Tag: Spotlight

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

Mandatory Health Insurance for SA is an ‘Upgrade’ on NHI, Proponents Say

On By ModernMedia
Photo by Hush Naidoo Jade Photography on Unsplash

By Chris Bateman

The idea of mandatory medical scheme coverage for employed people has made a comeback after the case for it was made at a recent conference. The policy move was previously on the cards in South Africa but faded after the ANC opted for National Health Insurance (NHI) at its 2007 national congress where Jacob Zuma was elected as the party’s new leader. Chris Bateman unpacks how a system with mandatory medical scheme membership for the employed might work and asked local experts whether it represents a viable alternative to government’s NHI plans.

A vigorous public debate has ensued since outgoing Netcare CEO, Dr Richard Friedland, on behalf of the Hospital Association of South Africa (HASA) delivered a strongly argued case for a return to what he described as the original ANC healthcare plan. He was speaking on “Viable and Near-term Opportunities to Providing Enhanced Healthcare in South Africa,” at HASA’s annual conference in Sandton held early in September.

Since then, the leadership of Business Unity SA (BUSA) met with President Cyril Ramaphosa and Health Minister Dr Aaron Motsoaledi, and his deputy and other senior officials, in mid-September to discuss “matters of concern” related to the NHI. The President requested BUSA to put forward specific proposals on “the remaining matters of concern” as a basis for re-engagement.

Some observers have suggested to Spotlight that these consultations are a first sign of government openness to changing or tweaking its NHI plans. But whether this means the door is actually open for a system of mandatory health insurance, or for mandatory health insurance as a stepping-stone toward NHI, is still unclear.

The NHI Act, that was signed into law by Ramaphosa in May, envisages a single-payer system where medical schemes are only allowed to cover health services that are not covered by the NHI fund.

How mandatory health insurance would work

Under mandatory health insurance, everyone who is in formal employment, or who earns above a certain threshold, would be forced by law to be a member of a medical scheme. This will result in medical scheme membership swelling substantially and some pressure being taken off the public healthcare system. It is also expected to result in medical scheme premiums being reduced because more healthy, younger people will join the schemes. People who are unemployed or who cannot afford health insurance will still be dependent on the public healthcare system.

Friedland said such mandatory healthcare insurance will triple the medical scheme market from 9.2 million to potentially 27.5 million beneficiaries over time and reduce those dependent on the state from 53.8 million to 35.5 million. In so doing, it would boost public healthcare per capita spending by 52%, (from R5 054 to R7 659), without any additional funding of the public sector budget, alleviate the strain on public hospitals and clinics, shorten waiting lists, and free up money to hire more staff and improve infrastructure. He said it is a “far faster and more efficient tool” for achieving health equity.

Responding to the counter argument that a mandatory health insurance system would entrench existing health inequalities, Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, said the opposite is true. “It accelerates convergence between the two systems faster than the NHI proposals,” he told Spotlight.

The relief for people who can afford medical scheme cover could also be significant. Friedland said mandatory medical scheme membership would bring more young and healthy people into the system, thus reducing the cost of monthly premiums by 25% to 30%.

Mandatory contribution schemes for civil servants have been implemented in more than half of the countries in Africa, while Thailand and many other Asian countries have started with mandatory cover for the formal sector before expanding to the non-formal sector. Such systems with what amounts to many medical schemes, rather than a single large fund, are also in place in several European countries, including the Netherlands and Germany.

Not a new idea

Mandatory health insurance, or an expanded role for medical schemes, are by no means new ideas in South Africa. Friedland told Spotlight that the ANC government’s own broad ranging 2002 inquiry into the various social security aspects of the South African health system concluded that national health insurance or the complete nationalisation of the private sector, could not be seriously considered as a reasonable option. (The inquiry itself was based on the Health Subcommittee Findings of the Committee of Inquiry into a Comprehensive System of Social Security.)

That 2002 report concluded: “National health insurance is not an option that emerges overnight as an alternative to social health insurance. Instead, it becomes feasible within market economies where formal employment levels are high. Prior to this, mixed systems are inevitable.”

One indication of how committed government was to such a mixed system with an expanded role for medical schemes in the early and mid-2000s, is the fact that the legislative framework to enable the expansion of medical scheme coverage was incorporated into the 2008 Medical Schemes Amendment Bill. That bill did not go as far as making scheme membership mandatory, but a mandatory system was clearly a next step on the reform agenda, as outlined in the very wide-ranging 2002 Taylor report on social security in South Africa. But presumably because of the NHI proposals, the 2008 amendments were allowed to lapse – and the scaffolding for a progressive expansion of medical scheme coverage collapsed.

There have since been several committees of inquiry and technical processes that validated an ongoing role for medical schemes, of which the Competition Commission’s Health Market Inquiry (HMI), that ran for five years (2014 to 2019), was the most technically detailed, consultative and authoritative. The HMI report did not recommend that medical scheme membership be made mandatory for people who are employed, but it did recommend a continued role for medical schemes and suggested that the most viable path to NHI may well involve first fixing the regulation of medical schemes.

Van den Heever said South Africa needs to quickly return to the pre-2008 reform trajectory to help stabilise the health system, “before more harm is done”. Government needs to summon up the political will to address the systemic governance failures of the public health system, removing the “bad actors and provincial cabals” that were destroying the integrity of South Africa’s free public health services, he added.

Better regulation also needed

For a system of mandatory health insurance to work, medical schemes will have to be more effectively regulated. Here the HMI report found that government had dropped the ball. It attributed the private health market failure and rampant medical inflation directly to government neglecting to regulate the private healthcare industry.

Health actuarial consultant, Barry Childs, joint CEO of Insight Actuaries and Consultants, told Spotlight private healthcare sector reforms urged by the HMI were ignored, resulting in ongoing confusion, high costs, complicated products and waste, among other problems. “Our incomplete medical scheme regulation keeps costs up, (for example anti selection, Prescribed Minimum Benefits), with benefits out of reach of most. We still don’t have a proper framework for lower cost-lower benefit products for those who cannot afford medical schemes,” he said.

The HMI report recommended a framework that went “way beyond naïve approaches to price control”, said Van den Heever, and addressed the powerful incentive structures driving unproductive forms of competition. In addition, he said, the industry-wide pooling approaches (risk equalisation and social reinsurance) followed international best practice and fully addressed issues of pooling fragmentation.

In the five years since the publication of the Commission’s HMI report, none of its major recommendations have been implemented.

Jobs and taxes

One common thread running back to the 2002 report, is the idea that South Africa is not economically ready for NHI and that a mixed system, possibly with mandatory health insurance, is more compatible with the current realities of high unemployment and a relatively small tax base.

“The root cause of inequity and inequality is not just a new form of apartheid. The real reason is the catastrophic level of unemployment. Until we address that, we will not solve an entire range of inequities, including food security, housing, education, and healthcare,” said Friedland.

On joblessness, Childs said South Africa was on track with the rest of the world’s growth up to 2008 but thereafter flat lined for over a decade. “We have dramatically underperformed the rest of the world and our peer group of middle-income countries in long term economic growth.”

In South Africa, unemployment is at an extremely high 33.5%, while in 2002 it was at 26%.

“If an NHI was unaffordable in 2002, how much more so is it today?” Friedland asked. He said that in this context, strong partnership, collaboration, and co-operation between the public and private sector is needed to bridge the polarisation that has arisen.

Analysis commissioned by BUSA found that raising the extra R200bn the health department says it needs to fund NHI would entail unrealistic and unaffordable tax hikes. It would either increase personal income tax by 31%, push VAT from 15% to 21.5%, or require the collection of a payroll tax of R1 565 per month from everyone in formal employment.

Van den Heever said that while government has a discretion to increase tax rates to any level it chooses, it cannot control the resulting amount of funds raised. He said that once tax capacity is reached, a hard ceiling on government revenue results at any given level of economic growth. The only way to grow revenues thereafter is through economic growth, failing which, revenues stagnate beyond government control.

The “big idea”, he said, was that new taxes would fund the move of medical scheme members to the public sector, in the form of a single NHI Fund, such that both public sector and medical scheme populations were covered in the same system – with net gains in coverage for both.

However, contrary to what was “correctly understood” from 1994 to the 2002 Taylor Commission, “the maths for such an approach, just does not add up”, said Van den Heever.

“The fastest way to de-segment the system is to allocate all new government revenues arising from economic growth to the people who need it most. This is not what the NHI proposals envisage. They want to dilute the public spend by trying to cover higher income groups. It is dangerous magical thinking that allows government to avoid dealing with the complex problems of the health system. Government needs to get back to its day job and do the heavy lifting needed to get our health system working again.”

Government response

Spotlight shared an earlier draft of this article with the National Department of Health for comment. While the department did not comment directly on mandatory health insurance, Foster Mohale, the department’s Director of Communications, emphatically reiterated their support for NHI and the NHI Act that was signed into law in May.

“There is no better time than now to reform South Africa’s health system. It is time to do away with the apartheid type of health system, and to reconfigure it into one that ensures that every South African gets the health care that they need, when they need, where they need and without incurring financial hardship. With the enactment of the NHI Act, the time for piecemeal approaches that retain benefits for the few and leave the majority to the whims of the market is no more,” Mohale told Spotlight.

He said that many countries, including Japan and the United Kingdom, have implemented health system reforms directed at achieving universal health coverage during times of crisis and low economic growth. “Therefore, to say that South Africa must sit and wait for some oracle numbers to emerge before instituting NHI is merely to argue that we must consciously let those that are carving profits and dividends from the anomalies that characterise our health system to continue. This is an irresponsible position that the Department cannot adopt as health is a constitutionally enshrined right for every South African, not just a privileged few,” he said.

On the questions of taxes, Mohale said: “We will not delve into the projected tax implications because we believe this is a matter that squarely falls under the purview of the National Treasury and the Minister of Finance. Suffice to say at the right time, and after necessary deliberations through formal government structures and processes, any information relating to this will be communicated to the public for comments prior to finalisation.”

Note: The 2002 Tailor report titled ‘Transforming the present – Protecting the future’ is not readily available online. There is this PDF version (unfortunately not searchable and with poor accessibility). For ease of use, we have created a Word version of the document that you can access here. Health is discussed in chapter 8.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Mental HealthTags :

SA Has the Third Highest Suicide Rate in Africa – There are Steps We can Take to Tackle it

On By ModernMedia
Photo by Alex Green on Pexels

By Vincenzo Sinisi

South Africa has the third highest suicide rate in Africa and Africa has higher rates of suicide than any other continent. In the wake of World Suicide Prevention Day on September 10th, clinical psychologist Vincenzo Sinisi asks what can be done to bring down suicide rates.

Africa is currently the region with the highest suicide rate worldwide, according to the World Health Organization (WHO). This is driven by a combination of factors, including poverty, unemployment, and untreated mental health issues.

South Africa, with a suicide rate of 23.5 per 100 000 people, ranks third worst on the continent. South Africa is closely followed by Lesotho and Eswatini – countries where limited access to mental health services exacerbates the issue.

Age and gender impact suicide risk. In South Africa, for instance, suicide has been rated as the fourth leading cause of death among people aged 15 to 24, reflecting the devastating mental health toll on young people. The gender disparity is stark – men are four to five times more likely to die by suicide than women. However, women tend to report twice as many suicide attempts as men, indicating a significant gap in prevention efforts targeting both genders

Why is it happening?

While suicide is a global challenge, it manifests differently across Africa due to a variety of factors – these include economic hardship, mental health stigma, and the scarcity of healthcare resources.

Mental healthcare in Africa is severely underfunded. Many African countries have an insufficient number of mental health professionals – sometimes as few as one psychiatrist per 500 000 people. This is compounded by widespread mental health stigma, which prevents many people, particularly men, from seeking help. In some African cultures, suicide is stigmatised to the extent that it is linked to supernatural beliefs, such as curses or sorcery. These deep-seated cultural beliefs often lead to underreporting of suicide cases and contribute to delayed intervention.

In addition to cultural taboos, socioeconomic stressors like unemployment, poverty, and housing insecurity further drive suicide rates across the continent. In South Africa’s townships, the levels of indebtedness and joblessness create a cycle of despair that feeds into psychological distress, ultimately increasing the risk of suicide.

In South Africa, the impact of socioeconomic instability on mental health is evident, particularly in rural and impoverished urban areas. The link between unemployment and mental health distress is well-documented, and for many, this distress leads to thoughts of suicide. In economically deprived areas, suicide prevention efforts are often undermined by poor access to healthcare and low mental health literacy. As economic hardship worsens, so does the mental health of affected populations.

What to do?

Preventing suicide in South Africa and on the African continent more broadly requires a multi-level strategy, combining grassroots initiatives with government support. Many successful interventions have originated from community-based programmes tailored to local needs and cultural contexts – there are after all large differences between countries and, for example, between urban and rural areas.

As a starting point, community involvement is crucial in creating a supportive environment for those at risk. By training community leaders, including traditional healers and faith-based leaders, to recognise signs of mental health struggles, these communities can provide immediate support. Peer support networks have also proven effective, especially in areas with limited access to formal healthcare services. Such networks empower individuals to check in on one another and provide emotional support in times of crisis.

For example, the South African Depression and Anxiety Group (SADAG) runs mental health education programmes across rural South Africa, equipping local leaders and volunteers with tools to recognise and respond to signs of suicide. These efforts are helping to reduce stigma and encourage early intervention in communities often overlooked by national healthcare systems.

While community-led efforts are invaluable, government policy is essential for creating systemic change. South Africa’s National Mental Health Policy Framework (2023-2030) aimed to integrate mental health care into the primary healthcare system. Still, its implementation has been slow, particularly in rural areas. Expanding this framework and ensuring proper funding for mental health initiatives must be a priority. (Spotlight previously reported on expert responses to the new mental health policy.)

Governments can also collaborate with NGOs and the private sector to expand mental health services.

Telehealth and digital solutions have for example emerged as potential tools for addressing mental health challenges, particularly in areas where access to mental health professionals is limited. Telehealth services enable patients in remote and underserved areas to consult with mental health experts without travelling long distances. This is especially helpful for individuals who might otherwise be unable to access support due to geographic or financial barriers. One such initiative I am involved with is TherapyRoute.com, a platform that connects people with therapists and psychologists across Africa and  that maintains a database of South African community health clinics.

Such a digital approach, though promising, still faces challenges. Internet access remains inconsistent in many parts of Africa, and telehealth services must continue to evolve to ensure they are accessible to most of the population. Increasing investment in digital infrastructure will be a critical part of expanding access to mental health services.

Practical strategies

Meanwhile, there are practical things we can do now. Suicide prevention is after all not the responsibility of healthcare professionals alone – everyone can contribute.

We can all be on the lookout for the warning signs. Sudden withdrawal from social activities, mood changes, declining self-care and hygiene, and expressions of hopelessness or helplessness (e.g., “I can’t go on” or “Everyone would be better off without me”) should never be ignored.

If someone you know appears to be at risk, ask direct questions about their mental health. Don’t be afraid to ask if they are considering suicide. Studies show that directly asking about suicide can reduce the risk of an attempt by giving the person a chance to talk about their feelings.

We can also respond as a community. We can organise peer support groups where people can check in on one another. Training community leaders, traditional healers, or local volunteers to recognise suicide risk and provide mental health first aid is another effective way to support those at risk. Running community-wide campaigns to raise awareness about mental health issues and reduce stigma can help normalize seeking professional help.

Governments also have a critical role to play. They must prioritise mental health by increasing funding for prevention and treatment programmes, particularly in rural and underserved areas. The success of such programmes depends heavily on their accessibility to people from all economic backgrounds.

In South Africa, government should focus on implementing the National Mental Health Policy Framework, ensuring it reaches the rural areas that are most in need. By integrating mental healthcare into primary healthcare services, as envisaged in the policy framework, more people will have the chance to receive timely care.

Ultimately, suicide prevention requires a multi-level approach, with involvement from individuals, communities, governments, and the private sector. By recognising warning signs, reducing mental health stigma, and expanding access to care through both in-person and telehealth services, we can make meaningful strides in reducing the suicide rate across Africa.

*Sinisi is a clinical psychologist and psychoanalyst in private practice in Cape Town. He is also a faculty member of the South African Psychoanalysis Association, The South African Psychoanalytical Initiative, and the Centre for Group Analytic Studies.

People in need of help can contact SADAG on the following helplines:

  • 0800 21 22 23 (8am to 8pm)
  • 0800 12 13 14 (8pm to 8am)
  • SMS: 31393

Also see this webpage for a longer list of helplines.

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Diseases, Syndromes and Conditions HIVTags :

SA’s HIV Burden a Concern as New Mpox Strain Spreads in DRC – but Much Still Unknown

On By ModernMedia
Mpox (monkeypox) virus. Source: NIH

The African Centre for Disease Control and World Health Organization have raised the alarm following a drastic uptick in mpox cases. This surge is being driven by a new strain of the virus. Elri Voigt reports about what we know so far and potential implications for South Africa.

Mpox, a viral illness first identified in Africa in 1970, made headlines in 2022 when it spread across the globe for the first time. Since then, the outbreak has evolved, with multiple strains of the virus circulating in different countries. A new strain, known as clade Ib, first discovered in the Democratic of the Republic of Congo (DRC), is responsible for much of the most recent surge in mpox cases.

These recent developments are complex, and the situation is likely to change. This was the common theme of a special session on the mpox outbreak during the World Health Organization (WHO) Regional Committee for Africa meeting at the end of August. This session took place two weeks after the WHO declared the outbreak to be a Public Health Emergency of International Concern.

“We don’t have one outbreak. We have multiple outbreaks in one,” Dr Jean Kaseya, the Director General of the African Centre for Disease Control (CDC) remarked.

These outbreaks are caused by different clades of the mpox virus. Clades are a classification system based on the genetic similarities between different strains of a virus, explained Professor Tulio de Oliveira, Director of the Centre for Epidemic Response and Innovation (CERI) at Stellenbosch University (SU). “So, what it means is that when we see a genetic change [in a virus] that’s really visible and that may have impacted it, normally we call it a different clade or genotype or variant,” he said.

This is similar to classifying different strains of SARS-CoV-2 as variants, Dr Duduzile Ndwandwe, a molecular biologist working for Cochrane South Africa, an intramural research unit within the South African Medical Research Council, told Spotlight.

She explained that the different mpox clades and sub-clades have mutated so they have genetic differences but still fall under the umbrella of mpox.

“In a nutshell…it’s just talking about the differences in the genome sequence of the virus, how many mutations [it has] or how big the mutations are in that virus’s strain of mpox,” she said.

‘Jump in evolution’

Dr Aida Sivro, senior scientist at the Centre for the AIDS programme of Research in South Africa (CAPRISA), in 2022 told Spotlight that there are two clades of the mpox virus, which were then referred to as the Central African Clade (clade I) and the West African Clade (clade II).

Since then, clade I went through a big jump in evolution and a sub-clade emerged in the DRC, now called clade Ib, De Oliveira told Spotlight. The previous outbreak in 2022 was mostly driven by another sub-clade called clade IIb.

To further complicate matters, there’s a third strain of the virus also circulating – clade Ia.

At the moment, the DRC accounts for about 90% of mpox cases in the African Region, according to Dr Fiona Braka, the Emergency Response Manager for WHO’s AFRO region. She explained that right now the situation is not fully understood because a lack of diagnostics and testing capabilities is limiting understanding of the true burden of disease.

What we do know, she said, is that there are two distinct outbreaks in the DRC. Based on the information currently available, clade Ia is circulating in regions in the country where mpox is considered endemic and affecting mostly children. While clade Ib is spreading mostly among adults in the eastern provinces of South Kivu and North Kivu.

The clade Ib strain has since spread from the DRC to neighbouring countries Burundi, Rwanda, Uganda and Kenya, according to Braka. Sweden and Thailand have also identified one case each.

As of 1 September, the WHO reported that there have been 3 751 confirmed cases of mpox and 32 deaths across 14 countries in African in 2024 alone. But there are many more suspected cases of mpox that have not been tested.

Implications for South Africa

De Oliveira said at this point, South Africa shouldn’t be overly concerned about mpox, but it should be alert. The best way to do this is to make sure the public know what the symptoms are so they can present for diagnosis and treatment if they suspect they have the virus.

In a similar vein, Ndwandwe said the public shouldn’t panic, but we as a country need to remain vigilant. She added that because clade Ib is spreading on the African continent, there is a risk of it spreading to South Africa through cross-border travel, making it a public health concern.

This year, 24 cases of mpox have been reported in South Africa. Three people have died, while 19 have recovered. Two people are still considered to have active disease, with the most recent case identified in early August.

But this doesn’t necessarily mean there aren’t more cases of mpox in the country. “What we do suspect is that we may have milder cases that are actually not reported,” Nevashan Govender, the operation manager of the Emergency Operations Center at the National Institute for Communicable Diseases (NICD) told Spotlight.

He said so far, all the cases in the country have been caused by clade IIb and no cases of clade Ib have been identified.

A polymerase-chain-reaction (PCR) test is the gold standard test used to determine whether someone has mpox. But genome sequencing would need to be done to identify what clade they have.

Lots of unknowns around new strain

At the moment, there are a lot of unknowns around clade Ib.

What is of concern, according to Braka is the severity of disease seen especially in people who are immunocompromised and in pregnant women and children. Ndwandwe added to this and said there is a concern that clade Ib has higher fatality rates than clade IIb.

De Oliveira cautioned against jumping to conclusions about the severity of this new clade without sufficient data. He said we don’t know for sure yet if clade Ib is causing more severe disease than IIb. What we do know from mpox in general, he said, is that when someone is immunocompromised in some way, they tend to develop more severe symptoms.

Govender echoed De Oliveira’s caution that we don’t yet know enough about clade Ib to say definitively if it is for example more transmissible than other clades

“It’s not to say that it isn’t [more transmissible], but there is just not a lot of evidence stating that it is absolutely true…There’s a lot of knowledge and information gaps,” he said.

The NICD in a recent update also stressed that there are a lot of unknowns about this new strain. It added: “South Africa continues to prioritise enhanced surveillance and raising awareness for mpox.”

The state of vaccines and treatment for mpox

Spotlight reported previously that the smallpox vaccine, which hasn’t been routinely administered in South Africa since the 1980s when smallpox was eradicated, is thought to offer some degree of protection against mpox. However, it’s difficult to predict just how much protection the smallpox vaccine would provide, Sirvo told Spotlight for that previous article.

There are currently three vaccines against mpox that have been approved in some countries, a spokesperson from the vaccine alliance Gavi told Spotlight. These are LC16m8, JYNNEOS and ACAM2000.

LC16m8 is a third-generation small pox vaccine manufactured by KM Biologics. According to WHO, from 2022 it had mainly been used in Japan.

The JYNNEOS vaccine is a third-generation smallpox vaccine, manufactured by Bavarian Nordic, Ndwandwe said, and it was used during the outbreak in 2022. She added that this vaccine is considered the preferred option due to its safety profile and targeted protection against mpox.

ACAM2000 is a second-generation vaccine for smallpox and manufactured by Emergent BioSolutions. But it was only approved by the FDA for use in those at high risk for mpox at the end of August this year. It was not widely used during the 2022 outbreak but was available in some places under a compassionate use protocol (a means of providing medicines or vaccines that have not yet been registered).

In 2022, the Centre for Disease Control (CDC) recommended that JYNNEOS be used as the primary vaccine against mpox because it was associated with fewer side effects than ACAM2000.

While these vaccines exist, it doesn’t mean everyone can access them easily. Countries on the African continent have so far relied on vaccine donations facilitated by the WHO, with an initial 10 000 doses expected to arrive in Africa sometime this month.

Vaccine manufacturers KM Biologics and Bavarian Nordic have submitted proposals to the WHO for emergency use listing (EUL), according to WHO Director-General Dr Tedros Adhanom Ghebreyesus. He added this will allow UNICEF and the vaccine alliance GAVI to buy the vaccines to supply to countries that haven’t issued their own national regulatory approval yet.

The treatment options for mpox are also limited. According to this WHO factsheet on mpox, some antivirals have received emergency use authorisation in some countries and are being evaluated in clinical trials. However, so far there is no proven effective antiviral treatment for mpox.

Tecovirimat, which was approved to treat smallpox, is one of these antivirals being evaluated. According to the CDC, studies in animals have shown the antiviral might help treat mpox but it is still considered an investigational drug for mpox. The drug has been used in some cases of severe mpox.

When asked about this, Ndwandwe agreed more research needs to be conducted to fully understand the evidence around using Tecovirimat. “But what we know now is that the fact that it was authorised for compassionate use, there is some benefit to using that treatment, given that there isn’t any other [treatment,” she said.

Mpox vaccine and treatment availability in South Africa

According to De Oliveira, a small batch of vaccines against mpox and an antiviral drug were made available to South Africa through donations during the outbreak earlier this year.

But the country would need more vaccines if cases increase to protect those at risk for severe disease.

At the moment, South Africa does not have access to any mpox vaccines and has asked for a donation of 40 000 vaccine doses, Foster Mohale, spokesperson for the health department told Spotlight. The country has requested the JYNNEOS vaccine, based on the recommendation by the National Advisory Group on Immunisation.

He added that South Africa’s request to its international partners and the WHO is ongoing support with access to tecovirimat should the need increase. He also requested the WHO’s assistance in procuring the 40 000 vaccine doses to vaccinate high-risk groups if mpox cases increase.

When asked if the department will be entirely reliant on donations of mpox vaccines or would seek to procure its own if cases increase, Mohale said it depends. “South Africa has been in communication with the vaccine manufacturer, Bavarian Nordic, and will consider procurement if needed,” he added.

Because there is a shortage of mpox vaccines and treatment and uncertainty about the sustainability of donated supplies, Ndwandwe said: “Our best defence at this point in time is to prevent [the spread of mpox cases] as much as possible and detect the cases as they start, early on.”

Symptoms of mpox

Govender said the NICD is urging people not to panic but to stay informed on the signs and symptoms of mpox using some of the accurate information available from either the National Department of Health or the NICD.

“The first line of defence for any public health emergency and outbreak comes from when people take initiative to protect themselves,” he said.

Mpox, which is spread by close contact, either household or sexual contact, with someone who has the virus, could initially manifest in flu-like symptoms or the characteristic mpox rash. These include a fever, sore throat, muscle aches, headaches and swollen lymph nodes, according to the WHO factsheet on mpox. The rash starts flat and then becomes a blister filled with fluid, which eventually dries and falls off. The rash can occur on someone’s palms or soles of their feet, face, mouth and throat and sometimes the genital areas.

Children, pregnant women and those who are immunocompromised are most at risk for developing severe disease or dying, the factsheet stated. This includes people living with HIV whose viral load is not well controlled.

Mpox is a virus and as with all viral infections it’s the immune system that fights it off, Ndwandwe explained. However, if someone is immunocompromised, so has a weakened immune system, there is a greater chance that the mpox virus will overtake their immune system and cause severe disease.

This is one of the reasons why we would be concerned about the disease in South Africa, Professor Helen Rees, the Co-Chair of the Incident Management Team (IMT) on mpox, previously told eNCA.

“We have many people living with HIV in the country, many of whom are on antiretroviral therapy, their immune system is good. But we have many others, who don’t know what their status is and might be vulnerable to severe mpox,” she said.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Ethics and Law Medical IndustryTags :

Fight Not Yet over as Case Against Vertex is Dropped After Cystic Fibrosis Medicine Price Cut

On By ModernMedia
Cheri Nel launched a court case against Vertex to force them to allow their generic cystic fibrosis drug to be imported into South Africa. Credit: Spotlight

By Catherine Tomlinson

Last year a South African woman took a multibillion-dollar United States pharmaceutical company to court with the aim of securing access to life-changing cystic fibrosis medicines. That case has now been dropped following a reduction in the price charged for the medicines in South Africa.

Cheri Nel, a Johannesburg-based investment banker, has dropped a potentially landmark court case against Vertex Pharmaceuticals. Nel was asking the Gauteng Division of the High Court in Pretoria to grant a compulsory licence to allow generic versions of a cystic fibrosis medicine called Trikafta to be imported into South Africa. No such compulsory licences on medicines have ever been granted in South Africa.

Trikafta, which was registered in the United States in 2019, has been hailed as a “miracle” treatment for cystic fibrosis, which causes severe damage to the lungs, digestive system and other organs in the body. The medicine is effective in treating around 90 percent of people living with the condition. It significantly improves the quality of life of people living with cystic fibrosis, eliminating many of its debilitating symptoms, while also slowing the disease’s progression and extending survival.

In February 2023, when Nel launched her lawsuit against the Boston-headquartered pharmaceutical company, the only way people in South Africa could access Trikafta was by travelling to Argentina to buy it from an Argentinian company selling a generic version of the medicine.

This is because Vertex, the company that holds the patents on Trikafta in South Africa, refused to register the medicine with the South African Health Products Regulatory Authority (SAHPRA) or identify a local distributor that could import unregistered Trikafta via Section 21 authorisations – a mechanism allowing importation of unregistered medicines.

The United States list price for Trikafta is currently over $300 000 (around R5.5 million at the current rand/dollar exchange rate) per person per year, which South Africans feared they would also have to pay if or when Vertex finally started supplying its medicine in the country. Researchers in the United Kingdom have estimated that Trikafta can be produced for under $6000 (around R110 000 at the current rand/dollar exchange rate) per person per year.

When Nel filed the case, generic Trikafta from Argentina – called Trixacar – was much cheaper than Vertex’s product (but still prohibitively expensive for many) at around $60 000, or almost R1 million per person per year. But the Argentinian company selling generic Trixacar faced potential patent infringement challenges if it shipped Trixacar to South Africa. Thus, the only way to get the medicine into South Africa at the time was to travel to Argentina to collect it. People living with cystic fibrosis in South Africa learnt how to do this through an informal network or Buyers Club of people around the world that were reliant on the Argentinian product.

Launching a legal case

Nel argued that Vertex was abusing its patents in South Africa by refusing to make Trikafta available in the country on reasonable terms, while also blocking other manufacturers from supplying the medicine in the country. If successful, Nel’s case would have allowed generic Trikafta to be shipped directly to South Africa, removing the need for travel to Argentina to access the medicine.

According to Nel, Vertex argued in the company’s answering documents to her legal filing that, as she was the only named applicant in the case, a compulsory licence for importation could only be considered for her.

Nel then worked with the South African Cystic Fibrosis Association (SACFA) to get other people living with cystic fibrosis admitted as co-applicants in the case. This process of seeking more people to join her case, she said, was time-consuming, difficult, and expensive, but more than 100 people were working towards being admitted as co-applicants before the case was dropped.

Under pressure, Vertex starts providing Trikafta in South Africa

As the case gained momentum and made headlines around the world, Vertex finally opened the door to allow some people living in South Africa to access their product.

In May 2024, Vertex identified Equity Pharmaceuticals as the local company through which Trikafta could be imported into South Africa via Section 21 authorisations. These authorisations are granted by SAHPRA to enable importation of an unregistered medicine and are meant to be used in exceptional circumstances to remedy the need for an unregistered medicine, such as when there is a shortage of the registered product.

While Vertex has not confirmed to Spotlight or stated publicly the price of Trikafta for people living in South Africa, Nel and Doctors Without Borders’ Candice Sehoma told us that the company is charging around R400 000 ($22 000) for a year’s supply of the medicine.

While still unaffordable for many and much higher than the estimated cost of manufacturing, the R400 000 price is drastically lower than the R5.5 million price charged in the United States and originally feared for South Africa.

It seems improbable that Vertex would have offered the much reduced price to people living in South Africa had Nel not launched the court case

Some medical schemes now paying for Trikafta

As emerged in April this year, Vertex reached an agreement with some medical schemes in South Africa to provide the medicine for people on top-end plans.

“Four private healthcare providers are currently funding Trikafta for eligible patients and we are open for conversations with more insurance companies,” Vertex’s spokesperson Daria Munsel confirmed to Spotlight.

The exact nature of the conversations and/or agreements between Vertex and medical schemes in South Africa however remains somewhat unclear.

Discovery Health‘s CEO, Dr Ron Whelan, told Spotlight it has engaged Vertex about the “benefits available” and “affordable access” of the class of medications that Trikafta falls in but there is “no specific commercial agreement in place” in South Africa.

He noted that Discovery Health Medical Scheme members on the comprehensive and executive plans have a suite of benefits available for the treatment of cystic fibrosis with medicines like Trikafta “of up to R400 000 per annum” for eligible people.

According to Vertex, uptake of its product has been swift and is already starting to make a difference in the lives of people living with cystic fibrosis in South Africa. “Over 100 South Africans with CF [cystic fibrosis] have been prescribed our triple combination treatment in just the first two months of the medicine being available,” said Munsel.

The cystic fibrosis registry, an initiative which seeks to identify and collect data on the outcomes of people living with cystic fibrosis in South Africa, identified 525 people living with cystic fibrosis in the country as of December 2020. Experts believe there are many more undiagnosed cases.

Why did Nel drop the case?

Not only is Vertex’s price for people in South Africa now lower than the 2023 price of Argentinian generics, but the cost of a year’s supply of generic Trikafta from Argentina have increased from around $60 000 to around $100 000 due to hyperinflation in that country.

With Vertex now offering a price lower than the cost of Argentinian generics, Nel decided that her legal case was no longer the best avenue to enhance access to the medicine. The aim of the case “was to get access to the medication… to put pills in patients’ mouths”, she told Spotlight.

Nel said it is now probably better to redirect efforts to getting government at national or provincial levels to buy the medicine for patients in the public sector.

“There is a lot of work still to be done… my efforts are still there, it’s just being redirected,” she said.

“The fact that Trikafta will now be available in South Africa at a much lower price compared to generic versions globally, certainly undercuts the legal case for a compulsory license,” said Tendai Mafuma of SECTION27, a public interest law centre. The Treatment Action Campaign and Doctors Without Borders, represented by SECTION27, were admitted as friends of the court in the case.

Why won’t Vertex register its product in SA?

While much has changed because of Nel’s legal action, Vertex has held fast on its refusal to register Trikafta with SAHPRA.

When asked about Vertex’s plans to register Trikafta in South Africa, Munsel said: “We strongly believe that this [Section 21 Authorisation] is the fastest and most efficient route to sustainable access in South Africa, which does not require a regulatory filing.”

While registering medicines can be onerous and time consuming, it is a routine practice required for pharmaceutical companies to operate around the world. Full registration also typically requires that safety, effectiveness and quality is more closely scrutinised than is the case with Section 21 authorisations.

Nel believes that Vertex has chosen not to register Trikafta in South Africa because of the price transparency requirements embedded in South African law. If other countries know what price South Africa is paying then they may also demand a lower price, she said.

The law requires that there is a transparent pricing system for medicines sold in the private sector, but these requirements do not extend to unregistered medicines imported through Section 21 authorisations, explained Mafuma.

Note: SECTION27 was involved in the court case that is the subject of this article. Spotlight is published by SECTION27, but is editorially independent – and independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Paediatrics VaccinesTags :

Childhood Vaccine Coverage in SA Declined in 2023, Finds WHO Report

On By ModernMedia
A marker used to measure immunisation coverage is to look at whether children received three doses of the vaccine against diphtheria, tetanus and pertussis. Photo by Mufid Majnun on Unsplash

By Elri Voigt

New data from the World Health Organization (WHO) and UNICEF show that globally childhood immunisation coverage stalled in 2023, while in South Africa it decreased. Elri Voigt unpacks the new data and asks local experts to put it in context.

A new report found that vaccination coverage rates around the world have not yet returned to levels seen in 2019, before the COVID-19 pandemic disrupted immunisation programmes.

There has been no meaningful change in immunisation coverage between 2022 and 2023, according to the WHO and UNICEF report published in July. It means progress in immunisation coverage has effectively stalled, leaving 2.7 million additional children who are either unvaccinated or under-vaccinated compared to pre-pandemic levels in 2019.

A marker used to measure immunisation coverage is to look at whether children received three doses of the vaccine against diphtheria, tetanus and pertussis – referred to as DTP3. Global coverage for DTP3 stalled at 84% in 2023, according to the report.

At the same time, the number of children worldwide who have not received any vaccinations has increased. We refer to these kids as zero-dose children. Ten countries account for 59% of all zero-dose children, with the global number in 2023 rising to 14.5 million compared to 13.9 million in 2022, according to the report.

Coverage slightly down in SA

Data from the report showed a slight decrease for a number of outcome measures in South Africa between 2022 and 2023. It was one of 14 countries in the African region that saw a decrease in coverage for DTP1 (the first dose of the vaccine for diphtheria, tetanus and pertussis), slipping from 87% in 2022 to 81% in 2023. Coverage for DTP3 also decreased, falling from 85% in 2022 to 79% in 2023.

South Africa was also one of 10 countries in the African region that saw a decrease in coverage for the first dose of the measles vaccine, and was singled out by the report as having the sharpest decline in coverage in the region between 2022 and 2023. Measles coverage dropped from 86% in 2022 to 80% in 2023.

Commenting on the accuracy of the new data, Professor Shabir Madhi, Dean at the Faculty of Health Sciences at the University of Witwatersrand (Wits), said it used administrative data, which can bias the estimates. He explained that the report bases vaccine coverage on the number of vaccines procured by government and deployed to facilities. For example, if a facility gets 100 doses of the measles vaccine and ends up discarding 50 doses, that doesn’t necessarily get reported.

The WHO acknowledges the potential for data inaccuracies. It stated that they calculate the estimated percentage of immunisation coverage by dividing the number of doses administered to a target population by the estimated number of people in that target population.

Madhi said a more accurate picture of childhood immunisation coverage in the country can be found in National Vaccine coverage surveys, like the Expanded Programme on Immunisation (EPI) National Coverage survey. Spotlight previously reported on results from the most recent EPI survey conducted in 2019.

Madhi said it appears the new report did not incorporate data from the EPI survey. However, even without this data, he said the WHO estimates are not too far off the local data. He remarked that he doesn’t feel “too strongly either way” about the accuracy of the WHO data since the bottom line is vaccine coverage in the country is lagging.

“Fluctuations in immunisation coverage are not uncommon,” Dr Haroon Saloojee, a professor of Child Health at Wits University told Spotlight. “One should not make too much of a fall or increase in coverage rates over one year, unless it is drastic.”

Data from the WHO report for vaccine coverage in South Africa between 2018 and 2022 had actually showed an overall upward trend, which was “promising”, according to Saloojee. However, he said the latest data from the report “holds no good news for South Africa” because the dip in coverage in 2023 was noteworthy.

How does SA compare?

“South Africa’s performance is moderate when compared globally, and poor compared to other high-middle income countries,” said Saloojee. “Considering that South Africa is a high-middle-income country, we should be performing much better in all our health indicators.”

He pointed out that countries in a similar bracket like Cuba and Uruguay have achieved high immunisation coverage through robust healthcare systems and effective public health policies.

Regarding zero-dose children, the report ranked South Africa 6th worst in the African region. In 2022, the country ranked 13th. With a total of 220 000 zero-dose children, the country accounted for 3% of all zero-dose children in the African region. Nigeria had the highest percentage at 32% of all zero-dosed children in the region, followed by Ethiopia with 14%.

‘Dysfunctionality of primary healthcare’

Apart from the international comparisons, Madhi pointed out that South Africa is not meeting its own targets of having at least 90% of children in each district fully vaccinated.

The EPI survey found that only seven of the 52 districts in the country were able to achieve the national target of 90% of children fully vaccinated under one year of age. Together, the data from the survey and the WHO clearly shows that childhood immunisation targets are not being met in the country.

For Madhi, the results from the EPI survey “speaks to dysfunctionality of primary health care in the country”. He said the immunisation of children, which is the bedrock of primary healthcare when it comes to children, acts as a “canary in the mine with regards to how well primary healthcare is working”.

He said South Africa is a leader in the field when it comes to evaluating and introducing vaccines to the public immunisation programme. But when it comes to implementation, for the vast majority of districts we “are falling completely flat on our face and coming short in terms of reaching our own targets”.

Implications for children

The health implications for children who are not unvaccinated or only partially vaccinated are significant.

“They are less protected against what can be life threatening diseases. And those life-threatening diseases include diseases such as measles, but also other life-threatening diseases such as pneumonia,” Madhi said.

“We’re selling ourselves short as a country in addition to actually compromising the health of children by not ensuring that we’re doing everything that’s possible to actually get children to be vaccinated,” Madhi added. “It also comes with other consequences, so it sort of lends South Africa to be more prone to outbreaks.”

Saloojee added that it is also likely that children who are not fully vaccinated are “not receiving many of the other health, education and social development services all children require and that is being provided by government, such as early childhood development services and child support grants”.

The reasons for immunisation coverage lagging are complex and the responsibility for fixing the problem lies with more than just one entity. Spotlight previously reported on some of the reasons children are remaining unvaccinated or under-immunised as identified by the EPI survey.

Madhi said there needs to be a fundamental relook at the country’s immunisation programme. Proper governance structures need to be put in place and the programme will need to be implemented all the way down to the sub-districts. There is also a need for real-time data and monitoring of that data so interventions can be done when children are missing their immunisations. He also suggested ring-fencing funds for vaccines, at either a national or provincial level, to ensure that money earmarked for vaccines are used for that purpose so as to ensure less stock-outs.

“The immunisation programme hasn’t changed much from what I can gather over the past 20 years, let alone the past 10 years. So we can’t expect a different outcome if the strategy that we’re using which has failed is the strategy that you continue pursuing,” Madhi said.

Saloojee said the National Department of Health can play a pivotal role in strengthening the immunisation programme by “providing leadership, resources, and policy support”. He said that to his knowledge the health department is currently preparing a national immunisation strategy to take us to 2030, but the draft is not up to scratch. The strategy, he says, will need to offer clear objectives, establish realistic indicators of, and targets for, measuring success, and attract a fully funded mandate.

Spotlight asked the National Department of Health for comment on the new WHO report and how it plans to respond to improve immunisation coverage. While the department acknowledged our questions, they did not provide comment by the time this article was first published.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : HIVTags :

Medicines Stockouts Persist in North West as Tide Turns Slowly

On By ModernMedia
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/

By Nthusang Lefafa

Despite some improvement over the past three years, the North West province continues to experience medicine shortages, according to a survey by a community clinic monitoring initiative. We unpack the latest findings and ask why shortages persist in the province.

Some people in need of HIV or tuberculosis (TB) medicines were sent home empty handed after visiting clinics in the North West. This is according to the latest survey of public healthcare services in the province published by community-led clinic monitoring group Ritshidze. The survey data was collected in April and May this year.

Of the roughly 490 000 people living with HIV in North West, around 380 000 (77%) are on antiretroviral treatment, according to figures from Thembisa, the leading mathematical model of HIV in South Africa. Antiretroviral treatment is recommended for everyone living with the virus.

According to Ritshidze, besides HIV and TB medicines, other commonly reported stockouts at clinic-level include pain medicines (such as Paracetamol and Ibuprofen), cardiac medicines (such as Aspirin), contraceptives, dry stock (gauze, bandages, needles), maternal health medicines, psychiatric medicines, and different vaccines.

Out of the 72 facilities surveyed in the province, medicine stockouts lasting one to three months were reported at 20 and stockouts lasting three to six months were reported at six.

‘Failed to comply’

The North West health department, according to Ritshidze, has failed to comply with national guidelines recommending that people living with HIV should be provided with a three or more month supply of antiretrovirals at a time. They found that 71% of people surveyed in 2024 received antiretroviral refills of three to six months – in each of the previous three years this number was below 30%. There was large differences between districts, with 97% of people surveyed in Bojanala district reporting getting a 3 month supply of ARVs — compared to 37% in Dr Kenneth Kaunda.

Giving people longer antiretroviral refills like this means people do not have to visit health facilities as often to collect their medicines.

Various factors influence giving more people longer antiretroviral refills, Tebogo Lekgethwane, Director of Media and Communications in the province’s health department, told Spotlight.

A crucial factor, he said, is that patients must have a good track record of collecting their medication as well as a history of a documented undetectable viral load. “There’s therefore a criteria for multi-month supply which includes the fact that patients should have been on treatment for six months, they are compliant and clinically stable,” said Lekgethwane.

No “crisis” of medicine shortages

While the year-on-year comparisons should not be overinterpreted – Ritshidze themselves advise caution – the numbers nevertheless provide some indication that when it comes to medicines stockouts things are trending in the right direction. The total number of stockouts in the province reported to Ritshidze plunged from 895 in 2021 to 148 in 2024 – over the same period stockouts of HIV medicines went from 115 to 19 and stockouts of TB medicines from 28 to 7.

Lekgethwane was at pains to point out that Ritshidze’s findings do not necessarily represent the actual picture of the entire province. He said that the department believes that the Ritshidze report is subjective and relies on isolated incidents. These incidents, Lekgethwane said, are often quickly addressed.

“The current provincial medicine availability report shows that medicine availability has stabilised above 80%. As at the end of June 2024, ARV stock was at 89.5%, Expanded Programme on Immunisation and Contraceptives remained above 90%, TB treatment at 79%, Oncology treatment at 81.7% and Diabetes Mellitus at 85.8%. Therefore the province does not have a crisis of medicine shortages,” he said.

Asked what exactly these percentages mean, Lekgethwane said that it indicates the actual medicines stock available in the province in relation to what is required.

A pharmacy expert consulted by Spotlight further explained that the percentage indicates the percentage of medicines on a list or in a class that is available in the province.

The way these numbers are tracked is somewhat tricky. Firstly, if a clinic is supposed to have 10 different HIV medicines in stock, but they only have 8 in stock, then its HIV medicines availability would be at 80% (having a single pack of a medicine counts as having it in stock). When many facilities are considered together, as with an entire province like North West, the key indicator looks at what percentage of those facilities have medicines availability above 90%. We thus understand the figures shared by Lekgethwane to mean that 89.5% of facilities, depots and so on in the province have HIV medicines availability above 90%.

Catching up with payments

Past medicine shortages in the province were partly attributed to companies ceasing delivery of medicine due to non-payment of invoices. While the North West health department was under National Department of Health administration in 2020, the offices at the Mmabatho Medical Depot was raided. The search uncovered a number of unpaid invoices worth millions, some dating back to 2014. One unpaid invoice was for more than R16 million.

Bolstered by a Pharmaceutical Intervention Team to address medicine shortages, Lekgethwane said the department’s payments system is now in top shape.

“Payment of suppliers has remained a priority and the finance unit has assisted the team by making good progress on payments of supplier accounts. The unit continues to investigate and intervene when suppliers indicate their account status to the pharmacies.

“This has led to an increased number of deliveries from suppliers to the depot and increased direct deliveries to pharmacies from contracted companies as well as deliveries of main orders, allocation of orders and emergency orders from the depot to the pharmacies,” he said.

“The Department can confidently confirm that the financial management of pharmaceuticals has been improved resulting in 97% of 2024/2025 accruals being paid and remaining with only two accounts that are on hold. The two accounts that are on hold will only be paid once their compliance requirements are sorted,” said Lekgethwane.

He said that the intervention team has the capacity to assess and intervene, in among others, pharmaceutical supply chain issues, system effectiveness, distribution and delivery processes, storage capacity, human resource capacity and safety issues.

Lekgethwane said the team’s first priority was to assess the Mmabatho Medical Depot before moving onto pharmacies in hospitals and clinics across the province.

Getting medicines to rural areas

While Ritshidze also raised concern around transportation for the delivery of medicines, the department said transportation has never been a challenge.

“There are contracted service providers who deliver to the Mmabatho Medical Depot and the depot delivers to hospitals. Clinics receive their medicine from their referral hospital,” said Lekgethwane.

“However, the department is currently implementing the bulk pharmacies for districts to bring medicines closer to facilities”, he added. A bulk pharmacy is a medicine storage facility which serves as a medical depot. It is situated in the districts and helps with bringing medicines closer to rural areas so that medicines do not have to be transported from major towns.

In this regard, Lekgethwane said the Dr Kenneth District Bulk Pharmacy was recently opened and soon the General De la Rey Bulk Pharmacy will open.

He said the department is confident that the use of these bulk pharmacies will improve medicine storage and distribution capacity.

Shortage of pharmacists and pharmacy assistants

The Ritshidze report found that only 9% of surveyed facilities had a pharmacist and only 18% had a pharmacist assistant. Government regulations state that either pharmacists or pharmacy assistants should be responsible for stock receiving orders and updating the stock visibility system. However, Ritshidze found that enrolled nurses, enrolled nurse assistants, facility managers, and even cleaners acted in that capacity at some clinics.

The province has a 6% vacancy rate for pharmacists while 342 are currently employed, according to the 2024/2025 health department annual performance plan tabled in the North West Provincial Legislature earlier this month. The plan states that the department’s organisational structure makes provision for 10 pharmacists to be appointed in the province for every 100 000 uninsured individuals.

The DA’s Hendriette van Huyssteen says there is a challenge of pharmacists and pharmacy assistants where there are clusters of less than 10 000 uninsured individuals (where one pharmacist would be allocated for 10 000 uninsured individuals) and the clinics servicing them are far removed from one another.

“With the NHI [National Health Insurance] being signed into law, the number of pharmacists will become only a greater challenge. The cost per pharmacist employee stands at R765 000.00 per annum. It is unclear as to where the funding would come from for the remuneration of the additional pharmacists needed under the NHI, as even the NHI Act is unclear in this regard,” she said.

Notwithstanding the issue of budget constraints, the training of more pharmaceutical staff is integral to having fully functional health systems, said Professor Andrew Robinson. He is a deputy dean in the Faculty of Health Sciences at North West University (NWU). He was previously a deputy director general in the North West health department.

“To improve the pharmaceutical skills in the province, the NWU must ensure it aligns its pharmacy training to address the skill needs of the provincial health department to ensure equitable health service delivery to all, which is necessary for successful implementation of the NHI,” he said.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : General Interest VaccinesTags :

“Not Being Afraid to Speak out, it does get me into Trouble Quite Often,” Says Prof Shabir Madhi

On By ModernMedia
Professor Shabir Madhi of Wits University. Photo: supplied.

By Biénne Huisman

Amid the uncertainty of the early days of the COVID-19 pandemic, Professor Shabir Madhi often stood out for his clarity of thought in making sense of rapidly evolving scientific evidence. Biénne Huisman chatted to Madhi about vaccines, ongoing challenges with the Gauteng health department, and being outspoken about issues such as the war in Gaza.

Professor Shabir Madhi became known to many in South Africa for leading the charge in two of the first COVID-19 vaccine clinical trials conducted in Africa – those for the AstraZeneca and Novavax vaccines. At a time of much scientific uncertainty, he was often quoted in the press – gaining a reputation for keeping his cool and calling things as he saw them based on available evidence.

He spoke out against the politicisation of science and was a staunch advocate for access to vaccines, especially for older people at higher risk of severe illness and death. He wasn’t afraid to ruffle feathers, openly criticising government’s COVID-19 vaccine communication efforts and arguing that government should take vaccines to the people, rather than the other way around. He called for the ending of strict lockdowns, before many others did so. Reflecting on his reputation for not holding back on his beliefs, he admits to “having a short fuse, especially when people are talking nonsense – or what I consider to be entirely off the mark”.

What may be less obvious to the public, is that Madhi’s healthcare impact precedes COVID by decades.

Internationally respected for his research into paediatric infectious diseases, his work has helped to save the lives of hundreds of thousands of children and informed World Health Organization policy (WHO) – notably relating to the pneumococcal conjugate vaccine (to prevent pneumonia and meningitis) and the rotavirus vaccine (to prevent diarrhoeal disease in young children).

His work continues. Just last year a landmark study, led in South Africa by Madhi’s Vaccines and Infectious Diseases Analytics Research Unit at the University of the Witwatersrand (Wits), found that immunisation of pregnant women safely protected their unborn babies from respiratory syncytial virus (RSV). As Spotlight reported at the time, researchers estimate the vaccine can save thousands of young lives.

Speaking to Spotlight over Zoom from Wits in Johannesburg, where he is Dean of Health Sciences, Madhi relays his love of treating kids – who “most importantly, don’t lie, and who are the most vulnerable”.

“Accidental vaccinologist”

Madhi has been described as an “accidental vaccinologist”. Shrugging inside a navy suit, he says he never intended to become a physician, let alone a professor in vaccinology. At medical school at Wits, he nearly dropped out after a month.

As a child, growing up in Lenasia, Madhi wanted to become an engineer. But born to a mathematics teacher father and a stay at home mum, money was tight. His only opportunity to attend university presented itself via a bursary in medicine.

“I only really started to enjoy medicine once I specialised in paediatrics,” he says. “But more importantly, that’s when I realised the huge potential that existed in medicine to make a difference, particularly the potential for vaccines to make a big difference over a short period of time – not on an individual level, but at a community level. And that’s what really drove me into the space of research.”

While doing his peadiatric training at Chris Hani Baragwanath Academic Hospital (he obtained a master’s degree in paediatrics from Wits in 1998), it struck him that the leading causes of death among children were entirely preventable.

“Back then, close to 750 000 children were dying of measles globally; half of those deaths were happening in Africa, despite the vaccine for measles being available since the 1970s. South Africa was one of the countries with a poor public immunisation programme; up until 1992 South Africa didn’t have a public immunisation programme.”

In 2009, in a first on the African continent, pneumococcal and rotavirus vaccines were finally officially rolled out in South Africa.

“While I was training at Baragwanath, there was a ward just for children with gastroenteritis or diarrhoea,” he recalls. “But six months after we introduced the rotavirus vaccine in South Africa [in 2009], we shut down the diarrhoea ward at Baragwanath and probably every other diarrhoea ward in the country.”

Contributing internationally

Today Madhi’s CV is long. He sits on scores of scientific advisory committees, attending conferences and delivering talks around the world.

Since 2019, he has served on a global panel of experts convened by the WHO, the Strategic Advisory Group of Experts on Immunization (SAGE), of which he now is deputy chair. He also chairs the SAGE working group on polio.

“I’m really enjoying SAGE at the moment,” he says. “This is where I think I am making a meaningful contribution. It really is an eye opener to the different types of research that’s taking place globally; but also the type of challenges we face in terms of ensuring that children are adequately immunised.

“It’s great to be working on new vaccines, coming up with new vaccines; but that’s a meaningless exercise unless you can ensure that those vaccines are getting into the arms of children – because that is what saves lives. So yes, dealing with issues around implementation and advocacy.”

SAGE requires frequent trips to Geneva, where the WHO is based.

Our discussion turns to business travel – the amount required for a researcher to remain “relevant and competitive”. With typical candour, Madhi outlines challenges faced by researchers from the global south.

“I think coming from South Africa, coming from the African continent, it’s more of a challenge for researchers to establish themselves, for a number of reasons. Firstly to become known in the international space, you probably need to deliver so much more than what is expected from our northern hemisphere counterparts.

“Then in addition to the inconvenience of needing to travel so often, there are subtle things which people in the northern hemisphere don’t have to deal with. Needing to get visas and dealing with customs officials when entering countries.

“It can become an extremely unpleasant experience, and you really need to swallow your pride given what is blatant racism at times. For example, nowadays I refuse to fly through Germany because the customs office in Frankfurt is probably the worst I have encountered. All of a sudden, they would keep me and question me for both arrival, as well as departure…”

Local challenges

The discussion turns back to South Africa, and health challenges in his home province of Gauteng. Here also Madhi has tried to make a difference, but it hasn’t been plain sailing.

Commenting on a floundered memorandum of agreement (MOA) signed between Wits and the Gauteng Department of Health in June 2022, Madhi says: “The bottom line unfortunately; the Gauteng Department of Health simply doesn’t have stability of leadership. At the level of the MEC in particular; I mean since I’ve been dean, there’s been about four or five heads of department. And it becomes difficult to follow through with any of these programmes.”

Madhi adds that Wits university executives had worked on the memorandum for seven years. The agreement set out a plan to combine university and government resources in “academic health complexes” for enhanced service delivery. But the Department of Health put it on hold three months later, following a related Public Service Commission inquiry.

He explains: “They convened this big workshop, spending probably a mini fortune, to basically facilitate the establishment of an MOA, not just between Wits and the Department of Health, but between the Department of Health and many other academic hospitals in the province. Because of the intervention, the Department of Health indicated that they weren’t going to implement our MOA until that particular commission concluded their work. But since then, there’s been absolutely no report from that meeting.”

Not afraid to speak out

On social media, Madhi speaks out about atrocities being committed in Gaza.

To Spotlight, he says leadership holds no place for neutrality.

“As part of leadership, and I do consider myself a leader in the different roles that I play – either in my research unit or currently as university dean – you need to be prepared to take a stance. You can’t remain neutral on positions. You need to interrogate facts. And once having interrogated the facts, you need to reach a conclusion; then follow through with what is required, if there’s anything that needs to be implemented.”

Madhi says his leadership style was honed during childhood. “Not being afraid to speak out, it does get me into trouble quite often,” he says, laughing. “I think that’s just part of my upbringing, being an activist during apartheid in the Lenasia Youth League and other activist organisations. My upbringing was, when things are not what it’s meant to be, you speak out; you champion the right cause.”

These days Madhi lives in Northcliff with his wife, with whom he has two children. His favourite football team is Arsenal and a book he says he recently enjoyed was The Covenant of Water – a three generation family account set in India, by physician and author Abraham Verghese.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Lab Tests and Imaging Respiratory DiseasesTags :

“We Were the First Ones to Do It”: Innovative SA Study Takes TB Testing to People’s Homes

On By ModernMedia
Tuberculosis bacteria. Credit: CDC

By Tiyese Jeranji

Most tuberculosis (TB) tests still require a trip to the clinic. Now, new technology has made it possible to test people at home. This could be a big deal for South Africa, where much TB goes undiagnosed. We unpack the findings and implications of a recent study into such TB home testing.

One of the biggest challenges in combatting TB in South Africa is that many people who fall ill with the disease are diagnosed late, or not diagnosed at all.

The World Health Organization (WHO) estimates that 280 000 people fell ill with TB in the country in 2022. Of these, roughly 66 000 were not diagnosed, and accordingly also not treated. Apart from the damage to the health of the people who are not diagnosed and treated, this also has implications for the further spread of TB since untreated TB is often infectious TB – people become non-infectious within a few weeks of starting TB treatment.

Typically, people who fall ill with TB only get diagnosed once they turn up at clinics with TB symptoms – this is called passive case-finding. In recent years, there has been a growing recognition that passive case-finding alone is not good enough if we want to diagnose more people more quickly. As a result, many people in South Africa considered to be at high risk of TB are now offered TB tests whether or not they have symptoms – an approach called targeted universal testing. Screening for TB using new mobile X-ray technology has also been piloted in the country.

Now, in the latest such active case-finding innovation, researchers have been offering people TB tests in the comfort of their own homes.

Dr Andrew Medina-Marino, a senior investigator at the Desmond Tutu Health Foundation (DTHF), tells Spotlight no one in the world was testing for TB at home until they recently started doing so at the DTHF’s new research site in the Eastern Cape.

The testing is done using a molecular testing device, roughly the size of a two litre Coke bottle, called the GeneXpert Edge. The GeneXpert Edge is a portable version of the GeneXpert machines that have been used in labs across the country to diagnose TB for over a decade.

The GeneXpert Edge is a standardised testing device that detects TB DNA in sputum. (Photo: Nasief Manie/Spotlight)

One challenge with the device was that it needed to be plugged into a power outlet in a wall and not all homes in the area have power. “So what we did is, we hooked up a car-like battery to the device and we were able to take it into people’s homes,” says Medina-Marino.

‘Acceptable and feasible’

A study lead by Medina-Marino, and recently published in Open Forum Infectious Diseases, set out to determine the acceptability and feasibility of in-home testing of household contacts of people with TB.

The study was conducted among 84 households in Duncan Village, a township in the Buffalo City Metropolitan Municipality in the Eastern Cape. The Metro had an estimated TB incidence of 876 cases per 100 000 population in 2019, according to the National Institute for Communicable Diseases. This number is much higher than the latest WHO estimate of 468  per 100 000 for South Africa as a whole.

From July 2018 to May 2019, people diagnosed with pulmonary TB were recruited from six government health clinics in the area. They were asked for permission to visit their homes to screen their household contacts for TB. Household contacts were verbally assessed for signs or symptoms of TB, including night sweats, weight loss, persistent cough and a fever.

Households where people had any signs or symptoms of TB were randomised to either be referred to a local clinic for TB testing or tested immediately in their home. Of the eighty-four randomised households, 51 household contacts were offered in-home testing. Everyone accepted the offer for in-home testing.

For the test with the GeneXpert Edge, Medina-Marino says household contacts had to produce a sputum sample. About 47% (24/51) were able to produce sputum. This was then mixed with a reagent containing the required components for a polymerase chain reaction test. This solution was then loaded into a disposable cartridge/test module and inserted into the Edge device. Results were available in about 90 minutes. Anyone who received a positive test result in their home were immediately referred to a clinic for TB treatment.

Regarding the 47 household contacts referred for testing at the clinic, only 15% (7 people) presented for clinic-based TB evaluation, 6 were tested, and 4 out of 6 returned for their results.

Ultimately, the study found that in-home testing of household contacts for TB was acceptable and feasible.

“It’s feasible. If you compare the rate of uptake of treatment versus the rate of uptake for testing, it looks like it’s performing much better when you do home based testing versus referral for testing at the clinic,” says Medina-Marino.

Risk of stigma?

Similar to when HIV home-based testing studies were carried out, Medina-Marino says prior to their study, community members expressed concerns about stigmatising houses that were visited. “[A] lot of people were saying: ‘If you go to people’s houses, you’re going to stigmatise the household.’”

But what they actually found was that people didn’t feel stigmatised. Household contacts of people with TB felt that coming to the house to test people brought a sense of security in the home. He adds that it was easy for people to believe the results because everything was done in front of them.

In instances where people didn’t have TB, Medina-Marino says household contacts were comforted that they didn’t have to be scared of the person tested. In instances where people did have TB, he says the attitude of household contacts was supportive to start treatment.

How the test compares to other tests

Apart from testing for TB, the GeneXpert Edge can also detect whether someone’s TB is resistant to rifampicin. This is one of the medicines in the standard four-drug combination used to treat TB.

Unlike the latest lab-base GeneXpert tests, the GeneXpert Edge does not detect resistance to any TB medicines other than rifampacin. “It is hard to fit the probes needed to detect other forms of resistance into the cartridge,” says study co-author Professor Grant Theron, head of the Clinical Mycobacteriology and Epidemiology Research group at Stellenbosch University’s Molecular Biology and Human Genetics Unit.

Theron notes that the sensitivity and specificity of GeneXpert Edge is similar to that of lab-based GeneXpert machines if the tests are done on specimens from the same type of patient and the same test cartridge. (High sensitivity means the likelihood of false negatives is low wile high specificity means the likelihood of false positives is low.)

Performance may however differ because of differences between people who test at home and people who test at the clinic. Theron explains that in their study they tested people who did not yet feel sick enough to go to get tested at the clinic. People who are sicker, and who are accordingly more likely to go to the clinic, are likely to have more pathogen in their sputum samples and be easier to diagnose.

‘A breakthrough for TB’

Home-based tests is a significant breakthrough in TB because of its crucial role in detecting cases early and enabling timely tracing and testing of household contacts, says Dr Ntokozo Mzimela, a lecturer in integrated pathology in the Faculty of Health Sciences at Nelson Mandela University.

She tells Spotlight it also offers several advantages over clinic-based tests. “They are highly accessible, facilitate mass testing, reduce the risk of disease transmission, and address patient reluctance by allowing testing in the comfort and privacy of one’s home.”

Mzimela adds the GeneXpert Edge and portable X-ray screening serve complementary roles in TB diagnosis. “While the X-ray reveals lung abnormalities, the Edge confirms the presence of TB bacteria. Both tools are essential and should be used in conjunction to provide comprehensive diagnostic insights and ensure accurate and timely treatment for patients,” she says.

Professor Keertan Dheda agrees that home-based testing could link up neatly with portable X-ray, but adds it is still too early to determine where home-based TB testing will fit into the country’s TB testing programme. Dheda heads up the Division of Pulmonology at Groote Schuur Hospital and the University of Cape Town.

“We don’t yet know whether testing everyone is the right approach or whether reflex testing based on chest x-ray abnormalities is the right approach,” Dheda says. “Now that feasibility has been established, it means that more studies can be undertaken, and operational research can be commenced.”

Further studies are already underway, Medina-Marino tells Spotlight.

He says the study in Duncan Village found that about 60% of household contacts who had TB symptoms could not cough up a sputum sample. His team therefore decided to combine in-home testing with an oral swab.

“So in the study that we’re doing now in households, we found an additional 12 people who cannot produce sputum but on their swab test, they showed a positive swab result. Tongue swabs increase yield of case finding among those unable to produce sputum,” he says.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : PaediatricsTags :

How ‘NHI on Wheels’ is Bringing Life-changing Healthcare to Young People in Rural Eastern Cape

On By ModernMedia
Children lining up to see the dentist at the Ekuphumleni Community Hall, near Whittlesea. (Photo: Sue Segar/Spotlight)

By Sue Segar

The Keready project uses mobile clinics to take healthcare services to rural areas. Sue Segar spent time with the project as they took eye, dental, and other healthcare services to communities in the Eastern Cape.

In the small Eastern Cape town of Bizana, hundreds of children stream into a large hall at the Oliver and Adelaide Tambo Regional Hospital on a brisk Tuesday morning in May. There’s a festive but orderly vibrancy in the air – the scene made all the more colourful by different school uniforms and young voices from tiny six-year-olds to learners in their late teens.

They’ll be assessed, and helped by doctors from Keready – an organisation offering mobile health services in many far-flung communities lacking healthcare services.

For weeks leading up to today, outreach teams from Keready’s mobile clinic operation have gone from school to school, asking teachers to identify children with eye problems. Today they arrived on various forms of transport – some on the back of a bakkie – from deeply rural communities as far as 100 kms away. Most of the children have little access to health services, particularly eye care, so the response is substantial.

I have travelled here with three doctors and an admin assistant from Keready’s East London office. They join other healthcare staff, including from the health department, for this two-day mega outreach in partnership with the Umbono Eye Project.

“Over the past three months, school educators identified 492 learners from 26 schools who have impaired vision,” says Ewan Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape, who heads up Keready’s Eastern Cape team. “We will attend to these learners and if necessary, provide them with prescription spectacles and meds.”

Ntombizedumo Bhekizulu, a teacher at the Mhlabuvelile Senior Primary School at Ludeke Mission, has come with 16 children, “the ones who struggle to see what we write on the chalkboard”.

Bulelwa Mqhayi from Nomathebe Primary School in Isithukutezi adds: “It’s great that they can help these kids. Most of the parents are unemployed and on social grants and don’t have the money to take the kids to specialists. The clinics don’t help us with eye problems.”

The youngsters will also have a range of other health checks and will be sent to see one of the doctors on site if found to be in need of further health assistance. The health department has deployed a mobile dental unit, an audiologist, as well as a medic to provide advice on family planning and reproductive health.

A child being signed in for a health check at Bizana. (Photo: Sue Segar/Spotlight)

Before arriving at the registration desk, the children have already been given deworming tablets and a Vitamin A supplement, provided by the health department, while each group is given a health talk on age-dependent topics ranging from hand hygiene, to TB and HIV.

After handing in their registration and consent forms, the children go through basic vision screening tests by a team of “eye care ambassadors” – young people supported with employment opportunities through the Social Employment Fund, which is managed by the Industrial Development Corporation.

If the school children fail the eye screening test, they are sent to see optometrist Johan van der Merwe.

In between patients, he tells Spotlight he’s already found a number of “low vision candidates” and one who might need to be placed in a special school. “I’ve just done a full refraction on one child … It’s clear that he has a lens defect,” says Van der Merwe. Placing his hand on the head of another small boy, he continues: “This little one has been very quiet … he’s struggling to communicate. He needs thick lenses, or an operation by a specialist.”

Van der Merwe, who has been an optometrist for 22 years, joined the Umbono Eye Project permanently almost two years ago after volunteering his services once a week. “Before I joined, I was working in a mall in East London. I never saw sunlight.” He adds: “It has been very rewarding to make a difference to these children.”

Optometrist Johan van der Merwe assesses a child at Bizana. (Photo: Sue Segar/Spotlight)

At another mobile site, health department dentist, Dr Unathi Mponco, has been busy with youngsters suffering from a range of dental ailments. “There were sore teeth, rotten teeth, mobile teeth, and some children had very swollen gums…. Whatever I can treat on the mobile truck, I deal with here – otherwise if they need X-rays or the cases are more serious, I refer them to the hospital’s dental unit for a comprehensive exam,” she says.

In a mobile van outside the hall, health department medic Siyabonga Chonco has been consulting teenage girls all day offering family planning services. “The Alfred Nzo district has the highest rate of teen pregnancies in the Eastern Cape. We are trying hard to curb teenage pregnancy,” he says.

The teens are invited to ask any questions and to say whether they are sexually active and ready to take contraceptives. Chonco says in almost every case, he senses great relief from the learners to speak to an impartial young person. “They tell me that, at the clinics, the older nurses can be quite harsh…. They open up to me, especially with questions about contraceptives.”

He says broadly, young people are interested in long-term contraceptives. “They don’t want to have to go to clinics all the time.” Some will walk away with a contraceptive implant – a flexible plastic rod about the size of a matchstick that is placed under the skin of the upper arm to prevent pregnancy over three years – while others will choose injectables or pills.

At the end of two days in Bizana, the team has seen nearly 750 youngsters from about 40 schools, with 432 having had their eyes screened and 52 eligible for specs. For six of those children, the spectacles will be life-changing, says Van der Merwe.

Doctors Eileen Kaba and Anda Gxolo consulting with their little patients. (Photo: Sue Segar/Spotlight)

Apart from a few “high” prescriptions that might have to be ordered from overseas, a member of the team will deliver the specs personally to each learner, an occasion which is a highlight for the team. “When we first put the glasses on their faces, you just see smiles. The parents are so thankful. It makes this so worthwhile,” says Van der Merwe.

Keready is working closely with the provincial departments of health and education. The NGO recently received the Eastern Cape’s Batho Pele Award for enhancing healthcare in the province.

“We could never reach all these children as government,” says TD Mafumbatha, mayor of the Winnie Madikizela-Mandela municipality, adding “this is what collaboration looks like”.

But where did it all begin?

Keready, loosely translated as “We are ready”, was set up in February 2022 to encourage young people to vaccinate against COVID-19.

One of the people behind Keready is Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape. Harris was working as a consultant for the Fort Hare Institute of Health, when he was asked to help design the Eastern Cape’s COVID vaccine rollout strategy.

“The COVID programme was a success because, through advanced digitisation, we were able to map the 84 000 communities in South Africa to their nearest schools, clinics and hospitals,” he says.

And it is out of that awareness of the spatial distribution of healthcare needs that Keready was born.

After the COVID programme ended, Harris, as national lead for the project, was tasked with setting up Keready’s offices in  four provinces, including employing provincial leads, and staff as well as doctors and nurses. “Our vision was to give young doctors the opportunity to manage at the highest level, under our guidance.”

Implemented by DG Murray Trust (a South African philanthropic foundation) in partnership with the National Department of Health, Keready is funded by the German government through the KfW Development Bank.

The project reached full scale late last year with 46 mobile health clinics in four provinces:  Eastern Cape (8), Gauteng (16), KwaZulu-Natal (13), and the Western Cape (9).

These mobile clinics move into different communities every day. At times they use a loud-hailer to attract people. Sometimes they are based at schools, other times at taxi ranks and other hubs of activity.

People of all ages who visit the clinics are provided with a range of health services, including screenings and tests for HIV, TB and diabetes, as well as given family planning advice and immunisations. Medication is prescribed, and, where possible, dispensed on the spot.

Keready also runs a WhatsApp line where youth can ask young doctors and nurses any health-related questions and get straightforward, non-judgemental answers.

When learning about Keready during a walkthrough of exhibition stands set up at the Birchwood Hotel in Boksburg during the 2023 Presidential Health Summit, President Cyril Ramaphosa described the movement as “NHI on Wheels” because of its efforts in addressing universal health coverage.

From Bizana to Whittlesea

Two weeks later, I am again travelling with the same Keready team – this time to Whittlesea, outside Queenstown. Over two days, we visit the Ekuphumleni Community Hall and Kopana School in Ntabethemba. A highlight of this outreach is that teenage girls will be supplied with sanitary pads, thanks to a collaboration with pharmaceutical and healthcare company Johnson & Johnson.

On day one, hundreds more pupils than anticipated arrive. School principals were over-enthusiastic in spreading the word of the outreach resulting in taxi-loads of pupils from unexpected schools arriving. Irate teachers try to negotiate a way for their pupils to be seen.

Teacher Nolitha Tuta tells me many of the children she’s brought are from child-headed households and some have had little to no access to healthcare services.

While waiting in the queue, a mother of a child from Bhongolethu Primary School describes how she walked for hours to bring her child for eye testing.

Children line up for their health checks at the Kopana School in Ntabethemba. (Photo: Sue Segar/Spotlight)

Despite having waited until the end of the day, students from Zweledinga High end up being driven back home at sunset without being assisted.

After two days in Whittlesea, nearly 1 200 pupils from 36 schools have arrived. Nine schools were turned away. Nearly 700 learners have been screened for eye conditions, with 88 eligible for specs and four referred to an ophthalmologist.

The doctors look exhausted. Dr Anda Gxolo says over the past two days numerous children presented with ear problems. There were also long lines for dental care this time.

Despite the long hours, Dr Phumelele Sambumbu, who manages five of the eight Keready mobile clinics in the Eastern Cape, says she loves her work. “I come from these parts – from a village between Cofimvaba and Tsomo. My old grandmother is bedridden. I know first-hand how difficult it is to have access to care when you’re from a village like that and when you suffer from ailments like that. The idea of bringing health services to people who would otherwise struggle to access them is what drives me,” she says.

Mapping the need

Based on its relationship with the department of health, Keready has ambitious plans to expand its grassroots outreach programmes to help narrow the gaps in healthcare nationally.

A map on the wall of Keready’s office shows the number of government clinics in the Eastern Cape relative to schools. There are around 700 clinics in the province, but over 5000 schools (which works out to more than seven schools per clinic). Nationally, the ratio is similar with around 3 400 clinics and 25 000 schools.

It’s no surprise then that, according to Harris, staff on Keready’s 46 mobile clinics in the four provinces where it operates cannot keep up with demand for their services.

“Based on our mapping of the national population, we know there are 2 500 communities that don’t have reasonable access to a clinic. Just to deal with the gaps, we need 2 500 mobile clinics. We can tell you exactly where in the country to put them,” says Harris.

To reach ill people who are ill but don’t know it, Keready aims for nurse-supervised ambassadors to do door to door visits in communities to check who has TB, HIV and hypertension. “We have digitised every street and every house by satellite. Each house would be marked off; if TB’s picked up, it is mapped,” says Harris.

Plans for the door to door programme are well under way, he says. “In the Eastern Cape, Keready has partnered with the Small Projects Foundation to train 80 young people [as nurse-supervised ambassadors] from the Industrial Development Corporation’s Social Employment Fund to do health testing house to house.”

Eventually, says Harris, there could be 80 people linked to each of the 46 mobile clinics, meaning that a total of 3 680 trained people could be going from door to door.

“Going forward we’d want to find the disease before the disease finds us – TB, HIV, hypertension, diabetes and general growth issues [in children] are the core areas we will address in this programme,” he says.

But the extent to which Keready can deliver on its ambitious expansion plans will depend on funding and to what extent government continues to implement services using mobile clinic outreach programmes. The German financial contribution to the Keready project comes to an end in September. “We are working day and night to get more funding,” says Harris. He says they will soon be meeting with potential donors.

Disclosure: Segar was hosted by the Keready team.

Republished from Spotlight under a Creative Commons licence.

Read the original article

Categories : Substance UseTags : 1 Comment

Codeine Addiction in SA: New Guideline Aims to Curb Abuse

On By ModernMedia
Photo by cottonbro studio

By Jesse Copelyn

Rehab centres in South Africa have been admitting an increasing number of codeine users in recent years. Now, the country’s medicines regulator has published a draft guideline as part of a broader effort to track suspicious codeine sales.

South Africa’s medicines regulator – the South African Health Products Regulatory Authority (SAHPRA) – has released a new draft guideline which it says will help stem the misuse of codeine. The opioid, which is found in certain pain relief medicines and cough syrups, is used by some people in large doses to get high.

Under the new draft guideline, the regulator can request sales data (and other information) from manufacturers, suppliers or distributors of any scheduled medicines. This would allow them to track the flow of codeine all the way “from the manufacturer to the dispensary, be it a clinic, pharmacy, hospital, or doctor’s practice”, SAHPRA’s communications officer, Nthabi Moloi, told Spotlight.

Why is this important? Until now, health authorities have struggled to detect suspicious sales of codeine, which is found in both prescription and over-the-counter medicines. This problem manifests in two ways. For one, recreational users can often get a continuous supply of codeine directly from pharmacies. While people are only permitted to purchase a limited amount of the drug, many bypass this simply by buying from different pharmacies. It’s largely impossible to flag these individuals since there is no centralised data on what medicines people buy across vendors (though attempts have been made to address this).

The second issue relates to wholesale supply. Following a Carte Blanche investigation flighted last year, SAHPRA confirmed that a pharmacy group was making illicit bulk sales of codeine-based cough syrups. While patients are only allowed to get codeine from a licensed health worker or pharmacist, it’s thus no surprise that it can also be found on the black market.

The new draft guideline aims to tackle both of these problems by allowing SAHPRA to request information from companies and health workers about how much codeine they’re producing, selling or dispensing and who it is being provided to. This would “enable SAHPRA to detect anomalies in the distribution of medicines prone to abuse, such as abnormally large orders by dispensaries” Moloi explains.

It is the “first phase”, she says, of the codeine care initiative – which is an effort to centralise data on all codeine sales along the entire supply chain nationally. The plan is to ensure that the regulator can flag anything from an individual who is buying large amounts of codeine from multiple vendors to a wholesaler who is selling the drug to illicit dealers.

Codeine rehab admissions triple since 2019

The draft guideline, which is now available for public comment, comes at a time in which rates of codeine addiction are soaring throughout South Africa, according to admissions data from drug and alcohol treatment facilities. Most rehabilitation centres around the country are connected to a programme called the South African Community Epidemiology Network on Drug Use (SACENDU), which collects anonymised patient data from the different centres. Professor Nadine Harker, who oversees this project says “if you look at treatment admissions over time, there has been an increase [in codeine-related admissions] over the years – steadily but definitely”.

Indeed, SACENDU’s bi-annual reports show that in the first half of 2019, 277 people who went to SACENDU-linked rehab sites said they had been misusing codeine. This amounted to 3% of all admissions. But by the first half of 2023, this percentage had tripled to 9% – totalling 749 people. (In absolute terms the number slightly less than tripled).

Even before this uptick, health workers were concerned. In the mid-2010s, a survey of 238 (mostly private sector) doctors was conducted across South Africa. It found that 85% of these practitioners were worried about the easy availability of codeine in pharmacies.

Part of the concern is driven by the fact that people who use codeine-based medicines over a long time can develop a range of health complications, including stomach ulcers and liver damage (this is particularly when the medicines contain additional substances like paracetamol). And some people are more vulnerable than others, as genetic factors play a big role in how codeine affects a person.

Why is the problem getting worse?

Part of the spike in codeine use appears to be driven by a trend among young people, who sometimes mix codeine-based cough syrups with cooldrinks. The combination is often referred to as lean, and has become a popular party drug among high school students. Research shows that codeine’s low price and general accessibility is one reason for its popularity. Harker for instance notes that it’s often available at home, where kids “can pick it up out of their mom’s medicine cabinet”.

In other cases, people appear to be relying on the drug not for recreation but to cope with psychological distress. For instance, a 2022 study for which women were interviewed at rehab centres in the Western Cape and Eastern Cape found that many had turned to pharmaceutical products to deal with everything from trauma caused by physical abuse to grief over the loss of a child.

“I just wanted the pain to go away. I wanted my mind to switch off… [the tablets] actually made me dead inside if I can say that,” one woman explained.

A lack of awareness about the dangers of codeine also seems to play a role: 94% of doctors who were surveyed agreed that patients “do not fully understand the risk of dependence in taking over-the-counter medicines containing codeine”. The lack of regulatory control may contribute to this impression: one study at South African rehab centres found that “many participants were of the view that [over-the-counter] codeine-containing medicines were not drug[s] per se due to their free availability to purchase without any real regulations or protocols guiding their sale”.

Shouldn’t we just make codeine prescription-only?

Currently, the law states that codeine-based pills can be bought over the counter only under specific conditions. For one, they have to contain another active ingredient like paracetamol or ibuprofen, and each pill can contain a maximum of 10 milligrams of codeine. A person can only buy one pack and it must contain at most 5 days’ worth of medicine (with no more than 80 milligrams a day). Anything more and a script is needed.

Liquid codeine, like cough syrups, can be bought without a script if it contains no more than 10 milligrams of codeine per teaspoon (the maximum daily dose is 80 milligrams). The bottle itself may not contain more than 100 millilitres of syrup.

Products like Gen-payne, Myprodol, and Stopayne all contain small amounts of codeine – typically in combination with other painkillers such as paracetamol or ibuprofen. (Photo: Towfiqu Barbhuiya/Unsplash)

Some researchers that spoke to Spotlight argue these restrictions are too lenient, and that codeine should be ‘up-scheduled’, meaning that it would only be available if a patient has a script, regardless of the dose or combination. By doing this, children may find it harder to get a hold of cough syrups for lean, and people may generally become more aware of the addictiveness of the drug when used over the long-term.

Indeed, there are some studies which have found this approach to be effective in other countries. Research published in the journal Addiction found that when authorities in Australia made codeine prescription-only in 2018, a large poisoning information centre in the country began to receive significantly fewer calls about codeine-related incidents (both from health workers and members of the public).

But there are also potential downsides to this strategy. For one, as Spotlight has previously reported, increased regulation may make life harder for poorer patients seeking pain relief. This is given that they would have to spend more money for a consultation and prescription if they needed codeine-based painkillers.

Andy Gray, who chairs an advisory scheduling committee at SAHPRA, details a second issue: “I’m not convinced that up-scheduling would solve the issue if what we’re dealing with [in South Africa] is illegal behaviour… If [codeine] is being smuggled out of manufacturers or wholesalers, scheduling is not going to make a difference”.

Dr Andrew Scheibe, a harm reduction researcher at the University of Pretoria, notes a third related problem that may occur. “If people do have codeine-dependence and they’re unable to access the codeine, they might likely shift to accessing opioids… on the black market”.

Scheibe highlights the United States as an example, where prescription opioids like oxycodone and fentanyl have been at the centre of a major drug epidemic. “When they tried to increase restrictions on access to those opioids then people started using heroin,” he notes. A 2022 study found that this had taken place among opioid users interviewed in Connecticut, Kentucky and Wisconsin.

Whatever the answer, researchers agree that some basic steps need to be taken to educate the public. Harker says “a lot of awareness raising needs to happen at various levels, for instance at pharmacies”. She notes that “when someone purchases codeine over the counter, it’s important for a pharmacist to engage [with them and] make the consequences known to the individual if they use it outside of the dosages indicated… And we don’t do that enough from the medical or pharmacist’s side”.

Republished from Spotlight under a Creative Commons licence.

Read the original article