Early Online: Vol. 114 No. 4.

Maternal healthcare in South Africa faces huge private and public health systems challenges. A key challenge for policy makers is how to address the inappropriate patterns of obstetric care in the private sector and how to mobilise private sector resources to serve the broader population dependent on the public sector, without replicating those patterns of inappropriate care. Developing and implementing new obstetric care models that address these challenges and lend themselves to public private engagements could play a vital role in efforts to improve obstetric care in the country. Drawing on insights from research we carried out on the care and contracting models used by five rural district hospitals in the Western Cape Province to contract private general practitioners to provide caesarean delivery services, this article outlines a potential alternative private sector obstetric care model with the aim of stimulating discussion by all relevant stakeholders on the development of new obstetric models for improving obstetric care in the country.

Thematic analysis of the challenges and options for the Portfolio Committee on Health in reviewing the National Health Insurance Bill.

The Portfolio Committee on Health (PCH) obtained public input on the National Health Insurance Bill from a wide array of individuals and organisations between May and September 2021. The record of these submissions collated by the Parliamentary Monitoring Group provided the source material for this article. The concerns, suggestions and other issues raised by respondents were analysed to determine what challenges and options the PCH needs to take seriously as they prepare the Bill for Parliament. Prominent issues raised included concerns about the proposed governance structure, flaws in the funding model, the risk of corruption, the constitutional and human rights at risk, limited access to care for several groups, and the unresolved nature of the medical benefits to be provided under the Bill. Future legal contestation of the Bill on several of these issues has the potential to stop or delay its implementation for a long time. The PCH has some hard decisions to make: whether to address these concerns with quite radical revisions of the bill, to omit problematic elements, or to leave it unchanged, and accept the contestation this will bring.

The role of the Minister of Health in the National Health Insurance Bill: Challenges and options for the Portfolio Committee on Health.

The Portfolio Committee on Health (PCH) is responsible for obtaining public input on the National Health Insurance Bill, reviewing the Bill based on these inputs, and presenting the final Bill to the National Assembly. More than 130 individuals, organisations and institutions requested to make oral presentations, which commenced on 18 May 2021. Drawing on Parliamentary Monitoring Group meeting summaries and the presentations and submissions made by 82 respondents between 18 May and 10 September 2021, we examine governance concerns, especially in relation to the role and powers of the Minister of Health, and respondents' proposals for addressing them, and outline the challenges and options for the PCH in responding to the proposals.

Cost-effectiveness of intensive care for hospitalized COVID-19 patients: experience from South Africa.

BACKGROUND: Given projected shortages of critical care capacity in public hospitals during the COVID-19 pandemic, the South African government embarked on an initiative to purchase this capacity from private hospitals. In order to inform purchasing decisions, we assessed the cost-effectiveness of intensive care management for admitted COVID-19 patients across the public and private health systems in South Africa. METHODS: Using a modelling framework and health system perspective, costs and health outcomes of inpatient management of severe and critical COVID-19 patients in (1) general ward and intensive care (GW + ICU) versus (2) general ward only (GW) were assessed. Disability adjusted life years (DALYs) were evaluated and the cost per admission in public and private sectors was determined. The model made use of four variables: mortality rates, utilisation of inpatient days for each management approach, disability weights associated with severity of disease, and the unit cost per general ward day and per ICU day in public and private hospitals. Unit costs were multiplied by utilisation estimates to determine the cost per admission. DALYs were calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). An incremental cost-effectiveness ratio (ICER) - representing difference in costs and health outcomes of the two management strategies - was compared to a cost-effectiveness threshold to determine the value for money of expansion in ICU services during COVID-19 surges. RESULTS: A cost per admission of ZAR 75,127 was estimated for inpatient management of severe and critical COVID-19 patients in GW as opposed to ZAR 103,030 in GW + ICU. DALYs were 1.48 and 1.10 in GW versus GW + ICU, respectively. The ratio of difference in costs and health outcomes between the two management strategies produced an ICER of ZAR 73,091 per DALY averted, a value above the cost-effectiveness threshold of ZAR 38,465. CONCLUSIONS: Results indicated that purchasing ICU capacity from the private sector during COVID-19 surges may not be a cost-effective investment. The 'real time', rapid, pragmatic, and transparent nature of this analysis demonstrates an approach for evidence generation for decision making relating to the COVID-19 pandemic response and South Africa's wider priority setting agenda.

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance.

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation.

The Competition Commission Health Market Inquiry Report: An overview and key imperatives.

The Competition Commission's Health Market Inquiry (HMI) is the most systematic and comprehensive investigation carried out into the South African private health sector. The recommendations as set out in the HMI Final Report merit extensive discussion and debate, as they could - if implemented - have far-reaching consequences for the future of the healthcare system. The objective of this article is to contribute to this discussion by providing an overview of the key findings and recommendations of the HMI and highlighting the resultant key imperatives at this critical juncture of policy development.

Managing the healthcare demand-supply gap during and after COVID-19: The need to review the approach to healthcare priority-setting in South Africa.

Healthcare demands are rising globally, and regardless of the approach to financing and delivering healthcare services, no country can meet all the healthcare demands of its population. The demand-supply gap for healthcare services in South Africa (SA) is large, particularly for the public sector. The objectives of this article are to examine some of the underlying factors contributing to this gap, and how the COVID- 19 pandemic is likely to impact on them, and to describe why SA needs to adopt an explicit and equity-informed approach to healthcare priority-setting to assist in managing the gap.

Antibiotic prescription patterns of South African general medical practitioners for treatment of acute bronchitis.

BACKGROUND: Antibiotic resistance is a significant public health problem. Prudent use of antibiotics is crucial in reducing this resistance. Acute bronchitis is a common reason for consultations with general medical practitioners, and antibiotics are often prescribed even though guidelines recommend not prescribing them for uncomplicated acute bronchitis. OBJECTIVE: To analyse the antibiotic prescription patterns of South African (SA) general medical practitioners in the treatment of acute bronchitis. METHODS: The 2013 claims for members of 11 health insurance schemes were analysed to assess antibiotic prescription patterns for patients diagnosed with acute bronchitis. The patterns were assessed by type of bronchitis, chronic health status of the patients, sex and age group. The types of antibiotic prescribed were also analysed. RESULTS: Of 166 821 events analysed, an antibiotic was prescribed in more than half (52.9%). There were significant differences by type of bronchitis and chronic health status. Patients with viral bronchitis were more likely to be prescribed an antibiotic than those with bacterial bronchitis (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.08 - 1.26). Patients with a chronic illness were less likely to be prescribed an antibiotic than those without (OR 0.58, 95% CI 0.57 - 0.60). More than 70% of the antibiotics prescribed were cephalosporins, penicillins and other beta-lactams. CONCLUSIONS: Prescription rates of antibiotics for acute bronchitis by SA general medical practitioners are high. There is an urgent need to follow the guidelines for antibiotic use for acute bronchitis to reduce the likelihood of increasing resistance to available antibiotics.

Professionally applied topical fluoride and fissure sealants: matching insurance claims with evidence.

OBJECTIVE: The purpose of this study was to assess the extent to which medical aid schemes are funding evidence-based dental care, specifically assessing claims patterns for professionally applied topical fluoride and fissure sealant treatments to the beneficiaries of a large South African medical aid scheme. The rising costs of dental care provide the impetus to review spending patterns to assess whether resources are being utilised optimally. The emergence of evidence-based dentistry offers an important tool in this regard. METHODOLOGY: The 2005 membership and claims data of a large South African medical scheme were analysed for the period 1 January 2005 to 31 December 2005. The claim patterns for two dental caries preventive interventions with different levels of evidence were assessed and compared for two age groups: under 20 years of age and 20 and above. RESULTS: About 30% received a topical fluoride application, equally provided to both age categories. Less than 3% of all who visited the dentists received at least one sealant. Of those under 20 years of age, only 10% received this proven preventive intervention. CONCLUSIONS: This study highlights the need to substantially increase the provision of fissure sealants to children with erupting first (5-7 year olds) and second (11-13 year olds) permanent molar teeth and decrease the provision of professionally applied fluoride applications to those outside of specifically identified caries-risk groups. This study further illustrates the potential of applying evidence-based dentistry research findings to assessing the appropriateness of claim patterns as well as the funding thereof.

Access to health care in South Africa--the influence of race and class.

OBJECTIVES: The first democratic government elected in South Africa in 1994 inherited huge inequities in health status and health provision across all sections of the population. This study set out to assess the impact of the new government's commitment to address these inequities and implement policies to improve population health in general and address inequalities in health care in particular. DESIGN: A 1998 household survey assessed many aspects of health delivery, including their own perceived and actual access to health care among different segments of South African society. RESULTS: Race was the main predictor of perceived changes in access to health care, with black, coloured-and Indian respondents significantly more likely to feel that access had improved since 1994, compared with white respondents. Socio-economic status (SES) was the main predictor of actual access to health care, with low and middle SES classes significantly less likely to access care when ill. CONCLUSIONS: One-third of respondents perceived health care access to have improved between 1994 and 1998, and this response was partially determined along racial lines. About one-quarter reported an inability to access health care when they required it, and this response was partially determined along socio-economic lines. This set of contrasting responses suggests that at a political level perceptions are largely influenced by race, but at the operational level actual access is influenced by SES.

A comparison of service profiles in alternative dental care delivery systems.

The financial crisis within the health care sector has resulted in the search by medical benefit funds of worker organisations for cost-effective alternatives to the private health care sector. This study compares the profile of services rendered to members of a union medical benefit fund by an 'in house' dental clinic and private dental practitioners. A total of 2,858 union clinic claims and 10,811 private practitioner accounts were selected. Each treatment code was categorised into either preventive, restorative, extraction or denture services. For the union clinic and private dental practitioners a total of 3,021 and 15,853 treatment codes respectively were included in the analysis. Significant differences were found in the profile of services rendered by the union clinic and private dental practitioners. The union clinic provided predominantly preventive and denture-related treatment compared with private practitioners who provided mainly preventive and extraction services. Members and their dependants are far more likely to have dentures made through the dental clinic (the odds of having dentures made at the clinic were 4.67 times the odds of having dentures made through private practitioners). On the other hand, members were more likely to receive all the other services (restorative, preventive and extractions) from private practitioners. However, the nature of the study design and the findings do not allow conclusions to be drawn regarding whether these differences were due to demand or supplier influences.

Comparison of intra-examiner reproducibility in scoring caries in primary teeth of two scoring systems used to monitor caries progression.

The investigation was designed to compare the reproducibility of scoring systems proposed by Pitts (1), and Murray & Majid (2), when used to monitor caries progression in primary teeth. A sub-sample of the posterior bitewing radiographs of 301, 5-yr-old children from a Duraphat clinical trial were re-examined. The difference in the reproducibility of the two methods was not significant (P greater than 0.05). The concern regarding the effect on reproducibility of using scoring systems with subdivisions of enamel when measuring caries progression in primary teeth appears to be unfounded.

Progression of proximal caries in primary teeth in relation to radiographic scoring codes.

The posterior bitewing radiographs of 50 children from a Duraphat clinical trial were re-examined to compare the information provided on progression of caries of two scoring systems, that of Murray & Majid (1) and that of Pitts (2). Pitts' scoring system (Method 1), by recording the disease process at an earlier stage, and by avoiding the unnecessary loss of data, provided a more complete overall picture of the carious process than the scoring system used by Murray & Majid (Method 2). The progression rates were found to be significantly faster with Method 2 (P less than 0.05). With Method 1, a mean of 60% of enamel lesions per subject had remained confined to enamel 12 months later, the corresponding figure for Method 2 was 37%. Method 2, by excluding outer enamel lesions and overlapped surfaces, introduces biases which favour overestimating the proportion of lesions deemed to have progressed. The diagnostic criteria used by Murray & Majid lead to an overestimation of the rate of progression of caries in primary teeth.