Tag: South Africa

Categories : Healthcare Politics and RegulationsTags :

Opinion: There are Paths to Quality Universal Healthcare Besides NHI

On By ModernMedia
One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion in some quarters that the only two options are NHI and the status quo. PHOTO: Rosetta Msimango/Spotlight

By Marcus Low for Spotlight

One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion that the only two options are NHI and the status quo. Often implicitly, sometimes explicitly, defenders of NHI suggest that any argument against NHI is one for maintaining the current system. Since the current system doesn’t work very well for most people, this line of argument gets some purchase, even though it is based on a false premise.

In his book “Which country has the world’s best health care?”, oncologist and bioethicist Ezekiel Emanuel outlines the key features of healthcare systems in 11 different countries. Two things that stand out are that health systems differ substantially between countries and that most systems are the relatively messy products of complex histories and political and other compromises. This latter point about the path-dependency of healthcare systems is an important point we will return to.

Many varieties

South Africa’s proposed NHI system is sometimes clumped together with systems in other countries such as Canada, the United Kingdom, and Thailand. At times this is fair, at times it skims over important differences.

For example, NHI will be a single-payer system, which is to say, the NHI fund will be responsible for almost all purchasing of healthcare services in the country. In some respects, Canada has a similar system, except that rather than one system for the whole country, they in effect have 13 single-payer systems for each of their provinces and territories. Even Thailand, at times referred to as an example of NHI, technically has three funds rather than one, although it resembles South Africa’s NHI plans in several other respects. In principle, a large single-payer should be able to negotiate better deals than several smaller payers, but on the other hand, having Canada-style provincial funds would be more closely aligned with South Africa’s current governance arrangements and in some provinces, like the Western Cape, chances are people would have more trust in a fund run by the province than in one run nationally.

Another thing that quickly becomes apparent when looking at the variety of healthcare systems out there, is that a simplistic dichotomy between NHI and private healthcare is a false one. Countries like the Netherlands and Germany have achieved excellent health outcomes with systems that are neither NHI-style systems nor examples of the private sector running riot. Though the details are significantly more complicated than this, you can think of the Netherlands and Germany roughly as having many strictly regulated medical schemes (called sickness funds in Germany) with scheme/fund membership being compulsory (with some exceptions). The German system is progressive in that people with higher incomes contribute more than people with lower incomes – an important difference from South Africa’s medical schemes.

Funds in the Netherlands are also not primarily funded directly, as with our medical schemes, but receive funding from a central fund via a risk adjustment process. Both the German and Dutch systems have significant social solidarity built-in in the way it institutionalises the cross-subsidising of the poor by the wealthy.

In South Africa, such a system could, for example, be implemented by dramatically tightening up the regulation of medical schemes, putting in place a progressive mechanism for cross-subsidisation between schemes, making scheme membership compulsory for those who can afford it, and, over time, using tax revenue to pay for scheme membership for the unemployed (although this last element, like NHI, does come with a big question mark on affordability. Those with long enough memories might remember that a system roughly along such lines was on the cards in South Africa around the turn of the century. (see for example the Taylor report of 2002 and this interesting paper.)

Getting to there from here

One striking thing about NHI in South Africa is that for all the column inches, submissions to Parliament, and oral hearings across the country and in Parliament, hardly anyone seems to have shifted their positions in the last decade and there has been very little serious consideration of alternative paths to universal healthcare.

Photo by Hush Naidoo on Unsplash

One reason for this is the sense that the design choices behind the NHI Bill were essentially decided on by a relatively small group of people in the National Health Department and the African National Congress (ANC) around 10 or 15 or so years ago. What followed since then often felt like an attempt at co-opting rather than meaningful engagement. This was particularly apparent in the way some members of the Portfolio Committee on Health continuously pushed people on whether they are for or against NHI, rather than engaging with the substance of people’s submissions. Though the boxes for public engagement were ticked, the reality was often a parody of what such engagement is meant to be.

We could have gone a different route. It would have been entirely feasible to have a process for NHI akin to the much more meaningful set of engagements we had for the Competition Commission’s Health Market Inquiry into the private healthcare sector. In that case, people could make submissions, be heard by the panel, and crucially, one never got the sense that the outcome was preordained. Such a process may in some respects have given government officials and members of Parliament a few more headaches, but it would also have built trust and understanding of the technical issues, and for major reforms like NHI trust and public understanding is half the battle.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Categories : COVID Healthcare Politics and RegulationsTags :

Supreme Court of Appeal Rejects Appeal Over COVID Vaccine Sale Restriction

On By ModernMedia

The Supreme Court of Appeal has dismissed an application for leave to appeal by Solidarity and Afriforum over a 2021 court case where they challenged a condition by South African Health Products Regulatory Authority (SAHPRA) that the Johnson & Johnson vaccine be restricted to the government. SAHPRA said that this was not a condition that they had imposed.

On 26 July 2023, the Supreme Court of Appeal (SCA) dismissed an application for leave to appeal filed by Solidarity and Afriforum (the Applicants) on the grounds that there is no reasonable prospect of success.

The Pretoria High Court struck Solidarity and AfriForum’s application from the court roll on the grounds of an alleged lack of urgency, and the court also ordered them to pay SAHPRA’s legal costs which was filed in June 2021 by the Applicants, wherein they alleged that when SAHPRA approved and registered the J&J vaccine, SAHPRA imposed a condition that the sale of the J&J vaccine is restricted to the National Government. The applicants argued that SAHPRA was not mandated to stipulate the condition that only the government may purchase the J&J vaccine and questioned the legality of such a condition.

SAHPRA refuted this claim because this is not a condition that SAHPRA had imposed. Subsequently, the applicants proceeded to lodge an application for leave to appeal with the SCA . SAHPRA CEO, Dr Boitumelo Semete-Makokotlela said, “This court ruling indicates that SAHPRA is judicious in adhering to its mandate responsibly. We welcome the outcome of this judgement.”

Categories : HospitalsTags :

Mixed Responses to Gauteng Health’s Latest Security Plans

On By ModernMedia
Photo by Maxim Hopman on Unsplash

By Thabo Molelekwa for Spotlight

Following reports of healthcare workers who have been bitten, punched, hit in the face, robbed, assaulted, or even killed in healthcare facilities in Gauteng, the province’s health department announced that healthcare workers will now be trained in handling patients who become violent.

The initiative was recently announced by Motalatale Modiba, spokesperson for the Gauteng Department of Health, on social media.

A lack of security at public healthcare facilities is not a new problem. A previous series of Spotlight articles highlighted security challenges in public health facilities in several provinces – including Gauteng – and reports of robberies and assaults at some facilities. Last year, there was a fatal shooting of a nurse at Tembisa Hospital which sparked an outcry among health worker unions over the safety of their members.

The departments’ announcement prompted questions by organised labour and an opposition politician about whether the authorities have lost trust in the multi-million rand security measures already in place in health facilities to protect both workers and patients, with some arguing that security guards, rather than healthcare workers, should be responsible for safety.

However, according to Modiba, the training of staff has nothing to do with the security contracts of security companies.

“Security personnel are non-medical personnel, therefore, their presence in facilities does not substitute the need to ensure that our staff is empowered with techniques to know how to handle difficult patients,” he told Spotlight.

‘Just a tick-box exercise’

The training plans, however, have inspired little confidence among healthcare workers.

According to the nurses’ union Denosa’s Gauteng Provincial Secretary, Bongani Mazibuko, the training does not address the safety concerns that exist in the facilities. “It’s just a tick-box exercise to say the employer is trying to do something. The root cause of these attacks is the influx of mental health patients and the mixing of mental health patients with medical patients,” he told Spotlight.

The department in a statement in April said many of the incidents were reported at Weskoppies Psychiatric Hospital with 21 cases since January last year. At Carletonville Hospital there were nine safety incidents, nine incidents at the Far East Rand Hospital, seven at Chris Hani Baragwanath Academic Hospital, four at Thelle Mogoerane Hospital, and three at Kopanong Hospital. There were also reports of some isolated incidents at other facilities.

Mazibuko said that from the reports they received from their members working in Gauteng public health facilities, the training has also not yet taken place. “We would like the department to tell us which institutions they have provided the training to so that we can confirm with our members if they received the training or not.”

Modiba, however, did not respond to Spotlight’s questions about where training had taken place so far, how many healthcare workers have been trained, or the impact this is having.

Explaining aspects of the plan, however, Modiba said that the department training staff to know how to protect themselves is a practical step that shows that they are conscious of the environment they operate in. According to him, training on how to manage a violent mental healthcare user is generic to the training of doctors and psychiatric nurses as regulated by the Health Professions Council of South Africa, which is a statutory body established in terms of the Health Professions Act. “A special course on management of violent mental healthcare users is planned to be rolled out from the second quarter of the 2023-2024 financial year. It is based on a similar course attended by one of the healthcare workers in the UK. He will be working in one of our Specialist Psychiatric hospitals, Sterkfontein Hospital. He will be the main facilitator and will be working with other employees from the Regional Training Centres, the Office of Health Standards Compliance (OHSC), and Wellness Practitioners,” said Modiba. He said the department is also working with the police.

But Mazibuko said Denosa has had many talks with the department on healthcare workers’ safety concerns and the need to create a safe working environment. “This was part of our demands when we marched last year. Even on International Nurses Day, we were vocal about our concerns about the safety of our members at the workplace.”

He said the union had previously presented its safety campaign to the department.

SAMA ‘deeply concerned’

Meanwhile, following a scoping review study, the South African Medical Association (SAMA) recently published a report outlining the nature and extent of violence against healthcare workers between 2012 and 2022. The study found an increase in violent acts targeting healthcare workers, with the most affected being doctors, nurses, and paramedics. The study found that female healthcare workers were disproportionately affected compared to their male counterparts and most of the incidents were reported in Gauteng.

In an interview with Spotlight, SAMA Chairperson Dr Mvuyisi Mzukwa said they are “deeply concerned” about the safety of healthcare professionals. He said they appreciate efforts that can realistically improve the safety of healthcare workers in the workplace.

“SAMA has shared an interim report [based on the study findings] on violence targeting healthcare workers with DENOSA and the media. This report was designed to sensitise all stakeholders about crime targeting healthcare workers and to prime the stakeholders, including the National Department of Health, to initiate intersectoral solutions to limit and prevent safety threats in the workplace against all healthcare workers in the country,” Mzukwa said.

SAMA’s report found eight murders of healthcare workers reported in the media, “with six of the deaths (or 75%) occurring among doctors”. One nurse and one paramedic were also murdered in the set period the report found. “Of all the 45 media reports examined, only 17 arrests (38%) were reported, with only two resulting in successful prosecution.”

According to Mzukwa, SAMA had recommended that a multi-sectorial strategy for the security of healthcare workers to protect them from targeted crime be developed and implemented.

“Without this intervention, healthcare in itself continues being further jeopardised and more doctors will feel threatened and seek safer refuge in foreign countries, taking with them critical skills and expertise that are in dire need locally. Law enforcement agencies should also act swiftly in dealing with crime and to ensure the safety of both patients and healthcare providers,” Mzukwa said.

61 safety incidents

Speaking in the Gauteng Legislature in April, MEC for Health and Wellness, Nomantu Nkomo-Ralehoko said there were 61 incidents reported in health facilities between January 2022 and April 2023. She told MPLs that most of these incidents were attributed to mental healthcare users, while others relate to patients’ anger towards staff for various reasons, such as refusal to buy them items or patients trying to escape, as well as angry relatives and patients linked to criminal activities.

Nkomo-Ralehoko said that staff training in responding to aggression and violence in the affected institutions is one element of their intervention. She said the department will be installing CCTV cameras at strategic locations for monitoring purposes.

“Our goal is to minimise – if not eradicate – such incidents in our facilities. We have to work with healthcare workers and other stakeholders such as hospital boards, clinic committees, and the patients themselves to curb incidents of attacks inside our facilities,” she said.

But security concerns in Gauteng’s public health facilities are also fuelled by systemic and contract management issues – something the MEC vowed to address. In March, responding to concerns over these multi-million rand security contracts that are rolled over year on year without a proper tender, Nkomo-Ralehoko acknowledged that the situation is unacceptable. The department is spending over R59 million on month-to-month security contracts at its facilities.

“The security contracts are rolled over irregularly as there is currently no contract in place; only service level agreements are used to manage the contracts,” she said.

Responding to a question from Spotlight on the progress with the new security tender, Modiba said that the tender was advertised and has since closed. “The evaluation committee has been appointed and will now go through the evaluation process to assess the various bids that have been received. We are still on course to complete the process within this financial year,” Modiba said.

But according to Denosa’s Mazibuko, in-sourcing security services, separating mental health patients from other patients, and ensuring that mental health patients are only admitted to where the institutions can commit them, will help the department and the healthcare workers work in a safe space.

He said that the fact that there have been years of year-on-year security contracts, shows that the department is not in touch with the challenges on the ground. “In-sourcing of security will help as well since it will address the issue of security withholding their services as they have not been paid and security being given proper gear for work,” he said.

According to Jack Bloom, the Democratic Alliance’s health spokesperson in Gauteng, the department is failing in its basic responsibility to provide a safe working environment for staff and patients in public hospitals.

“A huge amount of money is spent on security companies that don’t do their job, and it is high time that new security contracts are awarded to competent providers,” he said.

Bloom said that healthcare providers should not have to defend themselves against attacks because that is what security guards are supposed to do. “There needs to be a complete overhaul of security arrangements at our hospitals, with a professional assessment of what should be provided at a reasonable cost,” he said.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Categories : Diet and Nutrition Healthcare Politics and RegulationsTags :

Health Activists Make Over 12 000 Submissions on Draft Food Labelling Regulations

On By ModernMedia
These are examples of the proposed new black and white warning labels on food packaging. Photo: supplied

By Mary-Anne Gontsana

Over 12 000 submissions have been collected by Community Media Trust and the Healthy Living Alliance (HEALA) in response to the Department of Health’s draft Regulations Relating to the Labelling and Advertising of Foodstuffs.

The draft regulations were gazetted in January and consumers had until 21 July to comment. These regulations, among other things, propose the mandatory use of new and bolder warning labels on unhealthy food which include items high in salt, sugar, saturated fats and items containing artificial sweeteners.

Community Media Trust (CMT) is a not-for-profit company, mainly focused on health and human rights and has partnered with the Healthy Living Alliance (HEALA), a coalition of organisations focused on nutrition.

In February, CMT and HEALA staged a flash mob as part of the “Less Sugar, More Life” campaign in Cape Town ahead of the Finance Minister’s Budget Speech, advocating for an increase in the sugary drinks tax. They were disappointed by the announcement that the tax would be frozen for two years.

Following a massive media campaign on the draft regulations, CMT and HEALA successfully collected thousands of submissions.

CMT’s co-director Lucilla Blankenberg said the warning labels had been tested with audiences and researchers. If you’re a diabetic shopping for food and there was a clear warning label saying, ‘high in sugar’, the consumer won’t have to spend time trying to work it out because the message is simple.

The proposed warning labels are black and white triangles and would clearly indicate when food is high in sugar, salt and fat or contains artificial sweeteners.

“The reason the food industry is fighting back is because if food has a warning label, it cannot be marketed directly to children. Which means cartoons and animation that will attract children cannot be used to market a food item that has a warning label. If a pack has a warning label they can’t make any health claims whatsoever,” said Blankenberg.

“We won’t see the results immediately, but it will happen over time, especially for the children. With warning labels, it will be easier for parents to avoid buying certain food,” said Blankenberg.

HEALA’s communications manager Zukiswa Zimela said conversations proposing front of pack warning labels started in 2016.

Zimela said research for the campaign was initially done by the University of Western Cape to determine which foods qualify to have front of pack warning labels. She said the research gave more insight into what consumers thought of the current information on packaging as well as what the new warnings should look like.

“We started the campaign in May and went to eight provinces, mainly to educate and inform communities about the importance of front of pack warning labels and the food they were eating,” said Zimela. She said they found that many consumers agreed that they did not understand the nutritional information on food packaging.

She said the food industry had used scare tactics like saying warning labels would cause job losses which was “completely untrue”.

“This is not something new, warning labels have been done in other countries like Chile, Mexico, Peru and Columbia and there has been no evidence that jobs have been lost because of it. This is just undermining the government’s plan to get people to eat better.”

Zimela said HEALA will be monitoring the responses to the regulations. “Should the regulations be implemented, we need to make sure that they are not watered down or seen as useless.”

Sugar industry warns against “demonising sugar”

The South African Sugar Association (SASA) told GroundUp it had also submitted comments on the draft regulations, and that the front of pack warning labelling system was of particular concern to the industry.

SASA executive director, Trix Trikam, said: “The objective of this system is to encourage the reduction of energy/calorie intake, saturated fat and salt to prevent obesity and non-communicable diseases.

“It is well known and there is evidence that sugar is not the sole contributor of kilojoules to the diet and should therefore not be singled out in a regrettable out-of-context manner,” he said.

He said the warning labels should not be done in a sensationalist or alarmist manner “which seeks to demonise sugar” because that would have “a significant adverse impact on the sugar industry”.

Trikman suggested that the warning labels should instead reflect the calories in a food product. “SASA is also not convinced that the perceived cut-off values for sugar is evidence-based. A possible solution to that would be to use the perceived cut-off values based on percentage of energy value and not the amount of sugar per volume of product,” said Trikam.

“The draft regulations make it mandatory for a warning symbol to be placed on the front of pack labels for foods that exceed a perceived cut-off value for sugar. In order to avoid the warning symbol for sugar, food manufacturers will seek to find ways of removing sugar from their products. This will lead to a decrease in the demand for sugar and will ultimately negatively impact the livelihoods of those dependent on the sugar industry in the deeply rural areas of KwaZulu-Natal and Mpumalanga.”

Trikam said SASA is concerned about the obesity rates in South Africa but added that the solutions should be evidence-based.

Disclosure: GroundUp was once a project of, and still has a close relationship with, Community Media Trust.

Republished from GroundUp under a Creative Commons Licence.

Source: GroundUp

Categories : Gender HIVTags :

Feature: The Complexities of Traditional and Medical Circumcision in the Eastern Cape

On By ModernMedia
Circumcision rates in South Africa have increased dramatically over the last decade with 62.5% of males aged 15 to 49 who were circumcised as of 2022. PHOTO: Rodger Bosch

By Siyabonga Kamnqa for Spotlight

There is compelling scientific evidence that Voluntary Male Medical Circumcision (VMMC) is both safe and significantly reduces a man’s risk of becoming infected with HIV. While there can also be some protection from traditional circumcision, the protective effect of medical circumcision is thought to be much greater. The World Health Organization (WHO) has recommended medical circumcision for HIV prevention since 2007.

Circumcision rates in South Africa have increased dramatically over the last decade. According to estimates from Thembisa, the leading mathematical model of HIV in South Africa, 62.5% of males aged 15 to 49 were circumcised as of 2022. In 2012, this number stood at 38.8%. Experts ascribe some of the reduction in the country’s rate of new HIV infections to the massive circumcision drive over the last decade.

But the choice between medical, traditional, or no circumcision is often about much more than HIV risk. For one thing, traditional circumcision has great cultural meaning for some groups.

‘From boyhood to manhood’

Spotlight visited Lwazi Mfeka* at his ibhoma (traditional hut) during his last week at an initiate school in the Eastern Cape this winter. The first-year Walter Sisulu University student asked to remain anonymous for fear of victimisation, as talking openly about initiation is taboo in many rural communities.

He said leaving his ibhoma on the last day of his tenure as an initiate is a moment that will forever be etched in his mind. Not only did this signal the end of a “challenging” three-week period at the school, but it was also a symbolic moment where he says he has graduated from boyhood to manhood.

Mfeka said he was supposed to have undergone the ritual in December last year, but due to a bereavement in his family, he couldn’t. “At varsity, I was often mocked and isolated because I was still a ‘boy’. This bothered me a lot and I couldn’t wait to come here (to the mountain) and finally become a man,” he said.

He admits he was gripped by fear in the months leading up to his initiation.

“For starters, many young boys die while undergoing the custom and I didn’t want to add to the numbers. But, fortunately, my dad chose an ingcibi (traditional surgeon) with a good track record. I first had to go and get tested by a doctor for chronic illnesses such as HIV and TB as I had to present a medical certificate to the ingcibi before being circumcised. At the initiation school, everything was done according to the rules. After each cut, the spear gets sanitised to avoid any spread of infections,” Mfeka said.

Botched circumcisions

Mfeka’s fears are not without merit. In recent years, traditional male circumcision has often made headlines for all the wrong reasons, with the lives of young men lost due to botched or unhygienic circumcisions.

According to Mamnkeli Ngam, spokesperson for the Eastern Cape Department of Cooperative Governance and Traditional Affairs, in the 2022 winter initiation season, 11 of 10 794 boys who underwent traditional circumcision in the province died, while in the summer initiation season, 23  of 51 601 died. Ngam says around 20 000 boys went into the mountains to undergo traditional circumcision this winter (2023).

He told Spotlight that some fly-by-night ingcibis, desperate to make a quick buck, are the ones giving the custom a bad name. He says that assisted by the local chiefs and the police, they have been clamping down on illegal initiation schools and arresting bogus traditional surgeons.

“During the period between 1 June to 20 July, nine bogus traditional surgeons have been arrested in the Eastern Cape,” Ngam said.” We have been conducting safety campaigns ahead of the winter circumcision season to educate communities. Circumcising boys without parental consent [and] not having undergone medical examination to perform the procedure is against the law.”

Nkosi Mpumalanga Gwadiso, the Eastern Cape House of Traditional and Khoisan Leaders’ chair, told Spotlight that parents need to be involved throughout the process. “Often, parents leave everything to the amakhankatha (traditional nurses). That’s where things go wrong. As chiefs, we always emphasise the importance of parental involvement from day one until the initiates come back home safely. Some traditional nurses are the reason things go wrong because they neglect the initiates and go drinking. It is therefore the responsibility of the fathers to ensure that they visit the initiation schools regularly and monitor everything,” Gwadiso said.

While numbers vary widely and we haven’t been able to get a full picture, we understand that initiation schools can admit around 100 initiates during each of the winter and summer circumcision seasons. Our informal survey of several initiation camps in the former Transkei suggests the cost is typically around R300.

The medical alternative

While medical male circumcision is a generally available alternative to traditional circumcision, its provision in the Eastern Cape is influenced by cultural factors. For example, according to Eastern Cape Provincial Health Department spokesperson, Yonela Dekeda, the department does not conduct open marketing or demand creation in the communities/public “due to cultural dynamics within the province”.

“Medical Male Circumcision services are actually confined within the health facility level. Therefore, intake depends on the walk-ins, not on demand creation or promoting of the MMC services,” Dekeda said. “MMC is the choice of individual families. However, as the department, we are ensuring that all the designated MMC sites are well equipped with necessary MMC equipment, including training of clinicians such as medical doctors, clinical associates, and professional nurses to provide quality voluntary medical male circumcision services.”

Despite the lack of promotion, some young men, such as Bandile Macetywa*, have opted to go the medical route. He asked that we not use his real name for fear of victimisation from people who disapprove of his decision not to be circumcised in the traditional manner.

Speaking to Spotlight, the 20-year-old from Cofimvaba in the Eastern Cape said he pleaded with his parents, who are staunch traditionalists, to do the custom the medical way. “I know I disappointed my parents, especially my father, but at the end of the day, it was about my safety. I was happy when they respected my decision,” he said.

However, Mecatywa says he is all too aware of the discrimination that awaits him in society. “There are already naysayers. But I’m just glad the whole process went well. For Pete’s sake, we are in 2023. People are free to choose where they get circumcised. Some people had the guts to tell me to my face that I deserved to be abducted and circumcised again the traditional way?” he said.

Mecetywa believes many lives will be saved if rural communities can be educated to accept medical male circumcision. “It is much safer with [fewer] risks of getting infected while undergoing it. I am not saying traditional male circumcision is wrong. But why do initiates continue to die or have botched operations if things are done the right way,” he asked.

While the department does not actively promote medical circumcision, and while Mecetywa is clearly very aware of being in a minority, there are in fact significant numbers of medical circumcisions being conducted in the Eastern Cape. According to Dekeda, 14 637 were performed in the province in 2022, while 14 300 have been performed so far this year.

Medical male circumcision is an elective procedure that is widely available in the public sector, often provided via NGOs. The process typically involves counselling, a pre-assessment to check for anything that may hamper a client’s ability to be circumcised, post-operative care, and follow-up visits. Clients will typically also be offered an HIV test.

VMMC in the Western Cape

Meanwhile, in the Western Cape, the Department of Health and Wellness in collaboration with the City of Cape Town and the Department of Cultural Affairs and Sport has implemented an initiation consent form as a mechanism to uphold ethics. It includes medical screening that helps minimise and mitigate potential risks.

Western Cape Department of Health spokesman Mark Van der Heever told Spotlight, “The initiation consent form is further reviewed to enable alignment to developments as these emerge. Training and capacitation of traditional surgeons is a key element to strengthening partnership following a whole of government and whole of society approach.”

Van der Heever says since 2020, 274 circumcisions were performed by a Medical Officer invited by the traditional healers to perform the circumcisions.  A total of 131 977 medical male circumcisions, according to Van der Heever, were performed at the Western Cape health facilities since 2013, with 13 105 performed just last year.

The rest of the stats are as follows:

2013 – 12 581

2014 – 15 990

2015 – 14 131

2016 – 11 982

2017 – 15 127

2018 – 14 557

2019 – 18 000

2020 – 5 750 (COVID)

2021 – 10 754 (COVID)

2022 – 13 105

Van der Heever adds that between April and March 2023, Medical Male Circumcision was reported at 130 public health sites and a total of 12 259 circumcisions were performed across the province.

“The province also has two Men’s Health Clinics (in Karl Bremer and Elsies River). With the intention of increasing access to services, we are in discussions to upskill clinicians to enable service provision at health facilities. Current service provision is based on roving teams in both the metro and rural districts, which limit access to availability of the team.”

Republished from Spotlight under a Creative Commons 4.0 Licence.

Source: Spotlight

Categories : HIVTags :

Opinion: HIV Investments Remain No-brainers, but Some Things Need to Change

On By ModernMedia
Photo by Miguel Á. Padriñán

By Marcus Louw for Spotlight

Making the case for governments and donors to pump money into the HIV response has become more difficult over the last decade. This is partly a result of the notable successes we’ve had – for example, in 2022, HIV-related deaths in South Africa were down to less than a fifth of what it was in 2005. There is clearly some justification for the point of view that HIV simply isn’t the crisis it used to be.

That said, it is also true that about 8 million people in South Africa are living with HIV. This number will continue to rise in the coming years as the rate of new HIV infections is much higher than the rate of HIV-related deaths. Barring a major scientific breakthrough, all these millions of people will require antiretroviral medicines for the rest of their lives, both for their own health and to reduce onward transmission of the virus. In this context, a failure to maintain and improve HIV treatment and prevention programmes will have catastrophic consequences.

There is also increasing competition with other areas of urgent need. In recent years, climate change and COVID-19 have understandably made the headlines much more frequently than HIV. There is also a slow shift underway in South Africa’s disease burden, away from HIV and tuberculosis toward non-communicable diseases (NCDs) such as diabetes and hypertension.

Still a no-brainer

Despite these shifts, there is good reason to think that spending money on HIV continues to offer excellent value for money. For example, according to a recent report by Economist Impact (part of the Economist group that also publishes the Economist magazine), for every dollar spent on HIV in South Africa from 2022 to 2030, it is estimated the country will see GDP gains of over $7.

We also have a good idea of the impact and cost-effectiveness of specific HIV-related interventions. According to the most recent version of the South Africa HIV investment case, published in December 2021, condom provision continues to be the most cost-effective intervention in South Africa, followed by antiretroviral treatment, infant testing, pre-exposure prophylaxis for men who have sex with men, and general population testing. Voluntary medical male circumcision has become less cost-effective as coverage levels have risen in recent years, but remains worth it. In fact, the investment case leaves no doubt that most of the key interventions needed to combat HIV in South Africa are both worth it and affordable.

Despite all this, according to a recent UNAIDS report, global investment in HIV has taken a knock in recent years, and in 2022 we were essentially back down to the same level as in 2013. Such reductions constitute a crisis in HIV funding, especially in poor countries that are heavily reliant on donor funds. In South Africa, key interventions like antiretroviral treatment and condoms generally remain funded, but public sector health budgets have been shrinking in real terms, something that is no doubt impacting the HIV programme.

Time to leverage HIV investments

This brings us back to the knotty problem with which we started – while HIV remains a large and serious problem and most investments in combatting HIV remain excellent value for money, making the case for these investments has become more difficult due to competing priorities and the fact that, in South Africa at least, people are not dying of AIDS at nearly the rate they did 20 years ago. How to best make the case in a way that convinces governments and donors to put up the money in this context is a devilishly hard problem.

There are certainly no simple solutions.

What there is, though, is some indications that a too narrow focus on HIV is becoming a harder sell. There is also a risk that as funds for HIV get harder to come by, and the clamour for funding NCDs becomes more pronounced, we may end up pitting diseases against each other in a way that benefits no one.

Given the incredible acuteness of our HIV crisis ten and 20 years ago, a laser focus on HIV was right and necessary. Today, however, the reality is that many people living with HIV are also living with NCDs like diabetes or hypertension, something that will become only more so as the population of people living with HIV grow older. It is clear that we need to start doing a better job of integrating care and treatment for all the different diseases one person might have – the key is to do so in a way that doesn’t drop the ball when it comes to HIV.

In some areas progress is already clear – medicines distribution via pickup points closer to people’s homes were fuelled by the need to get ARVs to people, but is now also being used to distribute medicines for some NCDs. In other areas, such as data systems, integration however remains limited and the systems available for HIV and TB remain superior to those for NCDs.

There appears to be a broader policy shift along these lines. As recently reported on Devex, the Global Fund to Fight HIV, TB, and Malaria’s current five-year strategy explicitly endorses and promises funding for integrating non-communicable disease services with TB and HIV programmes. UNAIDS’s new ‘The path to end AIDS’ report also makes the right noises on the “deeper integration of HIV and other health services”, as does South Africa’s National Strategic Plan for HIV, TB, and STIs 2023 – 2028.

Of course, the road from policy-level ambitions such as these and change on the ground can be a long one – to some extent such integration has been on the cards for over a decade. But, rising NCD rates, an ageing population of people living with HIV and comorbidities, and funding pressures mean that getting integration right is now more urgent than ever.

One of the arguments for HIV-specific funding has always been that HIV investments have benefited healthcare systems more generally, even if that was not the primary intention. Maybe in this next act of the HIV response then, the key will be to stop thinking of health system improvement as a side effect of HIV investments and instead lean into the idea of explicitly leveraging what we’ve done and will continue to do in HIV to improve health systems more generally.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Categories : General InterestTags :

Going Viral: Dr Chivaugn Gordon on Medical School with a Difference

On By ModernMedia
Dr Chivaugn Gordon, head of undergraduate education at UCT’s Department of Obstetrics and Gynaecology, reflects on her love of teaching future doctors about women’s health issues. PHOTO: Nasief Manie/Spotlight

By Biénne Huisman for Spotlight

With humour and wearing an occasional wig, Dr Chivaugn Gordon teaches medical students about serious women’s health issues. During hard lockdown she delighted students at the University of Cape Town (UCT) with educational videos using household items as props. For example, she created an endometrium (the inner lining of the uterus) from hair gel and red glitter, performed a biopsy on a potato, and showed a chicken hand puppet go into labour.

One video features a patient named Zoya Lockdownikoff – who is a spy – consulting with her doctor about abnormal menstrual bleeding. Gordon, in a blonde wig with round sunglasses, plays Lockdownikoff; and Gordon’s husband, Dr Adalbert Ernst, plays her doctor.

Lockdownikoff explains that the bleeding started when she “did a very complicated backflip to escape a very compromising situation” and that it’s ruining her expensive super-spy coats.

Gordon is head of undergraduate education at UCT’s Department of Obstetrics and Gynaecology, while Ernst is with the university’s Department of Anaesthesia and Perioperative Medicine.

Speaking from her yellow-walled lounge in Cape Town’s Bergvliet, Gordon says: “I became a doctor because I love working with patients. And then I realised, oh cool, I love teaching too. And now I can do these two things together.”

Interest in IPV

For Gordon a driving interest has been intimate partner violence (IPV) which she introduced into her undergraduate curriculum in 2015.

“The aim is to have graduating doctors who are able to recognise intimate partner violence. Everybody thinks that you can’t possibly be abused unless you have a black eye or a fractured arm. But actually, IPV is often more psychological. It’s often psychological abuse. So the challenge is to teach young doctors what are the red flags in someone’s behaviour, or in their clinical presentation, that might indicate IPV.”

Published online in April, Gordon delivered a talk for TEDxUCT called “Tackling IPV, one awkward dad conversation at a time”, in which she notes IPV is “a global pandemic that has been ongoing since time began”. The title refers to Gordon’s father who raised her.

According to a paper published in the journal Lancet Psychiatry last year, IPV is the most common form of violence worldwide; it is most prevalent in unequal societies, and its victims are mostly women and girls. The paper states that worldwide 27% of women and girls aged 15 and older have experienced physical or sexual IPV, but in South Africa the figure is estimated to be much higher, between 33 and 50%.

Gordon contributed to South Africa’s revised Domestic Violence Amendment Act of 2021, through UCT’s Gender Health and Justice Research Unit.

The new legislation broadens the definition of domestic violence to include (above and beyond physical and sexual abuse) emotional, verbal or psychological abuse, which is described as “a pattern of degrading, manipulating, threatening, offensive, intimidating or humiliating conduct towards a complainant that causes mental or psychological harm…including (repeated) insults, ridicule or name calling; (repeated) threats to cause emotional pain; the (repeated) exhibition of obsessive possessiveness or jealousy…”

Gordon highlights the term coercive control. “Because that underpins most serious intimate partner violence. So, somebody who is extremely controlling; they want their partner to do what they want, when they want, and how they want immediately. They normally start isolating you from friends and family so they can spin a narrative of your reality that can’t be contested by anyone else. And it also makes it more difficult to leave.”

Red flags

Gordon highlights some of the IPV red flags that doctors should look for in their patients.

“Depression, anxiety, PTSD, insomnia, [and] things like self-medicating with substances,” she says. “Because when you are living in absolute, abject terror every day of your life, it’s going to manifest in some kind of psychological manner. So, when people have been broken down and worn down and their self-esteem has been eroded it also affects the way they might interact with the healthcare professional.

“Big red flags come out in body language. Usually when someone goes to a doctor, they tell you everything about all their symptoms, because they want you to make them better. So, if you’ve got a patient who is closed off, they’re not making eye contact, they’re avoiding answering your questions, they’re just very reticent and you can’t get anything out of them…then you’ve got to think.”

Gordon stresses that IPV happens across economic strata and in all walks of life. “Every time I run this workshop, a medical student who comes from a very privileged background, from a very financially stable, loving home, comes to me, saying this is happening to her. It happens everywhere. I’ve got medical colleagues, several, who have experienced intimate partner violence. It doesn’t discriminate.”

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

Categories : HIVTags :

Over 4.7m People in SA Placed on New HIV Med in Four Years

On By ModernMedia
Photo by Sergey Mikheev on Unsplash

By Elri Voigt for Spotlight

In what is likely one of the largest treatment rollouts in South African history, well over four million people living with HIV have started taking the antiretroviral dolutegravir since its introduction around four years ago. Now, according to a recent study published in the Lancet medical journal, use of dolutegravir in South Africa is associated with more people staying on treatment and higher rates of viral suppression.

The use of a three-in-one combination of the antiretroviral drugs tenofovir, lamivudine and dolutegravir (TLD for short) for the treatment of HIV was first recommended by the World Health Organization (WHO) in 2018. A year later it was recommended in the South African treatment guidelines as first line treatment for HIV and a three-year tender was awarded. Since then, dolutegravir has largely replaced another antiretroviral called efavirenz.

Today, TLD is the recommended treatment option for most people living with HIV in the country. The 2023 National antiretroviral (ARV) guidelines also include recommendations for the use of child-friendly formulations of dolutegravir and dolutegravir containing regimens in kids. Spotlight reported on these here.

Around 4.7m people in SA taking dolutegravir

According to Foster Mohale, spokesperson for the National Department of Health, in 2019 the HIV clinical guidelines were revised to include a fixed combination dose of TLD “for all eligible people for use as the first line regimen.”

Based on this, the department set a goal that 90% of those eligible for it should receive TLD as a first line regimen. In terms of meeting this goal, Mohale says that by March 2023, just over four million (4 127 427) people were on TLD. Additionally, about 650 000 (653 884) people were on other dolutegravir based regimens. Altogether, there are thus now over 4.7 million people in the country on treatment combinations that include dolutegravir.

“Based on the March 2023 data, 90% of clients on first line regimen were on TLD. However, performance varies by province,” he says.

Of the total number of people on ART in the public health sector, 75.8% are on TLD, according to Mohale.

Trends in the roll out

While on paper the country’s transition from efavirenz to dolutegravir-based regimens seems to have been smooth, the reality on the ground has been more complex. A study published in the Lancet earlier this year looked at real-world rollout data from 2019 to 2022. The study was conducted in 59 clinics across the country and collected data from two cohorts-one cohort were first time initiators of ART and the other were transitioning from regimens that did not include dolutegravir to ones that did.

In the initiator cohort, just over 45 000 people were initiated on ART between December 2019 and February 2022. Of those, 68.9% were initiated on dolutegravir-based regimens, 31.1% on efavirenz-based regimens, and 0.1% on nevirapine-based regimens.

Those initiated on dolutegravir-based regimens were more likely to still be on treatment a year later and were also more likely to be virally suppressed than those who were initiated on the other regimens.

In December 2019, in the transition cohort, just over 180 000 people were on a non-dolutegravir first line regimen. By February 2022, 67% of them had transitioned to a dolutegravir-based regimen. These people were also more likely to be retained in care at 12 months and be virologically suppressed than those who had not switched to a dolutegravir-based regimen.

“That’s good for a number of reasons. It means that the treatment’s working, people are less likely to get unwell and also, they can’t transmit the virus onto other people,” explains Dr Jienchi Dorward, one of the study authors and an academic clinical lecturer at the University of Oxford and honorary associate scientist at the Centre for the AIDS Programme of Research in South Africa (CAPRISA).

‘Bumpy transition’

Dr Yukteshwar Sookrajh, a Senior Medical Practitioner at the eThekwini Municipality Health Unit who was also involved in the study, tells Spotlight that the rollout quickly gathered momentum.

“But initially there were some issues to navigate around drug interactions; concurrent TB infection and the use of dolutegravir in women of childbearing potential,” he says. “Once those concerns were addressed, the comfort of switching to dolutegravir was increased and we find that the majority of our patients have now safely transitioned across to dolutegravir-based regimens.”

In many ways South Africa was slow in rolling out dolutegravir compared to other African countries, according to Professor Francois Venter, the head of Ezintsha at Wits University. Reasons for this, he says, include an initial concern around the safety of dolutegravir use among pregnant women, and disruption in training due to the COVID-19 pandemic.

He says that the South African Clinicians society was alerted during the COVID-19 pandemic that many patients in the public health sector had still not been transitioned to dolutegravir. An education campaign was then launched to encourage clinicians to start or switch patients to dolutegravir.

However, as it stands now the rollout of the drug in the public sector has been a huge success, despite what Venter calls a “bumpy transition”.

Initial safety concerns

One important reason to conduct the study reported in the Lancet, according to Dorward, was a safety concern regarding the use of dolutegravir by pregnant women. An earlier study conducted in Botswana called Tsepamo found a higher prevalence of neural-tube defects (a type of birth defect) associated with dolutegravir exposure at conception than with other types of antiretroviral exposure. As more data has been gathered since, it has however become clear that dolutegravir does not in fact increase the risk of neural-tube defects.

But the Tsepamo scare did impact who was initiated and transitioned onto dolutegravir in first two years of the rollout.

“The initial concerns around neural-tube defects and the use of dolutegravir in women of childbearing potential clearly hampered rollout of dolutegravir in women – and this has been clearly demonstrated in this study,” says Sookrajh.

The Lancet study found that pregnant women and non-pregnant women were less likely to be initiated on dolutegravir than men early in the rollout, with the biggest difference between women and men aged 15 to 24 years old. This difference decreased with age and by age 55 there was no difference between men and women receiving dolutegravir.

But this changed over time and by September 2021 women were as likely to get initiated on dolutegravir as men. Spotlight previously reported that the rollout was done in two stages. In the first stage men, adolescent boys, women on reliable contraception, and older women were prioritised.

Of those who started treatment during the study period, 46.9% of the pregnant women in the cohort were initiated on dolutegravir-based regimens, while 63.9% of the non-pregnant women and 82.3% of the men in the cohort were initiated on dolutegravir-based regimens.

“In both those groups [cohorts] we found that women were less likely than men to get dolutegravir, but interestingly, this was particularly in younger women,” Dorward explains. “As time went on, the difference between men and women became much less…around June to September 2021 was a time period where we found that women and men pretty much began to equally get dolutegravir.”

Dorward says the data showed an uptick in women in the study being given dolutegravir once the South African guidelines changed to reflect that there was no longer a concern around neural-tube defects.  It is thus likely that the safety concern was responsible for the lower initial uptake among young women.

He adds that the messaging around this potential risk was based on the evidence available at the time and was clearly outlined in the guideline document and training for dolutegravir use, but these did not appear to adequately allay these concerns among healthcare workers.

“The risks versus benefits needed to be messaged in a more effective way such that healthcare workers were more comfortable and confident in offering dolutegravir to women,” he says. Based on this experience Sookrajh adds that in future there needs to be more engagement with “practitioners on the ground to determine what type of messaging and supportive materials are required to facilitate better understanding of guidelines at the coal face.”

Another concern for some healthcare workers has been that dolutegravir-based regimens have been associated with greater weight gain than efavirenz-based regimens. But, as argued in a recent editorial in the Southern African Journal of HIV medicine, association is not the same as causation and it may well be that efavirenz inhibits weight gain rather than dolutegravir promoting it. People living with HIV who start taking antiretroviral medicines often gain weight as their health recovers.

New guidelines should further boost uptake

Sookrajh says that the National Department of Health’s antiretroviral (ARV) 2023 guidelines will further improve the uptake of dolutegravir in the public healthcare system.

“With the April 2023 National Department of Health ARV Guidelines, we actually find that further barriers to switching to dolutegravir have been removed and dolutegravir is clearly placed as the preferred drug of choice in almost all scenarios for both first- and second-line antiretrovirals,” he says.

“I think the new [ARV] guidelines hopefully will be a big improvement for people who are on treatment, and part of that is possible because we’re using the drug that is better. You’re less likely to get resistance with dolutegravir so we’re less worried if people don’t take treatment properly that they might get drug resistance, although we still need more research to be sure about that,” Dorward says. “And it’s still very important for people to take treatment consistently to suppress the virus and maintain their own health and prevent onward transmission.”

According to Venter, there needs to be proper resistance surveillance to detect potential dolutegravir resistance.

“We can’t take for granted we’ll never have resistance [to dolutegravir]…eventually there will be the occasional patient that does have resistance, but we need proper surveillance there,” he says. “And then we need to keep an eye on things. There are still patients getting HIV…there’s still a lot of new infections…we need to make that stop…we’ve got amazing PrEP and way too few people getting it. So, we do need to start addressing that.” (PrEP, or pre-exposure prophylaxis, refers to antiretrovirals taken to prevent HIV infection.)

Venter adds that while successful in the public health sector, the uptake of dolutegravir has been extremely slow in the private health sector for reasons unknown to him.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : Hospitals Surgeries & ProceduresTags :

Cancellation of Operations at the Charlotte Maxeke Johannesburg Academic Hospital

On By ModernMedia

The Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) would like to dismiss the misleading information shared by Mr Jack Bloom regarding cancelled operations.

CMJAH would like to put it on record that there were no “more than 50 elective cases cancelled due to the cold weather conditions”. The statement by Mr Bloom creates the impression that all elective cases were cancelled, which is not true.

There were 53 operations scheduled for Monday, 10 July 2023, and 26 cases were done, while only 15 were cancelled due to low temperatures at theatres and 12 were cancelled for reasons not related to low temperatures.

Out of the 15 cancelled cases, 3 were for Thoracic, 6 were for Trauma Orthopaedic, 2 were for Paeds Orthopaedic, 1 was for Paeds plastics, and 3 were for Ear, Nose, & Throat.

The problem of temperature control has been a challenge for the facility for years, but it became worse in the last two years due to the copper theft which took place during the period when the facility was evacuated for months after the fire incident. This affected the central heating system of the facility, which regulates the level of acceptable temperatures in the entire hospital, but mostly in the theatres.

To remedy the situation, the process of installing Schedule 40 pipes, which are less susceptible to theft as they do not have an attractive market value as copper does, has started. During the installation process, the theatres and intensive care units (ICU) were prioritised. From the date of appointment, 28 June 2023, to date, the contractor has completed the installation of schedule 40 pipes for Blocks 2, 3 and 4. The installation process at Block 5 has already started and the work is progressing well, ahead of schedule.

The water system is currently running, with close monitoring, at all three blocks where the schedule 40 pipes were installed to check for any possible leaks as the system has not been running for the past two years.

The facility would like to apologise to the public for any inconvenience this might have caused. The installation of the schedule 40 pipes is a necessary project that would address the issue of copper theft and the central heating system.

The facility would further like to assure the public that this matter is getting the urgency it deserves, and cancelled cases are being attended to.

News release issued by the Charlotte Maxeke Johannesburg Academic Hospital

Categories : HospitalsTags :

Staff at Chatsworth Hospital Picket over Poor Working Conditions

On By ModernMedia
Staff, including nurses, at RK Khan Hospital in Chatsworth, Durban, picketed on Wednesday over poor working conditions at the facility. Photo: Tsoanelo Sefoloko

By Tsoanelo Sefoloko

Nurses, administration staff and general workers brought parts of RK Khan Hospital in Chatsworth, Durban, to a standstill for about an hour on Wednesday. They protested outside the hospital to highlight what they say are poor working conditions. 

Protesting nurses say they are forced to perform cleaning duties in addition to patient care because the hospital has not employed enough cleaners. Other workers complained of staff shortages in the administration and general units.

Workers say they met with the management in February. Union leaders had asked the facility to commit to resolving their complaints.

Nurse Zizakele Ndlovu said they were told by the union leaders that working conditions would improve. But nothing changed, she said.

“The conditions we work under at the hospital are not good. We end up having to work more hours, and we don’t get paid for overtime. Sometimes I even work as a clerk,” she said.

“The department treats us as if we don’t know our job, and we don’t deserve what we are asking for. We lost many workers to Covid; some retired and others resigned. Those vacancies have not been filled. Even at top management there are lots of vacancies and this leads to poor service.”

Chairperson at the hospital of the National Education, Health and Allied and Workers’ Union (NEHAWU) David Mpongose said they had engaged management and had been promised that the situation would improve.

“Our bosses are arrogant. They really don’t take us seriously. Each time they make empty promises, so we decided to protest for the provincial government to assist us,” said Mpongose.

Xolani Mnguni, a cleaner, said he earned R7800 per month under the hospital’s previous contractor, but now only earns R3000 under the current contractor. He also said he has to do jobs other than cleaning.

Hospital CEO Linda Sobekwa accepted the workers’ memorandum and signed it on behalf of the provincial health department. She promised to ensure that the department responded within ten days as requested.

Agiza Hlongwane, spokesperson for the KwaZulu-Natal Department of Health, said officials would consider the workers’ demands and respond to them.

Republished under a Creative Commons Attribution-NoDerivatives 4.0 International License.

Source: GroundUp