to know?
These downloadable Collaborator Guidelines will guide you through the process.


  1. Tollman S, Pienaar J, Mkhabela S. Developing district health systems in the rural Transvaal. Issues based on the Tintswalo/Bushbuckridge experience. S Afr Med J 1993;83:565–68.
  2. Tollman SM, Zwi AB. Health system reform and the role of field sites based upon demographic and health surveillance. Bull World Health Organ 2000;78:125–34.
  3. Tollman SM, Herbst K, Garenne M, Gear JSS, Kahn K. The Agincourt demographic and health study: site description, baseline findings and implications. S Afr Med J 1999;89:858–64.
  4. Tollman SM. The Agincourt field site—evolution and current status. S Afr Med J 1999;89:853–58.
  5. Tollman SM, Kahn K, Ng N (eds), Suzman R (Snr ed). Growing older in Africa and Asia: multicentre study on ageing, health and well-being. Glob Health Action 2010 Suppl 2.
  6. Collinson MA, Adazu K, White M, Findley S (eds). The Dynamics of Migration, Health and Livelihoods: INDEPTH Network Perspectives. England: Ashgate Publishing, 2009.
  7. Bam N, Kahn K, Nant’ulya W, O’ngayo S. Primary Health Care in Mpumalanga: Guide to District-Based Action. Durban: Health Systems Trust, 1996.
  8. Tollman S, Kahn K. Report on the meeting Strengthening ties: The Agincourt field site in its African context. Trop Med Int Health 1997;2:920–23.
  9. Fleisch B. Primary Education in Crisis: Why South African schoolchildren underachieve in reading and mathematics. Cape Town: Juta; 2008.
  10. Hunter LM, Twine W, Patterson L. “Locusts are now our beef”: Adult mortality and household dietary use of local environmental resources in rural South Africa. Scandinavian Journal of Public Health 2007;35(Supplement 69): 165-74.
  11. Case A, Menendez A. Does money empower the elderly? Evidence from the Agincourt demographic surveillance site, South Africa. Scandinavian Journal of Public Health 2007;35(Supplement 69): 157-64.
  12. Schatz E, Madhavan S, Williams J. Female-headed households contending with AIDS-related hardship in rural South Africa. Health & Place 2011;17: 598-605.
  13. Twine R, Collinson MA, Polzer TJ, Kahn K. Evaluating access to a child-oriented poverty alleviation intervention in rural South Africa. Scandinavian Journal of Public Health 2007;35(Supplement 69): 118-27
  14. Byass P, Fottrell E, Huong DL et al. Refining a probabilistic model for interpreting verbal autopsy data. Scand J Public Health 2006;34:26–31
  15. Fottrell E, Kahn K, Ng N et al. Mortality measurement in transition: proof of principle for standardised multicountry comparisons. Trop Med Int Health 2010;15: 1256–65.
  16. Byass P, Kahn K, Fottrell E, Collinson MA, Tollman SM. Moving from data on deaths to public health policy in Agincourt, South Africa: approaches to analysing and understanding verbal autopsy findings. PLoS Med 2010;7:e1000325.

back to top