Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

What values drive communities' nutrition priorities in a resource constrained urban area in South Africa?

BACKGROUND: Voices of under-resourced communities are recognised as important yet are often unheard in decisions about healthcare resource allocation. Deliberative public engagement can serve as an effective mechanism for involving communities in establishing nutrition priorities. This study sought to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. METHODS: We engaged 54 community members (28 men and 26 women aged > 18 years) from Soweto. We conducted seven group discussions to determine how to allocate limited resources for prioritising nutrition interventions. We used a modified public engagement tool: CHAT (Choosing All Together) which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. Choices were captured quantitatively, while group discussions were audio-recorded. A thematic analysis was undertaken to identify the reasons and values associated with the selected priorities. RESULTS: All groups demonstrated a preference to allocate scarce resources towards three priority interventions-school breakfast provisioning, six-months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants' allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children. Priority interventions were deemed critical to supporting children's optimal development and well-being, interrupting the intergenerational cycle of poverty and poor human development in the community. CONCLUSION: Our study demonstrates how public engagement can facilitate the incorporation of community values and programmatic preferences into nutrition priority setting, enabling a responsive approach to local community needs, especially in resource constrained contexts. Findings could guide policy makers to facilitate more appropriate decisions and to improve nutrition in the first 1000 days of life.

Developing and piloting a context-specified ethics framework for health technology assessment: the South African Values and Ethics for Universal Health Coverage approach.

OBJECTIVES: While ethics has been identified as a core component of health technology assessment (HTA), there are few examples of practical, systematic inclusion of ethics analysis in HTA. Some attribute the scarcity of ethics analysis in HTA to debates about appropriate methodology and the need for ethics frameworks that are relevant to local social values. The "South African Values and Ethics for Universal Health Coverage" (SAVE-UHC) project models an approach that countries can use to develop HTA ethics frameworks that are specific to their national contexts. METHODS: The SAVE-UHC approach consisted of two phases. In Phase I, the research team convened and facilitated a national multistakeholder working group to develop a provisional ethics framework through a collaborative, engagement-driven process. In Phase II, the research team refined the model framework by piloting it through three simulated HTA appraisal committee meetings. Each simulated committee reviewed two case studies of sample health interventions: opioid substitution therapy and either a novel contraceptive implant or seasonal influenza immunization for children under five. RESULTS: The methodology was fit-for-purpose, resulting in a context-specified ethics framework and producing relevant findings to inform application of the framework for the given HTA context. CONCLUSIONS: The SAVE-UHC approach provides a model for developing, piloting, and refining an ethics framework for health priority-setting that is responsive to national social values. This approach also helps identify key facilitators and challenges for integrating ethics analysis into HTA processes.

Assessing sugar-sweetened beverage intakes, added sugar intakes and BMI before and after the implementation of a sugar-sweetened beverage tax in South Africa.

OBJECTIVE: To provide insight into the context and public health implications of the South African sugar-sweetened beverage (SSB) tax (Health Promotion Levy; HPL) by describing SSB and added sugar intakes, as well as BMI, 1 year prior to, at the time of and 1 year after implementation of the HPL. DESIGN: Longitudinal dietary intake was assessed using a quantitative food frequency questionnaire (QFFQ) and BMI was measured via anthropometry. SETTING: Soweto, Johannesburg, South Africa. PARTICIPANTS: Adolescents, young adults and middle-aged adults (n 617). RESULTS: At baseline, median SSB intakes were 36 ml/d, 214 ml/d and 750 ml/d for those in low, medium and high consumption tertiles, respectively. SSB intake decreased by two times/week in medium consumers and seven times/week in high consumers between baseline and 12 months, equivalent to 107 ml/d and 536 ml/d reductions, respectively. These reduced levels were maintained in the following year (i.e. to 24 months). There was an overall decrease in the amount of energy consumed as added sugar in the low (-48 kJ/d), medium (-153 kJ/d) and high (-106 kJ/d) SSB consumption groups between baseline and 24 months; however, the percentage of total energy consumed as added sugar remained relatively consistent (between 10 and 11 %). There were small overall increases in BMI across low (0·6 kg/m2), medium (0·9 kg/m2) and high (1·0 kg/m2) SSB tertiles between baseline and 24 months. CONCLUSIONS: These findings suggest reductions in SSB and added sugar consumption contemporaneous to the introduction of the HPL - particularly for those with higher baseline intakes.

Double-duty solutions for optimising maternal and child nutrition in urban South Africa: a qualitative study.

OBJECTIVE: To obtain a community perspective on key nutrition-specific problems and solutions for mothers and children. DESIGN: A qualitative study comprising nine focus group discussions (FGD) following a semi-structured interview guide. SETTING: The township of Soweto in South Africa with a rising prevalence of double burden of malnutrition. PARTICIPANTS: Men and women aged ≥18 years (n 66). Three FGD held with men, six with women. RESULTS: Despite participants perceived healthy diet to be important, they felt their ability to maintain a healthy diet was limited. Inexpensive, unhealthy food was easier to access in Soweto than healthier alternatives. Factors such as land use, hygiene and low income played a fundamental role in shaping access to foods and decisions about what to eat. Participants suggested four broad areas for change: health sector, social protection, the food system and food environment. Their solutions ranged from improved nutrition education for women at clinic visits, communal vegetable gardens and government provision of food parcels to regulatory measures to improve the healthiness of their food environment. CONCLUSIONS: South Africa's current nutrition policy environment does not adequately address community-level needs that are often linked to structural factors beyond the health sector. Our findings suggest that to successfully address the double burden of malnutrition among women and children, a multifaceted approach is needed combining action on the ground with coherent policies that address upstream factors, including poverty. Further, there is a need for public engagement and integration of community perspectives and priorities in developing and implementing double-duty actions to improve nutrition.

Community perspectives on maternal and child health during nutrition and economic transition in sub-Saharan Africa.

OBJECTIVE: To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa. DESIGN: Thirty focus groups with men and women from three communities facilitated by local researchers. SETTING: One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition. PARTICIPANTS: Two hundred thirty-seven men and women aged 18-55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto. RESULTS: Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment. CONCLUSIONS: To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities' perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country's economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women's and children's nutritional status.

Health economic evidence in clinical guidelines in South Africa: a mixed-methods study.

BACKGROUND: Evidence-informed clinical practice guidelines (CPGs) are useful tools to inform transparent healthcare decision-making. Consideration of health economic evidence (HEE) during CPG development in a structured manner remains a challenge globally and locally. This study explored the views, current practice, training needs and challenges faced by CPG developers in the production and use of HEE for CPGs in South Africa. METHODS: This mixed-methods study comprised an online survey and a focus group discussion. The survey was piloted and subsequently sent to CPG role players - evidence reviewers, CPG panellists, academics involved with training in relevant disciplines like health economics and public health, implementers and funders. The focus group participants hold strategic roles in CPG development and health economic activities nationally. The survey evaluated mean values, measures of variability, and percentages for Likert scales, while narrative components were thematically analysed. Focus group data were manually coded, thematically analysed and verified. RESULTS: The survey (n = 55 respondents to 245 surveys distributed) and one focus group (n = 5 participants from 10 people invited) occurred between October 2018 and February 2019. We found the most consistent reason why HEE should inform CPG decisions was 'making more efficient use of limited financial resources'. This was explained by numerous context and methodological barriers. Focus groups participants noted that consideration of complex HEE are not achievable without bolstering skills in applying evidence-based medicine principles. Further concerns include lack of clarity of standard methods; inequitable and opaque topic selection across private and public sectors; inadequate skills of CPG panel members to use HEE; and the ability of health economists to communicate results in accessible ways. Overall, in the absence of clarity about process and methods, politics and interests may drive CPG decisions about which interventions to implement. CONCLUSIONS: HEE should ideally be considered in CPG decisions in South Africa. However, this will remain hampered until the CPG community agree on methods and processes for using HEE in CPGs. Focused investment by national government to address the challenges identified by the study is imperative for a better return on investment as National Health Insurance moves forward.

The roles of men and women in maternal and child nutrition in urban South Africa: A qualitative secondary analysis.

Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender-equitable nutrition practices, increase young women's self-efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children.

The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts.

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. PARTNERSHIP: The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. CONCLUSION: We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.

'I'd say I'm fat, I'm not obese': obesity normalisation in urban-poor South Africa.

OBJECTIVE: In the past decade, South Africa's obesity epidemic has increased in both children and adults, and being overweight is becoming the norm. Several contributing factors lead to the normalisation of obesity. One of these is the culturally entrenched likeness of larger body sizes or shapes within a milieu of easily accessible unhealthy food and beverages. This qualitative study advances knowledge about the influence of socio-cultural norms and obesogenic environments on weight under estimation and 'obesity normalisation' amongst black South Africans living in an urban setting. DESIGN: A theory-based qualitative study used focus group discussions (FGDs) with a semi-structured interview guide. FGDs were transcribed verbatim and analysed thematically using a constant comparison method. SETTING: Soweto, Johannesburg, South Africa, is a setting which has undergone rapid urbanisation and nutrition transition with ubiquitous availability of processed and fast-foods. PARTICIPANTS: Adults older than 18 years living in Soweto (n 57). RESULTS: There is a wide misperception about obesity amongst black Africans living in an urban setting in Soweto. Participants who admitted to being fat or overweight did not view themselves as such. This could be attributed to unchanging socio-cultural factors that reinforce the acceptability of bigger bodies and living in obesogenic environment. CONCLUSIONS: Without addressing socio-cultural norms that attribute bigger bodies to beauty and wealth, motivating individuals to address weight gain will prove difficult especially for populations living in obesogenic environments. A multi-faceted strategy is required to address obesity in urban South African settings.

Sugar-Sweetened Beverage Taxes: Industry Response and Tactics.

The consumption of sugary beverages (SBs) has increasingly grown in many countries and is a significant contributor to the rise in obesity and non-communicable diseases (NCDs). In response, public health officials in multiple countries have pushed for implementing a tax on SBs in order to reduce their consumption. Today, many individuals, especially those of lower socioeconomic status, live in environments in which unhealthy foods and drinks are more accessible than healthier ones. The beverage industry has greatly contributed to the formation of these "obesogenic" environments through their extensive advertising activities and effective marketing strategies. With rising public awareness of sugar's link to obesity, the industry has heavily invested in campaigns that seek to shift the blame away from their products and has aggressively opposed legislative efforts to pass an SB tax. This perspective will focus on explaining the rationale and necessity of an SB tax by highlighting the tactics the beverage industry has employed that have contributed to the formation and maintenance of the present unhealthy food environment.

Bibliometric trends of health economic evaluation in Sub-Saharan Africa.

BACKGROUND: Collaboration between Sub-Saharan African researchers is important for the generation and transfer of health technology assessment (HTA) evidence, in order to support priority-setting in health. The objective of this analysis was to evaluate collaboration patterns between countries. METHODS: We conducted a rapid evidence assessment that included a random sample of health economic evaluations carried out in 20 countries (Angola, Botswana, Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania, Zambia, Zimbabwe, Ghana, Kenya, Nigeria, Ethiopia, Uganda). We conducted bibliometric network analysis based on all first authors with a Sub-Saharan African academic affiliation and their co-authored publications ("network-articles"). Then we produced a connection map of collaboration patterns among Sub-Saharan African researchers, reflecting the number of network-articles and the country of affiliation of the main co-authors. RESULTS: The sample of 119 economic evaluations mostly related to treatments of communicable diseases, in particular HIV/AIDS (42/119, 35.29 %) and malaria (26/119, 21.85 %). The 39 first authors from Sub-Saharan African institutions together co-authored 729 network-articles. The network analysis showed weak collaboration between health economic researchers in Sub-Saharan Africa, with researchers being more likely to collaborate with Europe and North America than with other African countries. South Africa stood out as producing the highest number of health economic evaluations and collaborations. CONCLUSIONS: The development and evaluation of HTA research networks in Sub-Saharan Africa should be supported, with South Africa central to any such efforts. Organizations and institutions from high income countries interested in supporting priority setting in Sub-Saharan Africa should include promoting collaboration as part of their agendas, in order to take advantage of the potential transferability of results and methods of the available health economic analyses in Africa and internationally.

Cost of inaction on sugar-sweetened beverage consumption: implications for obesity in South Africa.

OBJECTIVE: To estimate the effect of increased sugar-sweetened beverage (SSB) consumption on future adult obesity prevalence in South Africa in the absence of preventive measures. DESIGN: A model was constructed to simulate the effect of a 2·4 % annual increase in SSB consumption on obesity prevalence. The model computed the change in energy intake assuming a compounding increase in SSB consumption. The population distribution of BMI by age and sex was modelled by fitting measured data from the 2012 South African National Income Dynamics Survey to the log-normal distribution and shifting the mean values. SETTING: Over the past decade the prevalence of obesity and related non-communicable diseases has increased in South Africa, as have the sales and availability of SSB. Soft drink sales in South Africa are projected to grow between 2012 and 2017 at an annual compounded growth rate of 2·4 % in the absence of preventive measures to curb consumption. RESULTS: A 2·4 % annual growth in SSB sales alongside population growth and ageing will result in an additional 1 287 000 obese adults in South Africa by 2017, 22 % of which will be due to increased SSB consumption. CONCLUSIONS: In order to meet the South African target of reducing the number of people who are obese and/or overweight by 10 % by 2020, the country cannot afford to delay implementing effective population-wide interventions. In the face of plans to increase growth of SSB, the country will soon face even greater challenges in overcoming obesity and related non-communicable diseases.

Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa.

BACKGROUND: Stroke poses a growing human and economic burden in South Africa. Excess sugar consumption, especially from sugar-sweetened beverages (SSBs), has been associated with increased obesity and stroke risk. Research shows that price increases for SSBs can influence consumption and modelling evidence suggests that taxing SSBs has the potential to reduce obesity and related diseases. This study estimates the potential impact of an SSB tax on stroke-related mortality, costs and health-adjusted life years in South Africa. METHODS: A proportional multi-state life table-based model was constructed in Microsoft Excel (2010). We used consumption data from the 2012 South African National Health and Nutrition Examination Survey, previously published own and cross price elasticities of SSBs and energy balance equations to estimate changes in daily energy intake and BMI arising from increased SSB prices. Stroke relative risk, and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study, were used to estimate the effect of the BMI changes on the burden of stroke. RESULTS: Our model predicts that an SSB tax may avert approximately 72 000 deaths, 550 000 stroke-related health-adjusted life years and over ZAR5 billion, (USD400 million) in health care costs over 20 years (USD296-576 million). Over 20 years, the number of incident stroke cases may be reduced by approximately 85 000 and prevalent cases by about 13 000. CONCLUSIONS: Fiscal policy has the potential, as part of a multi-faceted approach, to mitigate the growing burden of stroke in South Africa and contribute to the achievement of the target set by the Department of Health to reduce relative premature mortality (less than 60 years) from non-communicable diseases by the year 2020.

Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey.

BACKGROUND: Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care. METHODS: Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients' out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined. RESULTS: Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic. CONCLUSIONS: Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care.

Obesogenic Environments: Access to and Advertising of Sugar-Sweetened Beverages in Soweto, South Africa, 2013.

INTRODUCTION: Rates of obesity and overweight among South Africans are increasing. Food marketing has a profound impact on children and affects their lifelong eating patterns; in urban areas of South Africa, disposable incomes are growing and ultra-processed food is increasingly available at low cost. The combination of these factors will strain an already fragile health system. Our aim was to investigate the density of outdoor sugar sweetened beverage (SSB) advertising and the number of formal and informal vendors selling SSBs in a transforming, historically disadvantaged urban setting of South Africa. METHODS: A digital camera and global positioning system navigation system were used to record the location of SSB advertisements and food vendors in a demarcated area in Soweto. Data were collected by walking or driving through each street; a food inventory was completed for every food vendor. Spatial analyses were conducted using a geographic information system. RESULTS: A total of 145 advertisements for SSBs were found over a driven or walked distance of 111.9 km. The density of advertisements was 3.6 per km(2) in relation to schools, and 50% of schools had branded advertising of SSBs on their school property. Most (n = 104; 58%) of the 180 vendors in the study sold SSBs. CONCLUSION: This is the first study in South Africa to document the location of billboard advertisements and vendors in relation to schools. Marketing of products that contribute to obesity is common in urban Soweto. Our findings have implications for policies that regulate SSB advertising, especially in the proximity of schools.

Hypertension education and adherence in South Africa: a cost-effectiveness analysis of community health workers.

BACKGROUND: To determine whether training community health workers (CHWs) about hypertension in order to improve adherence to medications is a cost-effective intervention among community members in South Africa. METHODS: We used an established Markov model with age-varying probabilities of cardiovascular disease (CVD) events to assess the benefits and costs of using CHW home visits to increase hypertension adherence for individuals with hypertension and aged 25-74 in South Africa. Subjects considered for CHW intervention were those with a previous diagnosis of hypertension and on medications but who had not achieved control of their blood pressure. We report our results in incremental cost-effectiveness ratios (ICERs) in US dollars per disability-adjusted life-year (DALY) averted. RESULTS: The annual cost of the CHW intervention is about $8 per patient. This would lead to over a 2% reduction in CVD events over a life-time and decrease DALY burden. Due to reductions in non-fatal CVD events, lifetime costs are only $6.56 per patient. The CHW intervention leads to an incremental cost-effectiveness ratio of $320/DALY averted. At an annual cost of $6.50 or if the blood pressure reduction is 5 mmHg or greater per patient the intervention is cost-saving. CONCLUSIONS: Additional training for CHWs on hypertension management could be a cost-effective strategy for CVD in South Africa and a very good purchase according to World Health Organization (WHO) standards. The intervention could also lead to reduced visits at the health centres freeing up more time for new patients or reducing the burden of an overworked staff at many facilities.

Applying a private sector capitation model to the management of type 2 diabetes in the South African public sector: a cost-effectiveness analysis.

BACKGROUND: Diabetes mellitus contributes substantially to the non-communicable disease burden in South Africa. The proposed National Health Insurance system provides an opportunity to consider the development of a cost-effective capitation model of care for patients with type 2 diabetes. The objective of the study was to determine the potential cost-effectiveness of adapting a private sector diabetes management programme (DMP) to the South African public sector. METHODS: Cost-effectiveness analysis was undertaken with a public sector model of the DMP as the intervention and a usual practice model as the comparator. Probabilistic modelling was utilized for incremental cost-effectiveness ratio analysis with life years gained selected as the outcome. Secondary data were used to design the model while cost information was obtained from various sources, taking into account public sector billing. RESULTS: Modelling found an incremental cost-effectiveness ratio (ICER) of ZAR 8 356 (USD 1018) per life year gained (LYG) for the DMP against the usual practice model. This fell substantially below the Willingness-to-Pay threshold with bootstrapping analysis. Furthermore, a national implementation of the intervention could potentially result in an estimated cumulative gain of 96 997 years of life (95% CI 71 073 years - 113 994 years). CONCLUSIONS: Probabilistic modelling found the capitation intervention to be cost-effective, with an ICER of ZAR 8 356 (USD 1018) per LYG. Piloting the service within the public sector is recommended as an initial step, as this would provide data for more accurate economic evaluation, and would also allow for qualitative analysis of the programme.

Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis.

BACKGROUND: Excess intake of sugar sweetened beverages (SSBs) has been shown to result in weight gain. To address the growing epidemic of obesity, one option is to combine programmes that target individual behaviour change with a fiscal policy such as excise tax on SSBs. This study evaluates the literature on SSB taxes or price increases, and their potential impact on consumption levels, obesity, overweight and body mass index (BMI). The possibility of switching to alternative drinks is also considered. METHODS: The following databases were used: Pubmed/Medline, The Cochrane Database of Systematic Reviews, Google Scholar, Econlit, National Bureau of Economics Research (NBER), Research Papers in Economics (RePEc). Articles published between January 2000 and January 2013, which reported changes in diet or BMI, overweight and/or obesity due to a tax on, or price change of, SSBs were included. RESULTS: Nine articles met the criteria for the meta-analysis. Six were from the USA and one each from Mexico, Brazil and France. All showed negative own-price elasticity, which means that higher prices are associated with a lower demand for SSBs. Pooled own price-elasticity was -1.299 (95% CI: -1.089 - -1.509). Four articles reported cross-price elasticities, three from the USA and one from Mexico; higher prices for SSBs were associated with an increased demand for alternative beverages such as fruit juice (0.388, 95% CI: 0.009 - 0.767) and milk (0.129, 95% CI: -0.085 - 0.342), and a reduced demand for diet drinks (-0.423, 95% CI: -0.628 - -1.219). Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity. CONCLUSIONS: Taxing SSBs may reduce obesity. Future research should estimate price elasticities in low- and middle-income countries and identify potential health gains and the wider impact on jobs, monetary savings to the health sector, implementation costs and government revenue. Context-specific cost-effectiveness studies would allow policy makers to weigh these factors.

Cost-effectiveness analysis of infant feeding strategies to prevent mother-to-child transmission of HIV in South Africa.

Despite increasing availability of perinatal interventions to prevent mother-to-child transmission (MTCT) of HIV in South Africa, MTCT remains high due to breastfeeding. To inform policy decisions in the country, cost-effectiveness of alternative infant-feeding interventions was conducted. Mathematical modelling was used to simulate post-natal transmission and mortality due to infant feeding in a hypothetical cohort of 1 000 HIV-exposed infants. Lifetime costs to the health system were calculated for each strategy. Interventions compared with current practice were: increasing coverage of extended nevirapine prophylaxis (ENP) to infants from 30% (base case) to 60% without changing current feeding practices; actively supporting breastfeeding with ENP to infants for 12 months; and actively supporting exclusive formula (replacement) feeding for 6 months. HIV-free survival at 24 months and disability-adjusted life years (DALYs) averted were estimated for typical rural and certain urban settings. Base-case analysis revealed that expanding coverage of nevirapine prophylaxis with breastfeeding is cost-saving and improves HIV-free survival. Changing feeding practices is beneficial, depending on context. Breastfeeding is dominant (less costly, more effective) in rural settings, whilst formula feeding is a dominant strategy in urban settings. Cost-effectiveness was most sensitive to proportion of women on lifelong antiretroviral therapy (ART) and infant mortality rate (IMR). When >55% of women are on ART, breastfeeding dominates in the urban settings modelled, whilst formula feeding is cost-effective in rural settings when IMR ≤ 45/1000. The study concludes that strategies to support breastfeeding are essential. Strengthening health systems is critical to ensure optimal nevirapine delivery during breastfeeding. A case can be made for formula feeding or breastfeeding in HIV-infected women in specific contexts.