South Africa is not the only country faced with a flight of doctors over working conditions. According to a survey of UK medical students published by BMJ Open, one in three plan to leave the National Health Service (NHS) – either to practise abroad or to stop practising medicine entirely. Of those who plan to go abroad, nearly half plan on never returning.
The responses indicate that pay, work-life balance, and working conditions are the key drivers behind the decisions to leave.
The UK has 3.2 doctors for every 1000 people, ranking 25th among the Organisation for Economic Co-operation and Development (OECD) countries. This figure also represents the lowest number of doctors per head among European countries in the OECD, note the researchers.
In response to the shortage of doctors amid rising healthcare demand, the British government has opened new medical schools and expanded the student capacity of existing ones. But without addressing the issue of retention, increasing the number of medical students is unlikely to provide a sustainable long-term solution, they point out.
In a bid to understand current career intentions after graduation and on completion of the 2-year Foundation Programme, the researchers surveyed 10 486 medical students, around 25.5% of the total, from across 44 UK medical schools between January and March 2023.
The survey included sections on intended career immediately after graduation and after foundation training (if applicable), as well as the factors influencing decision-making.
Respondents’ average age was 22; around two thirds (66.5%) were women. All students were asked their career intentions after graduation with most (8806; 84%) saying they planned to complete both years of the UK’s foundation training after graduating.
But around 1 in 10 (10.5%;1101) intended to complete year 1 of foundation training and then emigrate to practise medicine: completion of the first year of foundation training provides doctors with full registration with the UK’s medical regulator (GMC), which is recognised internationally.
Another over 2% (220) planned to emigrate to practise medicine immediately after graduation while just over 1% (123) intended to take a break or undertake further study.
Just over 1% of respondents (132) planned to complete their first foundation year and then leave the profession, while just under 1% (104) intended to leave medicine permanently immediately after graduation.
Among the 8806 respondents intending to complete both foundation years, nearly half (49%;4294) planned to enter specialty training in the UK immediately afterwards.
Around a fifth (21%;1859) intended to enter a ‘non-training’ clinical job in the UK such as junior clinical fellowship or clinical teaching fellowship, or working as a locum doctor).
A further 23.5% (2071) intended to emigrate to practise medicine abroad, while around 6% (515) planned to take a break or undertake further study. Just 67 planned to leave medicine permanently after completion of year 2 of foundation training.
Around half (49.5%;1681) planned to return to UK medicine after a few years, while nearly 8% (267) intended to return after completion of their medical training abroad. But 42.5% (1444) indicated no intention to return.
Of those favouring emigration immediately after graduation, just under 81% didn’t intend to return to the UK. This fell to 60% (661) among those planning to emigrate after completing year 1 of foundation training and 29% (605) among those planning to emigrate after year 2.
Among the 2543 medical students expressing a preference for destination country, Australia was the most commonly mentioned (42.5%), followed by New Zealand (18%), the USA (10.4%) and Canada (10.3%).
In total, around a third of medical students (32.5%;3392) plan to leave the NHS within 2 years of graduating, either to practise abroad or to pursue other careers.
Remuneration at junior level, work-life balance, lack of autonomy over choice of training location, and the working conditions of doctors in the NHS were cited as the most important factors for those respondents intending to emigrate to continue their medical career.
These reasons were also given by those planning to abandon medicine altogether, with nearly 82% of them also listing burnout as an important or very important reason.
Only just over 17% of all respondents said they were satisfied or very satisfied with the overall prospect of working in the NHS.
Intention doesn’t necessarily translate into action, and minds may change, say the researchers. And while the 25% response rate is relatively large, that still means a substantial proportion of the medical student body weren’t surveyed.
But they highlight: “This study highlights that an alarming proportion of surveyed medical students intend to leave the profession or emigrate to practise medicine,” emphasise the researchers, “representing a potential loss of valuable medical talent.”
They continue: “The findings of this study emphasise the urgency of addressing the factors that are driving the exodus of doctors from the NHS and suggest that increased recruitment of medical students may not provide an adequate solution to staffing challenges.
“The causes of the problem are complex, and finding a solution will require a multifaceted approach. Steps could include improving work-life balance, increasing salaries, addressing the growing competition for specialty training posts and promoting greater flexibility in career pathways.”
They conclude: “Undoubtedly, the continued loss of skilled professionals from the NHS represents a significant concern, so it is critical to consider means of reversing this trend.”
Blood pressure among patients diagnosed with hypertension appeared to slightly increase and rates of systolic blood pressure being controlled during an outpatient visit appeared to slightly decrease during winter months, according to a new study presented at the American Heart Association’s Hypertension Scientific Sessions 2023.
Previous research has found that blood pressure varies with the seasons of the year, most of which is systolic blood pressure. The study authors sought to understand whether blood pressure control, defined in this study as less than 140/90mmHg among patients with hypertension, varied by season.
“Despite the smaller degree of systolic blood pressure variation in comparison to previous studies on seasonality in blood pressure, we were surprised to observe a large degree of change in blood pressure control between winter and summer months,” said lead study author Robert B. Barrett, a software engineer at the American Medical Association in Greenville, South Carolina. “Individuals with hypertension or values near the range of hypertension may benefit from periodic blood pressure monitoring and improvements in physical activity and nutritional patterns during winter months to offset adverse effects from seasonal blood pressure changes.”
The researchers reviewed electronic health records for 60 676 adults treated for hypertension between July 2018 and June 2023 at six health care centres. Each participant remained on their originally prescribed classes of antihypertensive drugs throughout the review period. The centres ranged from small health centres or clinics to large academic medical centres. Seasonal blood pressure readings were analysed to assess variations in blood pressure control during the northern hemisphere’s winter vs summer months (December through February vs June through August, respectively) as part of an American Medical Association-supported, quality-improvement program for clinicians and health care centres. Study participants were an average age of 62 years old; 52.3% identified as white race; 59.7% identified as female.
The analysis of the health records found that, on average, participants’ systolic blood pressure increased by up to 1.7mmHg in the winter months compared to the summer months. In addition, they found that blood pressure control rates decreased by up to 5% during the winter months.
Future directions for investigation might include analysing the frequency of heart disease and deaths during each season, the authors noted.
The study’s limitations include that the electronic health records did not capture a complete health history for each participant and that information collected for each patient was retrieved only from the institution where they were treated.
The ketogenic (keto) diet may lower testosterone levels in women with polycystic ovary syndrome (PCOS), according to a new paper published in the Journal of the Endocrine Society. The diet also appeared to lower follicle-stimulating hormone (FSH) levels, which may thereby improve the chances of ovulating. These improvements in hormonal balance could help alleviate fertility problems.
PCOS is the most common hormone disorder in women, affecting 7–10% of women of childbearing age. It can cause infertility and raises the risk of developing diabetes, obesity and other metabolic health problems.
Women with PCOS have at least two of these signs:
Elevated levels of testosterone and other androgen hormones associated with male reproduction,
Irregular periods, and
Large ovaries with many small follicles.
The keto diet is a high fat, low carbohydrate diet that has shown promising effects in women with PCOS. Studies have shown that it may help women lose weight and maintain weight loss, improve their fertility, optimise their cholesterol levels and normalise their menstrual cycles.
“We found an association between the ketogenic diet and an improvement in reproductive hormone levels, which influence fertility, in women with PCOS,” said study author Karniza Khalid, MBBS, MMedSc, of the Ministry of Health Malaysia in Kuala Lumpur, Malaysia. “These findings have important clinical implications, especially for endocrinologists, gynaecologists and dieticians who, in addition to medical treatment, should carefully plan and customise individual diet recommendations for women with PCOS.”
The researchers conducted a meta-analysis of clinical trials in women with PCOS on the keto diet and examined the diet’s effects on their reproductive hormones (FSH, testosterone and progesterone) and weight change.
They found women with PCOS who were on the keto diet for at least 45 days saw significant weight loss and an improvement in their reproductive hormone levels. Their FSH ratio was lower, which means they may have a better chance of ovulating. The women also had lower testosterone levels, which could help with excess hair growth and other symptoms of excess male sex hormones.
Researchers in Japan have shown that the commonly prescribed antipsychotic drug aripiprazole helps reduce sleep disruptions in patients with certain psychiatric disorders by improving their natural entrainment to light and dark cycles. Their findings are published in Frontiers in Neuroscience.
Many patients with psychiatric conditions, such as bipolar disorder and major depressive disorder, frequently experience disruptions in their sleep–wake cycles. Research has shown that the administration of aripiprazole, a commonly prescribed antipsychotic drug, alleviates the symptoms of circadian sleep disorders in these patients. This improvement may be attributed to the effects of aripiprazole on the circadian central clock, specifically the hypothalamic suprachiasmatic nucleus (SCN), which regulates various circadian physiological rhythms, including the sleep–wake cycle, in mammals. However, the precise mechanism through which aripiprazole addresses these sleep disorder symptoms remains elusive.
Researchers from the University of Tsukuba have discovered that aripiprazole can directly affect the mammalian central circadian clock; specifically, it can modulate the photic entrainment in mice. Located in the hypothalamic suprachiasmatic nucleus (SCN), the central circadian clock comprises clock neurons that synchronize with each other, maintaining a roughly 24-hour rhythm. Simultaneously, SCN is receptive to external inputs like light, aligning itself with the environmental light-dark cycle. The researchers have found that aripiprazole disrupts the synchronization among the clock neurons in the SCN, heightening the responsiveness of these neurons to light stimuli in mice. Additionally, aripiprazole influences intracellular signalling within the SCN by targeting the serotonin 1A receptor, a prominent receptor in the SCN.
These findings suggest that the efficacy of aripiprazole in alleviating circadian rhythm sleep disorder symptoms in psychiatric patients might be attributed to the modulation of the circadian clock by the drug. This study expands the potential clinical usage of aripiprazole as a treatment for circadian rhythm sleep disorders.
Children of a parent with alcohol or drug use disorder have a greater risk of intellectual disability, even if the problem only lies with the father, researchers from Karolinska Institutet report. According to the study, which is published in the journal eClinicalMedicine, preventive measures should be directed at both parents.
A woman’s consumption of alcohol during pregnancy has been well established as increasing the risk of the child developing. Research from Karolinska Institutet now shows that all forms of substance abuse, both in the mother and the father, and not only during pregnancy, can constitute a risk factor.
Previous efforts aimed at mothers
“Preventative measures, such as educating healthcare professionals and public health recommendations, have focused for decades on mothers with alcohol-related problems,” says Lotfi Khemiri, researcher at Karolinska Institutet. “Our findings highlight the importance of also directing such measures towards fathers with different types of substance use disorder.”
The study drew on data from Swedish registries with almost two million babies born between 1978 and 2002 and their parents. The researchers found that 1.2% of babies born to parents without such a disorder were diagnosed with an intellectual disability, compared with 3% of the babies who had one parent with a diagnosis related to a substance use disorder (alcohol or drug abuse).
Higher risk before birth
The elevated risk was greater if the parent had received a diagnosis before or during pregnancy rather than after birth. A substance use disorder diagnosis registered before birth was associated with more than twice the risk of intellectual disability in the baby, regardless of which parent had the diagnosis. The correlation was weaker but still statistically significant after adjustment of socioeconomic factors and psychiatric comorbidity in the parents.
“Since it was an observational study, we can draw no conclusions about the underlying mechanism, but we suspect that both genetic and environmental factors, including harmful effects of substance abuse on foetal development, may play a part,” says Dr Khemiri. “We hope that the results will contribute to the preventative efforts, as well as to the improved diagnosis of children with an intellectual disability and to timely intervention directed both to the child as well as parents in need of substance use disorder treatment.”
Alcohol a major risk factor
Intellectual disability was observed to be much more likely in alcohol-related problems during pregnancy, where the risk was five and three times higher depending on whether it was the mother or father who had the alcohol use disorder diagnosis.
In 2018 the first findings from a landmark tuberculosis (TB) vaccine trial were published in the New England Journal of Medicine. The experimental vaccine, called M72, was found to be roughly 50% effective in preventing pulmonary TB disease. It was the most promising finding for a new TB vaccine since the development of the BCG vaccine a century ago.
Since the study reported in the NEJM was only a phase 2B study, the results have to be confirmed in a phase 3 study before the vaccine can be considered for wider use. For a while, it seemed that the phase 3 study would never happen – that is, until a few months ago, two philanthropies, Wellcome and the Bill and Melinda Gates Foundation, announced that they would put up $550 million to get it done.
Meanwhile, on September 22, ministers, heads of state, and other officials from around the world will gather in New York for the second United Nations High-Level Meeting on TB. A draft declaration can be read here. The declaration is full of the kind of lofty rhetoric one would expect.
Yet, it is hard to avoid a sense that, for the most part, the emperor is wearing no clothes. After all, as one government representative after another read their speeches in New York, everyone in the room will know that it was not governments but two philanthropies who stepped up to ensure that arguably the most important TB trial of the decade goes ahead. When most needed, the groundswell of new government investment in TB research just wasn’t there.
The bigger picture
It is estimated that globally just over $1 billion was invested in TB research in 2021. In the preceding three years, the figure was hovering between $900 million and $1 billion. Astonishingly, $416 million (over 40%) of the $1 billion in 2021 was from the United States government. The second largest funder of TB research in the world is the Gates Foundation – which with its $113 million in 2021 invested more in TB research than any government except for the US. Together, these two entities account for more than half of all investment in TB research in 2021.
BRICS partners India and South Africa respectively invested $23.4 and $4.8 million in TB research in 2021. Both are classified as high TB burden countries.
At the 2018 UN High-Level Meeting on TB world leaders committed to provide $2 billion per year for TB research by the end of 2022. Figures for 2022 aren’t out yet, but given that the 2021 figure was only half the target, we are clearly not on track.
In addition, the target should probably be much higher if we are to have a good chance of getting the breakthrough diagnostics, treatments, and vaccines we will need to end TB. The Stop TB Partnership recently estimated that around $5 billion is needed for TB research per year from 2023 to 2030 – in other words, five times as much as the actual investment in 2021. This level of investment in TB research is needed because modelling suggests that with the currently available tools, we will at best see a relatively slow decline in TB rates in the coming years.
Why then a High-Level Meeting?
One may well ask what the point is of UN High-Level Meetings if key commitments made at these meetings are not kept and if the further development of critical new tools like M72 remains dependent on support from philanthropists. But that would be to mistake these meetings for an end in themselves rather than merely a means to an end.
A meeting of this nature will always just be one small part of a larger puzzle in the fight against TB. The bigger question is how the momentum and political potential created by the High-Level Meeting can be leveraged to get more done in other arenas, especially back in people’s home countries.
Governments are accountable to the people who elected them. There are, of course, some international pressures and some issues of international law, but on something like TB, the most important accountability levers are all domestic. Ultimately, political parties, trade unions, and domestic civil society have much more power over what a government actually does or does not do than some politely expressed peer pressure in New York or Geneva.
Unfortunately, at least here in South Africa, political parties and trade unions have generally failed to hold government to account when it comes to TB – although our Department of Health has nevertheless made some good policy calls and our investment in TB research is decent given the size of our economy.
All of this is not to say that the UN High-Level Meeting on TB is not important – it most certainly is. It is just that it should not be mistaken for an end in itself. Governments, and especially those in countries where many people get TB and die of TB, must invest more in TB. We shouldn’t let leaders of these governments get away with saying they’ll put up the money in New York, but then forgetting all about it once they go back home.
NOTE:The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation. Spotlight is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
People who had high blood pressure while lying flat on their backs had a higher risk of heart attack, stroke, heart failure or premature death, according to new research presented at the American Heart Association’s Hypertension Scientific Sessions 2023.
The autonomic nervous system regulates blood pressure in different body positions; but gravity may cause blood to pool when seated or upright, and the body is sometimes unable to properly regulate blood pressure during lying, seated and standing positions, the authors noted.
“If blood pressure is only measured while people are seated upright, cardiovascular disease risk may be missed if not measured also while they are lying supine on their backs,” said lead study author Duc M. Giao, a researcher and a 4th-year MD student at Harvard Medical School in Boston.
To examine body position, blood pressure and heart health risk, the researchers examined health data for 11 369 adults from the longitudinal Atherosclerosis Risk in Communities (ARIC) study. The data on supine and seated blood pressure was gathered during the enrolment period, ARIC visit 1, which took place between 1987–1989. Participants had their blood pressure taken while briefly lying down at a clinic. The average age of participants at that time was 54 years old; 56% of the group self-identified as female; and 25% of participants self-identified as Black race. Participants in this analysis were followed for an average of 25 to 28 years, up through ARIC visit 5, which includes health data collected from 2011–2013.
The researcher’s findings included:
16% of participants who did not have high blood pressure (130/80 mm Hg or higher) while seated had high blood pressure while lying supine (flat on their backs), compared to 74% of those with seated high blood pressure who also had supine high blood pressure.
In comparison to participants who did not have high blood pressure while seated and supine, participants who had high blood pressure while seated and supine had a 1.6 times higher risk of developing coronary heart disease; a 1.83 times higher risk of developing heart failure; a 1.86 times higher risk of stroke; a 1.43 times higher risk of overall premature death; and a 2.18 times higher risk of dying from coronary heart disease
Participants who had high blood pressure while supine but not while seated had similar elevated risks as participants who had high blood pressure while both seated and supine.
Differences in blood pressure medication use did not affect these elevated risks in either group.
“Our findings suggest people with known risk factors for heart disease and stroke may benefit from having their blood pressure checked while lying flat on their backs,” Giao said.
“Efforts to manage blood pressure during daily life may help lower blood pressure while sleeping. Future research should compare supine blood pressure measurements in the clinic with overnight measurements.”
The study’s limitations included that it focused on adults who were middle-aged at the time of enrolment, meaning the results might not be as generalizable to older populations, Giao said.
Recently, in a major feat for transparency and accountability, the North Gauteng High Court ordered that the public must have access to COVID-19 procurement contracts – details of which, until now, have been kept away from the public eye as the government cited confidentiality clauses.
The Health Justice Initiative’s – who brought the court application – victory is a crucial one given the staggering size of public procurement contracts in the health sector.
According to Zukiswa Kota, South African Programme Head at the Public Service Accountability Monitor (PSAM), this judgement deserves celebrating “as it deepens the case for transparency in public procurement and effectively challenges the many reasons often used to evade publication”. “Ultimately, what we need is proactive disclosure that is built into procurement legislation and – more importantly – is adhered to by government,” said Kota.
“It is inconceivable,” she said, “that in 2023 there continues to be limited transparency around fairly basic info – in this case COVID-19 vaccines. “The fact that there is no explicit transparency is an indictment and something we need to reflect on.”
The need for transparency has also been affirmed in the HJI judgement. “Non-disclosure of any of the records sought means that a shroud of secrecy is placed over the entire negotiation, procurement, and payment process – the very mischief our Constitution and legislation such as Paia seeks to address,” the judgement states. S217 of the Constitution states that public procurement by any state organ must be “in accordance with a system which is fair, equitable, transparent, competitive and cost-effective”.
The case for transparency
The call for open contracting and to strengthen public procurement legislation is not a new one. It is also not confined to COVID-19 vaccines, but all public procurement, also in the health sector.
Dominic Brown, director at the Alternative Information & Development Centre (AIDC), also recently during a webinar on the launch of a report on pending legislative and regulatory changes in the healthcare sector made the case for transparent procurement. The Rural Health Advocacy Project compiled the report that also provides several recommendations for procurement reforms.
“The level of public procurement in the country is approximately 25% of GDP and the majority of government’s involvement in the economy is through this procurement, so it’s no small issue. It’s of extreme significance,” said Brown.
He said that in 2016, the former chief procurement officer in National Treasury estimated that between 30 to 40% of the country’s procurement budget is lost to inflated prices and fraud by the private sector. At the time, this amounted to R230 billion.
“At the moment, our procurement budget is about R1 trillion, which means that we are losing between R300 and R400 billion each year as a result of corruption linked to public procurement and this has major detrimental impacts on service delivery.”
Putting this impact into perspective, especially as it pertains to the health sector, RHAP’s director, Russel Rensburg during the same webinar said that provinces can spend up to 30% of their health budgets on the procurement of goods and services, which can run into billions. “Contrast this with the huge chunk spent on employee costs (often between 60 and 65% of health budgets), and growing inefficiencies and waste due to non-compliance to legislative prescripts – the pool of money remaining for health services is limited,” he said.
“Lack of compliance with financial management policies, particularly around supply chain monitoring policies, has resulted in the deterioration of several financial management indicators. We’ve seen an increase in qualified audit opinions of health departments and an increase in irregular and wasteful expenditure – amounting to R6 billion in the last financial year,” said Rensburg. “Competent financial management is essential to ensuring that maximum value is achieved from the resources deployed.”
The need for this “competent financial management” in the public sector was highlighted again last week when the Gauteng Department of Health’s Annual Report for 2022/23 was tabled in the provincial legislature. The report showed irregular expenditure to the value of over R2 billion, which means legislative prescripts were not followed in the procurement of goods and services, among others. In the Auditor-General’s (AG) report, she flagged the irregular expenditure stating that there were no effective and appropriate steps taken to prevent it. “The majority of this irregular expenditure,” the AG stated, “was caused by the department’s failure to invite competitive bids” when procuring goods and services.
Legislative reforms and procurement
Currently, in Parliament’s National Assembly, MPs are set to deliberate on the Public Procurement Bill. The bill provides for far-reaching reforms in public procurement. In Parliament’s National Council of Provinces, deliberations on the National Health Insurance Bill are underway. This bill also provides for far-reaching reforms to how health services will be structured and funded.
Both pieces of legislation have major implications for procurement in the health sector.
Yet, with these legislative reforms underway in Parliament, some stakeholders say that neither bill in its current form, will be a silver bullet to address all shortcomings in public procurement in the health sector. Questions also remain if these bills will ultimately result in real consequences for errant public officials in supply chain management or overreaching political office bearers.
Added to this is the overlap between provisions in the two bills, several provisions that lack clarity, and some areas of conflict between the bills that may lead to confusion down the line.
The case for alignment between the bills
The Public Procurement Bill aims to standardise and create a uniform regulatory framework for all procurement by government departments and entities. The NHI Bill, in turn, if passed will transform how publicly-funded health services are organised and delivered. The bill provides for a NHI Fund that will “strategically purchase healthcare services on behalf of users”.
Rensburg explains this fund must transfer funds directly to accredited and contracted central, provincial, regional, specialised and district hospitals based on a global budget or Diagnosis-related Groups. The bill also provides for an Office of Health Products Procurement (OHPP), he said, but the exact scope of this office’s mandate is not yet clear.
According to the bill, this office (OHPP) will be responsible for “the centralised facilitation and coordination of functions related to the public procurement of health-related products”.
According to Yana van Leeve, from the law firm ENSafrica, the NHI fund will be a S3A public entity so the procurement bill will apply to that entity. S3A public entities under the Public Finance Management Act can be defined as a public entity with the mandate to fulfil a specific economic or social responsibility of government and they depend on government funding and public money.
Van Leeve was also a panellist during the RHAP webinar.
She explained that section 217 of the Constitution will also apply to this process of acquiring services because the NHI Fund will be engaging in public procurement when it engages healthcare service providers and health establishments in both the public and private sectors. Van Leeve said that it is not clear in the NHI Bill, however, that “there is an appreciation that this dimension of the scheme will amount to formal procurement and will thus be subject to normal procurement law”. “The implication would then be that one of the prescribed forms of procurement, for example, quotations or open bidding must be used to secure the services of these health service providers.” According to her, the NHI Bill, however, creates the impression that there is a different type of arrangement to be considered for the acquiring of such services. In section 39 of the NHI Bill, for example, accreditation of health service providers is required.
The procurement bill, in turn, provides for a Public Procurement Office that must create and maintain a database of prospective suppliers. Departments or other public entities may only procure from suppliers listed in this database. This may result in some practical problems as the requirements to be added to the existing central supplier database of National Treasury may differ from what the NHI Bill requires from suppliers. For example, to get on the database, National Treasury may consider a legitimate entity as one with a valid tax certificate, but, said van Leeve, “If you are procuring health products, for example, you may need other things to accredit a potential supplier, which treasury does not necessarily look at when it builds its database”.
“So, immediately you can see there will be tension between what the NHI envisage for creating its services and products lists versus what the public procurement office will develop in terms of the national supplier database. So, on the one hand, NHI is creating a special procurement system for health and providing for units and committees that will be responsible for identifying health services and buying health products and it’s not clear how these two pieces of legislation are going to interact.”
Van Leeve did say, however, that it is possible that the Minister of Finance “can differentiate between institutions and categories of procurement, but nothing in the procurement bill currently requires the minister to do so and there is no guidance on the considerations relevant to differentiating between categories of public institutions”.
She said it is possible for the bill to still make clear provision for the minister to make exemptions from the procurement bill. Currently, section 56(b) of the bill, for example, only provides – “the Minister may, with or without conditions, by notice in the Gazette, exempt a procuring institution from any provision of this Act, if— (a) national security could reasonably be expected to be compromised, or (b) the procurement is to be funded partially or in full by donor or grant funding and such exemption will benefit the public in general or a section of the public”.
But van Leeve insists that one way or the other, “It will be important – certainly in the way in which the NHI and procurement bills become operationalised for there to be comity between the bills.”
The RHAP report also recommends that “the relationship between health authorities and the public procurement structures proposed in the draft Public Procurement Bill must be clarified. The Public Procurement Bill makes no specific reference to health procurement as a special type of public procurement. At the same time, the NHI Bill contemplates a very particular regime in respect of health procurement. These two draft Bills will have to be aligned.”
According to the report, “the tension between the decentralised nature of public finance management in South Africa under the PFMA and Municipal Finance Management Act on the one hand and the highly centralised nature of public health services spending under the proposed NHI on the other hand, will have to be addressed”.
The shadow of politics
There are also other considerations besides overlapping provisions in the two bills – the shadow of politics through the blurring of the administrative and political interface often becomes a problem.
Rensburg highlighted, among others, it is still not clear how compliance with procurement policies will be audited and how often, or what the different sanctions will be for those not complying. “We see, especially with emergency procurement, that managing procurement functions is open to a lot of different kinds of pressures, he said. “The procurement bill does create frameworks for public office bearers to not be involved in the procurement process and for subject matter experts to be involved in procurement decisions, but there are a lot of things happening in the shadow that you can’t explicitly link to involvement of political principles in administrative processes,” said Rensburg.
“There is an added complexity,” Brown said, “when you hear, for example, of ANC tender committees, or when there is a tender chairperson who then can determine who gets and doesn’t get various contracts. This is deeply rooted in the state – from local government all the way up to national level, and across state-owned enterprises.”
Case in point, in the public health sector, the Digital Vibes scandal epitomised this “complexity” when then-Minister of Health, Dr Zweli Mkhize was implicated in tender irregularities and subsequently resigned.
Another criticism of the Public Procurement Bill is that it leaves a lot, arguably too much, of the detail of how procurement will actually work up to regulation rather than setting it down in primary legislation. This, suggested Caroline James and Sam Sole in a recent Daily Maverick article, leaves the door open to political interference.
Corruption Watch’s executive director, Karam Singh, during a different webinar in August on the procurement bill by the Special Interest Group on Public Procurement Law, also flagged some gaps in the definitions in the procurement bill, especially around issues like conflicts of interest and politically exposed persons.
In terms of chapter three of the procurement bill that deals with procurement integrity and prohibition of certain practices and debarment, anybody who is involved in the procurement process – that is from the accounting officer, bid committee, or tribunal – must comply with the prescribed code of conduct, failing which will constitute misconduct. According to Singh, however, the bill falls short of stipulating who must issue the code of conduct, how it would be updated, and where it would work, as well as where or when it must be made available. “There is very little detail on how misconduct would be handled,” he said, “and so there is a gap between understanding what this code of conduct would be, how it would come about and if it will be presented for public participation and public comment.” He said it is also unclear what would be the enforcement mechanism which would stand behind the code of conduct to make it effective.
Responding to concerns over tender corruption risks
In June this year, during a briefing by Dr Nicholas Crisp, Deputy Director-General in the National Health Department on the NHI Bill to MPs in the NCOP, concerns were flagged over the risk of tender corruption in the NHI Fund. Later, in August during a briefing to MPLs in the Western Cape provincial legislature, the same concerns were raised.
At every point, Crisp insisted, “The NHI Fund will handle very little by way of tender. The accreditation is not a tender process. It’s voluntary registration by a service provider – public or private – as long as they meet the criteria. The prices will be fixed and the way services are delivered will be fixed when it comes to the procurement.”
According to Crisp, when it comes to the procurement processes for goods, particularly health products, the NHI Fund is only involved in the first stage. “The Fund would not go about the logistics of purchasing anything. The providers needed to purchase once those prices were set. There was far less vulnerability in the Fund than first thought when one looked at the Bill,” he said.
Spotlight followed up with Crisp for further clarification in lieu of the RHAP report and the implications of the procurement bill for the NHI Bill. Crisp said, that according to the NHI Bill, the Fund will determine the Formulary that it will pay for and will establish the prices of the items in the Formulary. “It is the intention that the NHI agency will not buy any ‘health products’ and will not have storerooms and warehouses since the agency (the NHI Fund) is not a provider of services. The providers will buy what they need to deliver the benefits that they are accredited to provide. Accredited providers (public and private) will buy at the approved NHI prices and this is how the health department works now,” he said. “The provincial health departments do the buying and storing, etc.”
He stressed that the Fund will not go on tender for healthcare providers. “The bill in s39 says that providers will be accredited and all accredited providers will be paid for the benefits that they deliver. So, it is intended to not be exclusionary.”
On the implications of the Public Procurement Bill for the NHI Bill, he told Spotlight the department is still studying the procurement bill and these issues (as raised in the RHAP report and through various stakeholders) are being considered. He also noted that according to the NHI Bill, “If any other law, except the Constitution or PFMA, conflicts with the NHI Bill then the NHI bill prevails. But we will want to engage with the intentions, merits, and any potential challenges with Treasury,” he said.
Have your say
Members of the public have until 15 September to make written submissions on the version of the NHI Bill currently before the NCOP. Meanwhile, National Treasury this week briefed MPs in the Standing Committee on Finance on the Public Procurement Bill. The deadline for written submissions is 11 September.
Treating newly diagnosed Type 1 diabetes patients with semaglutide may drastically reduce or even eliminate their need for injected insulin, according to the remarkable findings of a small University at Buffalo study reported in the New England Journal of Medicine.
“Our findings from this admittedly small study are, nevertheless, so promising for newly diagnosed Type 1 diabetes patients that we are now absolutely focused on pursuing a larger study for a longer period of time,” says Paresh Dandona, MD, PhD, professor and senior author on the paper.
A total of 10 patients at UB’s Clinical Research Center in the Division of Endocrinology were studied from 2020 to 2022, all of whom had been diagnosed in the past three to six months with Type 1 diabetes. The mean HbA1c level over 90 days at diagnosis was 11.7, far above the American Diabetes Association’s HbA1c recommendation of 7 or below.
The patients were treated first with a low dose of semaglutide while also taking meal-time (bolus) insulin and basal (background) insulin. As the study continued, semaglutide dosing was increased while mealtime insulin was reduced in order to avoid hypoglycaemia.
“Within three months, we were able to eliminate all of the mealtime insulin doses for all of the patients,” says Dandona, “and within six months we were able to eliminate basal insulin in 7 of the 10 patients. This was maintained until the end of the 12-month follow-up period.”
During that time, the patients’ mean HbA1c fell to 5.9 at six months and 5.7 at 12 months.
Applying Type 2 diabetes drugs to treat Type 1 diabetes
For more than a decade, Dandona has been interested in how drugs developed for Type 2 diabetes might be utilized in treating Type 1 diabetes as well.
He and his colleagues were the first to study how liraglutide, another drug for Type 2 diabetes, might work in patients with Type 1 diabetes in a study he published in 2011.
“As we extended this work, we found that a significant proportion of such diabetics still have some insulin reserve in the beta cells of their pancreas,” Dandona explains. “This reserve is most impressive at the time of diagnosis, when 50% of the capacity is still present. This allowed us to hypothesise that semaglutide, which works through stimulation of insulin secretion from the beta cell, could potentially replace mealtime insulin administration.”
From the outset, the goal of the current study was to see if semaglutide treatment could be used to replace mealtime insulin, thereby reducing the insulin dosage, improving glycaemic control, reducing the HbA1c and eliminating potentially dangerous swings in blood sugar and hypoglycaemia.
The most common side effects for patients were nausea and vomiting as well as appetite suppression, which led a number of patients to experience weight loss, an outcome that Dandona says is generally an advantage since 50% of patients with Type 1 diabetes in the US are overweight or obese.
“As we proceeded with the study, we found that even the dose of basal insulin could be reduced or eliminated altogether in a majority of these patients,” he says. “We were definitely surprised by our findings and also quite excited. If these findings are borne out in larger studies over extended follow-up periods, it could possibly be the most dramatic change in treating Type 1 diabetes since the discovery of insulin in 1921.”
Early findings of a pair of studies from the University of Michigan Rogel Cancer Center shed light on new ways to anticipate recurrence in HPV-positive head and neck cancer sooner. The papers, published in Cancer and Oral Oncology, offer clinical and technological perspectives on how to measure if recurrence is happening earlier than current blood tests allow, and provide a framework for a new, more sensitive blood test that could help in this monitoring.
“When metastatic head and neck cancer returns, it impacts their quality of life and can be disfiguring, interfering with the ability to talk, swallow, and even breathe,” said Paul Swiecicki, MD, associate medical director for the Oncology Clinical Trials Support Unit at Rogel. “As of now, there’s no test to monitor for its recurrence except watching for symptoms or potentially using a blood test which may not detect cancer until shortly before it clinically recurs.”
The paper in Cancer aims to identify different clinical ways that providers can more strategically track for recurrence. To do this, Swiecicki and his team needed to first understand what patient population was at the highest risk to then figure out an appropriate monitoring pattern.
The team examined 450 patients with metastatic head and neck cancer, including people with HPV-positive and HPV-negative cancer. HPV-positive cancer is caused by the human papillomavirus and is increasingly more common in head and neck cancer patients. The team identified some predictors of when recurrences would happen, and to what organs the recurrent cancer would most commonly spread. Patients with HPV-positive cancers were found to develop recurrent disease significantly later than those that were HPV-negative, and also were more likely to spread to the lungs. Taken together, these characteristics may help create a “surveillance” method in the future that combines routine blood testing and imaging to hopefully catch these recurrences and intervene before it’s incurable.
Swiecicki is quick to mention that, at this point, the results of this study are largely theoretical and provide a helpful framework to direct further research. That’s where the newly developed blood test, highlighted in Oral Oncology, comes into play.
Current blood biomarker tests which test for pieces of tumour-shed DNA, may not be sensitive enough to detect a recurrence significantly earlier than clinical surveillance, though several studies with multiple types of tests are ongoing. A research team, led by Muneesh Tewari, MD, PhD, Swiecicki and Chad Brenner, PhD, aimed to create a highly sensitive blood test to detect cancer even when a smaller number of DNA fragments were present, with the intention of providing a better option for detecting cancer earlier in patients.
Not only is this test more sensitive and able to detect a smaller number of DNA fragments in blood, but it’s innovative in other ways too, says first author Chandan Bhambhani, PhD: “We achieved this level of sensitivity by looking for nine different pieces of the HPV genome DNA all at once,” Bhambhani says.
Tewari says this is a step towards a more proactive approach to tackling recurrence in head and neck cancer. “As of now, we only have the tools to react to symptoms when they recur. We want to find a way to be able to detect what’s causing the symptoms much, much sooner, even before the symptoms appear.”
As a clinician, Swiecicki agrees. “It’s exciting to have the ability to potentially detect cancer before it’s incurable and offer us a window for clinical trials to see if we could intervene on cancer to help give people both a better quality of life and perhaps longer quality of life, and even convert their disease from incurable to curable. We don’t know if that’s the case yet, but this is the first tool needed for that to develop.”
