South African Medical Journal - Volume 106, Issue 6, 2016
Volumes & issues
Volume 106, Issue 6, 2016
Health financing lessons from Thailand for South Africa on the path towards universal health coverage : guest editorialSource: South African Medical Journal 106, pp 533 –534 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10953More Less
Five years after the release of its Green Paper on National Health Insurance (NHI), 4 years after the institution of NHI pilot sites and following the recent release of the White Paper on NHI, South Africa (SA) needs to move beyond the phase 1 plans , policy making and health system strengthening activities to phase 2 - putting into place the legal and institutional frameworks and systems for implementation of its universal health coverage (UHC) system. In doing so, SA can draw on considerable practical lessons from other countries' reforms in managing UHC with favourable equity outcomes over the past decade. We outline some potentially significant lessons from the Thai health financing system for SA. Thailand has received widespread international recognition as one of several middle-income countries that have made enormous progress in building a UHC system and in achieving 'good health at low cost'. Although its per capita GDP is below that of SA, Thailand has not only massively improved health outcomes (e.g. infant mortality 9.8/1 000) but made great improvements in social security objectives (>99% population coverage, high level of financial risk and impoverishment protection). It has low out-of-pocket payments and health-related catastrophic expenditure has fallen from 2.7% to 0.49%, but there is some room for improvement for urban poor populations.
Author Ronald F. IngleSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i6.10720More Less
To the Editor: In Chris Bateman's Izindaba article entitled 'Consciously cutting to the bone of SA's surgical/anaesthetic delivery', Dr Joe Pahla is quoted as saying 'It was "critical" to put together a package of basic surgical skills that could be used in district and regional hospitals.' Of the challenges faced in rural medicine, it is surgery in particular that can engender feelings of lack of confidence, incompetence and anxiety.
Author Chris ArcherSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10407More Less
To the Editor: The medical indemnity insurance crisis has entered a new phase with one hospital group informing its doctors that they will be barred from use of its facilities after February 2016 if they do not have an indemnity policy with at least ZAR30 million cover. This attitude is likely to be adopted by the other hospital groups, who are all under pressure to ensure that they are adequately insured for any negligent act that may involve them or their staff jointly with the doctor against whom a claim is being raised. According to one source, the minimum excess that a hospital has to pay per insurable event is ZAR10 million. This requirement will, by some margin, trump the hospital income earned through admissions by an individual practitioner. This means that no individual practitioner can expect leniency from the hospital based solely on their income generating capacity. Add to this new requirement the premium of ZAR650 000 the Medical Protection Society (MPS) has commenced charging its obstetric customers for its occurrence-based cover this year (an increase of ZAR200 000 since 2015), and it becomes easy to appreciate the enormity of the crisis.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i6.10721More Less
To the Editor: Public health in sub-Saharan Africa (SSA) is at a crossroads owing to an increasing non-communicable disease burden, with a sizeable contribution from cardiovascular disease (CVD). CVD is the top cause of death globally, and an estimated 80% of CVD-related deaths occur in low- to middle-income countries, including South Africa (SA). Although epidemiological transition is an important factor contributing to the rise in cardiovascular risk factors and CVD, the emerging interaction between communicable diseases such as HIV/AIDS and CVD should not be neglected. HIV infection is now recognised as an independent cardiovascular risk factor; however, the data are mainly from developed countries.
Occupational health and safety and the National Public Health Institute of South Africa : deliberations from a national consultative meeting : correspondenceSource: South African Medical Journal 106, pp 538 –539 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i6.10738More Less
To the Editor: On 11 November 2015, the National Department of Health (NDoH) published the National Public Health Institute of South Africa (NAPHISA) Draft Bill 2015 for public comment. The aim of the Draft Bill is:
'[t]o provide for the establishment of the National Public Health Institute of South Africa in order to conduct disease and injury surveillance and to provide specialised public health services, public health interventions, training and research directed towards the major health challenges affecting the population of the Republic.'
Source: South African Medical Journal 106, pp 540 –541 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11041More Less
The National Department of Health (NDoH) is moving across provinces to centralise obstetric skills to a handful of district hospitals, urgently briefing district healthcare chiefs and ensuring they have sufficient blood supplies in a bid to further lower the 63% rise in caesarean section deaths due to bleeding between 2008 and 2014.
Source: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11040More Less
In spite of a new electronic claims system and ZAR52 billion in its coffers, the Compensation Fund keeps doctors waiting for payments for up to a year - prompting 19 radiologists to sue it for ZAR121.5 million in unpaid claims this March, in what could prove a landmark case.
Author Girish ModiSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11039More Less
There are fewer multiple sclerosis (MS) patients in wheelchairs than ever before in South Africa (SA), mainly owing to the advent of interferon drugs over the past decade and better second-line drugs over the past 3 years, says Prof. Girish Modi, Head of Neurology at the University of the Witwatersrand. He was responding to claims last month by the Biokinetics Association of South Africa (BASA) that physical activity helps manage symptoms and prevent complications and can perhaps even slow progression of MS.
Author R. MatzopoulosSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11034More Less
In the January edition of SAMJ, Prinsloo et al. reported that data from the police and a recent study of injury mortality based on postmortem investigations showed a significant decrease in homicide in South Africa (SA). In 2000, SA had one of the world's highest homicide rates, estimated at 67 per 100 000 population, but this had almost halved by 2009 to 38 per 100 000. Several studies have shown that the decrease has been most evident in firearm-related homicides and that it coincided with the introduction of stricter gun control legislation. One study estimated that more than 4 500 lives were saved across five SA cities from 2001 to 2005. Pro-gun interest groups seeking to promote gun ownership and diffusion have attacked these findings, suggesting that stricter gun control was only enacted in 2004 following the publication of regulations pertaining to the Firearms Control Act (FCA) of 2000. They also argue that the 5-year study period ignored a pre-existing downward trend in firearm homicide, and that postmortem figures conflicted with official statistics, such as those presented by Statistics South Africa (SSA).
Author Keith ScottSource: South African Medical Journal 106, pp 545 –546 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11036More Less
The Central Drug Authority (CDA)'s 'Position statement on cannabis' is a welcome, if somewhat belated, article that gives an indication of the South African (SA) government's response to the shifting sands of local and international public opinion and global drug policies. Most of the policies outlined in this document can be found in the CDA's National Drug Master Plan (NDMP). This article appears to be an attempt to clarify some of those policies, emphasise others and introduce one or two new strategies. Although the title of the paper points to a focus on cannabis, the CDA correctly ties in cannabis issues with those of alcohol, tobacco and other illicit psychoactive substances.
Author Quarraisha Abdool KarimSource: South African Medical Journal 106 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.11026More Less
Almost 40% of the population of sub-Saharan Africa are between the ages of 12 and 24 years. Adolescence is a time of important biological, physiological, neurological, behavioural and social transitions towards adulthood. This period of transition is characterised by higher impulsivity, increased sensation-seeking behaviour, higher risk-taking behaviours relating to substance use and/or sexual experimentation, an increased sense of self-awareness/invincibility, and a higher importance of social relationships involving partners and peers rather than parents and older siblings. Not surprisingly, the psychological stressors of going through adolescence, coupled with major hormonal, physiological and identity development and peer pressure (to fit in with dominant peer norms), result in enormous stress levels that sometimes lead to a variety of mental health disorders, e.g. inadequate coping and/or support structures.
Source: South African Medical Journal 106, pp 548 –550 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10943More Less
Adolescence is a period of significant physical, social and emotional change and therefore a vulnerable period for the development of mental illness. Many psychiatric disorders have their onset during adolescence. Approximately 20% of children have a mental health disorder, but the majority of disorders are not detected and treated. Risk factors for mental illness include: genetic vulnerability, neurobiological factors and psychosocial stressors. Common mental disorders during this period are mood, anxiety and substance related, with adolescents often presenting with comorbidity. Healthcare practitioners should screen for adolescent mental illness and associated suicide risk. Brief screening tools such as the Strengths and Difficulties Questionnaire are useful in detecting mood and anxiety disorders in primary care settings. While there is increasing evidence for the efficacy of psychotropic medications in adolescents, more research is still required. Management of adolescent mental health problems generally requires a combination of psychotropic medication and psychosocial interventions. Early intervention and support in an integrated medical and psychiatric healthcare system is required.
Source: South African Medical Journal 106, pp 551 –553 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10944More Less
Excessive alcohol consumption constitutes a significant public health problem for South Africans. Alcohol use by South African (SA) adolescents is characterised mainly by binge/heavy episodic drinking. Levels of binge drinking have been high, but relatively stable, among males since 2002, while there has been a significant increase in binge drinking by females since then. Binge drinking is a major risk factor for a range of alcohol-related harms in SA, including traffic-related accidents and deaths, interpersonal violence, fetal alcohol spectrum disorder (FASD), crime, sexual risk behaviour, HIV, tuberculosis and the resultant burden of all of these on the economy. Clinicians may play a key role in addressing adolescent alcohol use and alcohol-related harm. Such a role may involve screening, brief interventions and referrals to treatment. There are several assessment, screening and diagnostic tools to detect alcohol use and misuse, specifically among adolescents. Furthermore, various pharmacological and psychological approaches are available to treat adolescent alcohol problems. Special issues to consider when dealing with alcohol use problems among adolescents in SA include recognising the risk factors, and acknowledging and addressing the harms associated with alcohol use (including sexual risk behaviour and FASD) and the possible existence of comorbid mental health problems.
Clinical practice - the role of appropriate diagnostic testing in acute respiratory tract infections : an antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care : in practiceSource: South African Medical Journal 106, pp 554 –561 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10857More Less
Antibiotic resistance has increased worldwide to the extent that it is now regarded as a global public health crisis. Interventions to reduce excessive antibiotic prescribing to patients can reduce resistance and improve microbiological and clinical outcomes. Therefore, although improving outpatient antibiotic use is crucial, few data are provided on the key interventional components and the effectiveness of antibiotic stewardship in the primary care setting, in South Africa. The reasons driving the excessive prescription of antibiotics in the community are multifactorial but, perhaps most importantly, the overlapping clinical features of viral and bacterial infections dramatically reduce the ability of GPs to distinguish which patients would benefit from an antibiotic or not. As a consequence, the need for tools to reduce diagnostic uncertainty is critical. In this regard, besides clinical algorithms, a consensus of collaborators in European and UK consortia recently provided guidance for the use of C-reactive protein point-of-care testing in outpatients presenting with acute respiratory tract infections (ARTIs) and/or acute cough, if it is not clear after proper clinical assessment whether antibiotics should be prescribed or not. A targeted application of stewardship principles, including diagnostic stewardship as described in this review, to the ambulatory setting has the potential to affect the most common indications for systemic antibiotic use, in that the majority (80%) of antibiotic use occurs in the community, with ARTIs the most common indication.
Clinical alert - emergence of vancomycin-resistant Enterococcus at a tertiary paediatric hospital in South Africa : in practiceSource: South African Medical Journal 106, pp 562 –566 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10858More Less
Background. During 2013, the haematology/oncology unit at a tertiary level paediatric hospital in South Africa experienced the emergence of infection with vancomycin-resistant Enterococcus (VRE).
Objective. To describe the clinical and molecular aspects of the cases identified.
Methods. VRE isolates identified from blood culture specimens processed at the National Health Laboratory Service were screened for the presence of the vancomycin resistance genes vanA, B and C1, 2 and 3. Further characterisation of these isolates was carried out using pulsedfield gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Clinical records of infected patients were reviewed to identify possible risk factors, while surveillance with rectal swabs was performed to identify VRE-colonised patients.
Results. Four patients with haematological malignancies were identified with VRE bloodstream infections. Patients were immuno-compromisedat the time of the bloodstream infection (BSI), with receipt of vancomycin prior to VRE-BSI, and infections were treated with linezolid. Colonisation with VRE was found in 8 of 55 patients screened. Infected and colonised patients were isolated in the unit during their admission and strict contact precaution infection control practices were instituted. The vanA gene was identified in all of the isolates but one. PFGE and MLST results showed a degree of genetic relatedness between certain isolates obtained from rectal swab and blood culture samples, suggesting possible patient-to-patient transmission or persistence of the isolates in the unit.
Conclusion. Strict infection control practices are necessary to prevent infection and transmission of resistant organisms among vulnerable patients.
Clinical alert - heavy alcohol use in patients on highly active antiretroviral therapy : what responses are needed? : in practiceSource: South African Medical Journal 106, pp 567 –568 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10639More Less
Background. Alcohol has a negative effect on antiretroviral therapy (ART) adherence and HIV treatment outcomes.
Method. As part of formative work for a project to test the efficacy of an alcohol-focused intervention to reduce alcohol consumption and improve HIV treatment outcomes, we investigated the extent of problem drinking among patients at ART clinics in Tshwane, South Africa (SA), using the Alcohol Use Disorders Identification Test (AUDIT).
Results. The finding that a third of drinkers reported hazardous drinking, roughly 10% reported harmful drinking, and a further 10% were possibly alcohol dependent replicates the findings of similar research in the Western Cape and Gauteng provinces of SA. It also points to the need for more routine screening of ART patients for problematic alcohol use.
Conclusion. The 10-item AUDIT may be too time consuming for health workers in busy ART clinics to administer and score, necessitating even briefer screening instruments for assessing hazardous and harmful drinking.
Author D.J. SteinSource: South African Medical Journal 106, pp 569 –570 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10863More Less
There is an ongoing national debate around cannabis policy. This brief position statement by the Executive Committee of the Central Drug Authority outlines some of the factors that have contributed to this debate, delineates reduction strategies, summarises the harms and benefits of marijuana, and provides recommendations. These recommendations emphasise an integrated and evidence-based approach, the need for resources to implement harm reduction strategies against continued and chronic use of alcohol and cannabis, and the potential value of a focus on decriminalisation rather than the legalisation of cannabis.
Healthcare delivery - complex adaptive HIV/AIDS risk reduction : plausible implications from findings in Limpopo Province, South Africa : in practiceSource: South African Medical Journal 106, pp 571 –574 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10255More Less
This article emphasises that when working with complex adaptive systems it is possible to stimulate new social practices and/or cognitive perspectives that contribute to risk reduction, associated with reducing aggregate community viral loads. The process of achieving this is highly participatory and is methodologically possible because evidence of 'attractors' that influence the social practices can be identified using qualitative research techniques. Using findings from Limpopo Province, South Africa, we argue that working with 'wellness attractors' and increasing their presence within the HIV/AIDS landscape could influence aggregate community viral loads. While the analysis that is presented is unconventional, it is plausible that this perspective may hold potential to develop a biosocial response - which the Joint United Nations Programme on HIV and AIDS (UNAIDS) has called for - that reinforces the biomedical opportunities that are now available to achieve the ambition of ending AIDS by 2030.
Medicine and the law - when are doctors legally obliged to stop and render assistance to injured persons at road accidents? : in practiceAuthor D.J. McQuoid-MasonSource: South African Medical Journal 106, pp 575 –577 (2016) http://dx.doi.org/10.7196/SAMJ.2016v106i6.10503More Less
Unlike the USA, South Africa (SA) does not have 'Good Samaritan' laws that oblige doctors to stop at road accidents. In SA, the conduct of doctors in such situations is governed by the common law. Doctors coming across injured people at a road accident should stop and render assistance, unless they are likely to be exposed to personal danger or injury, they are mentally or physically incapable of assisting, or other medical or paramedical practitioners are at the scene. Where there is the threat of personal danger to the doctor, they must immediately report the accident to the police, advise the police to send protection and call for urgent ambulance assistance. Doctors should remain in a safe place near the scene until the police and ambulance arrive and check that paramedics are available to stabilise the injured before departing. Where there is the threat of danger, if doctors are mentally or physically unable to assist or if other medical or paramedical practitioners are at the scene, doctors may or may not be required to stop.
Medicine and the law - managing the remains of fetuses and abandoned infants : a call to urgently review South African law and medicolegal practice : in practiceSource: South African Medical Journal 106, pp 578 –581 (2016) http://dx.doi.org/10.7196/SAMJ.2016.v106i6.10598More Less
This article reviews South African (SA) law and its impact on the medicolegal management of fetal remains emanating from elective and therapeutic termination of pregnancies, stillbirths and miscarriages and the remains of abandoned or exposed infants. It was found that remains are treated differently, some constituting medical waste while others have sufficient status in law to allow for burial. This approach results in some women or couples being denied a choice with regard to disposal via culturally relevant practices, and is insensitive to the fact that all remains ultimately constitute human remains. The article argues that SA law is in urgent need of reform, and turns to foreign law and forensic practice to shed light on possible alternative approaches that could assist with developing the SA position and thereby improve the practical management of fetal and infant remains in SA.