A cost-effectiveness analysis of a South African pregnancy support grant.

Poverty among expectant mothers often results in sub-optimal maternal nutrition and inadequate antenatal care, with negative consequences on child health outcomes. South Africa has a child support grant that is available from birth to those in need. This study aims to determine whether a pregnancy support grant, administered through the extension of the child support grant, would be cost-effective compared to the existing child support grant alone. A cost-utility analysis was performed using a decision-tree model to predict the incremental costs (ZAR) and disability-adjusted life years (DALYs) averted by the pregnancy support grant over a 2-year time horizon. An ingredients-based approach to costing was completed from a governmental perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed. The intervention resulted in a cost saving of R13.8 billion ($930 million, 95% CI: ZAR3.91 billion - ZAR23.2 billion/ $1.57 billion - $264 million) and averted 59,000 DALYs (95% CI: -6,400-110,000), indicating that the intervention is highly cost-effective. The primary cost driver was low birthweight requiring neonatal intensive care, with a disaggregated incremental cost of R31,800 ($2,149) per pregnancy. Mortality contributed most significantly to the DALYs accrued in the comparator (0.68 DALYs). The intervention remained the dominant strategy in the sensitivity analyses. The pregnancy support grant is a highly cost-effective solution for supporting expecting mothers and ensuring healthy pregnancies. With its positive impact on child health outcomes, there is a clear imperative for government to implement this grant. By investing in this program, cost savings could be leveraged. The implementation of this grant should be given high priority in public health and social policies.

The Impact of COVID-19 Lockdown on Service Utilization Among Chronic Disease Patients in South Africa.

Introduction: Globally, the COVID-19 pandemic has brought many disruptions in health service delivery. Evidence show that the pandemic has negatively affected routine healthcare utilization such as maternal and child health services, but the literature on the effect on non-communicable diseases (NCDs) is scant in South Africa. These disruptions can have long-term health and economic implications for patients. Objective: To estimate the impact of COVID-19 lockdown on service utilization among chronic disease patients in South Africa using administrative data. Methods: Using monthly data from the Centralized Chronic Medication Dispensing and Distribution (CCMDD) program database covering November 2018 to October 2021, we examined the effects of COVID-19 lockdown on utilization among patients receiving antiretroviral therapy (ART) medication only (ART-only), patients receiving both ART and NCD medication (ART + NCD), and patients receiving NCD medications only (NCD-only). We employed segmented interrupted time series approach to examine the changes. We stratified the analysis by socioeconomic status. Results: We found that, overall, the lockdown was associated with increased utilization of CCMDD services by 10.8% (95% CI: 3.3%-19%) for ART-only and 10.3% (95% CI: 3.3%-17.7%) for NCD-only patients. The increase in utilization was not different across socioeconomic groups. For patients receiving ART + NCD medications, utilization declined by 56.6% (95% CI: 47.6%-64.1%), and higher reductions occurred in low SES districts. Conclusion: Patients should be educated about the need to continue with utilization of disease programs during a pandemic and beyond. More efforts are needed to improve service use among patients with multi-morbidities.

Cost-effectiveness of dental caries prevention strategies in South African schools.

BACKGROUND: In South Africa, an estimated 85% of the population relies on the public sector for oral health services. With poor infrastructure and inadequate personnel, over 80% of children with dental caries remain untreated. To reduce this burden of disease, one key goal is to promote good oral health and address oral diseases through prevention, screening, and treatment among children. While all policies have been proven to be effective in the control and prevention of dental caries, it is unclear which of those strategies provide value for money. This study evaluated five caries preventative strategies in terms of the cost and benefits among South African school children. METHODS: The study uses a hypothetical South African population of school aged learners aged 5-15. The context and insights of the strategies utilized at the schools were informed by data from both grey and published literature. Using Markov modeling techniques, we conducted a cost-effectiveness analysis of Acidulated Phosphate Fluoride (APF) application, atraumatic restorative treatment (ART), sugar-reduction and fissure sealants. Markov model was used to depict the movement of a hypothetical patient cohort between different health states over time. We assessed both health outcomes and costs of various interventions. The health outcome metric was measured as the number of Decayed, Missing, Filled Tooth (DMFT). The net monetary benefit was then used to determine which intervention was most cost-effective. RESULTS: The results showed that school-based caries prevention strategies are cost-effective compared to the status quo of doing nothing. The average cost per learner over the 10-year period ranged from ZAR4380 to approx. ZAR7300 for the interventions considered. The total costs (including screening) associated with the interventions and health outcome (DMFT averted) were: sugar reduction (ZAR91,380, DFMT: 63,762), APF-Gel (ZAR54 million, DMFT: 42,010), tooth brushing (ZAR72.8 million, DMFT: 74,018), fissure sealant (ZAR44.63 million, DMFT: 100,024), and ART (ZAR45 million, DMFT: 144,035). The net monetary benefits achieved for APF-Gel, sugar reduction, tooth brushing, fissure sealant and ART programs were ZAR1.56, ZAR2.45, ZAR2.78, ZAR3.81, and ZAR5.55 billion, respectively. CONCLUSION: Based on the net monetary benefit, ART, fissure sealant and sugar-reduction appear to be the most cost-effective strategies for preventing caries in South Africa. In a resource-scarce setting such as South Africa, where there is no fluoridation of drinking water, this analysis can inform decisions about service packages for oral health.

Beverage industry's advertising expenditures and airtimes in South Africa from 2013 to 2019 target children and families.

With the growing burden of non-communicable diseases (NCDs), countries across the globe are finding ways to reduce the consumption of ultra-processed food and drinks including sugar-sweetened beverages (SSBs). South Africa implemented a health promotion levy (HPL) in April 2018 as one strategy to reduce sugar intake. Such efforts are frequently countered or mitigated by industry action in various ways, including through marketing and advertising strategies. To better understand trends in the extent of advertising, this paper analyses advertising expenditures and exposure of children to SSB advertisements in South Africa. Using Nielsen's monthly data on advertising expenditure before and after the introduction of the HPL, for the period January 2013 to April 2019, the results show that manufacturers spent ZAR 3683 million to advertise their products. Advertising expenditure on carbonated drinks accounted for over 60% (ZAR 2220 million) of the total expenditure on SSBs. The results also show that companies spend less in advertising powdered SSBs (an average of ZAR 0.05 million per month). Based on expenditure patterns, television (TV) was the preferred medium of advertisements, with companies prioritizing what is often considered children's and family viewing time. Urgent mandatory regulations are needed to prevent child-directed marketing.

Indirect effects of COVID-19 on maternal and child health in South Africa.

BACKGROUND: The unfinished burden of poor maternal and child health contributes to the quadruple burden of disease in South Africa with the direct and indirect effects of the COVID-19 pandemic yet to be fully documented. OBJECTIVE: To investigate the indirect effects of COVID-19 on maternal and child health in different geographical regions and relative wealth quintiles. METHODS: We estimated the effects of COVID-19 on maternal and child health from April 2020 to June 2021. We estimated this by calculating mean changes across facilities, relative wealth index (RWI) quintiles, geographical areas and provinces. To account for confounding by underlying seasonal or linear trends, we subsequently fitted a segmented fixed effect panel model. RESULTS: A total of 4956 public sector facilities were included in the analysis. Between April and September 2020, full immunisation and first dose of measles declined by 6.99% and 2.44%, respectively. In the follow-up months, measles first dose increased by 4.88% while full immunisation remained negative (-0.65%) especially in poorer quintiles. At facility level, the mean change in incidence and mortality due to pneumonia, diarrhoea and severe acute malnutrition was negative. Change in first antenatal visits, delivery by 15-19-year olds, delivery by C-section and maternal mortality was positive but not significant. CONCLUSION: COVID-19 disrupted utilisation of child health services. While reduction in child health services at the start of the pandemic was followed by an increase in subsequent months, the recovery was not uniform across different quintiles and geographical areas. This study highlights the disproportionate impact of the pandemic and the need for targeted interventions to improve utilisation of health services.

Prescribed Minimum Benefits complaints: a five-year retrospective review.

BACKGROUND: No matter which benefit option members have chosen, medical schemes are required by the Medical Schemes Act no. 131 of 1998 to pay costs associated with the diagnosis, treatment, or care of a specified set of benefits known as Prescribed Minimum Benefits (PMBs). Medical scheme beneficiaries have the right to lodge complaints with the Council for Medical Schemes (CMS) when their claims are denied. OBJECTIVE:  To determine and describe the pattern of PMBs complaints received by CMS from January 2014 to December 2018. METHODS:  This was a cross-sectional study that utilised the CMS' clinical complaints. Data for PMBs, complainants, medical scheme types, and reasons for payment denial were extracted. The CMS' lists of chronic conditions, PMBs, and registered schemes were used to confirm PMBs and to categorise schemes as either restricted (i.e., to only members of specific organisations) or open (i.e., to all South Africans). Extracted and coded data were analysed using SAS v.9.4 software. RESULTS:  A total of 2141 complaints were retrieved and 1124 PMBs complaints were included in the study. The median of PMBs complaints per year was 225. Most of the complaints (43.6%, n=490/1124) were lodged by members themselves. Non-Communicable Diseases (NCDs) constituted most of the PMBs conditions that members complained about. Medicine and surgery were the services that were mostly denied full payment by medical schemes. Open medical schemes accounted for more (73.8%, n=830/1124) of the complaints. CONCLUSION:  Chronic conditions are the main diseases that medical scheme members complained about. Member education and clear definition of PMBs should be prioritised by medical schemes and the Council for Medical Schemes.

Perceived knowledge of scheme members and their satisfaction with their medical schemes: a cross-sectional study in South Africa.

BACKGROUND: South Africa has a dual healthcare system comprising of private and public sectors covering 16% and 84% of the population, respectively. Medical schemes are the primary source of health insurance in the private sector. The aim of this study was to assess members of medical schemes' perceived knowledge and satisfaction with their medical schemes. METHODS: A cross-sectional survey was conducted using a stratified systematic sample of members of 22 open medical schemes. Medical schemes members completed an online questionnaire on knowledge and satisfaction with their medical schemes. We calculated a composite perceived knowledge and satisfaction score. Descriptive, bivariate and multivariate analysis was conducted. RESULTS: A total of 336 members of medical schemes participated in this study. Respondents generally perceived themselves to have good knowledge of their medical schemes. Eighty-one percent of participants were satisfied with the quality of services received from their designated service providers (DSPs), however, only 9% were satisfied with accessibility of doctors under their DSP arrangement. Twenty-five percent of respondents were satisfied with scheme contributions and only 46% were satisfied with the prescribed minimum benefit package. CONCLUSION: Medical schemes remain a key element of private healthcare in South Africa. The analysis shows that medical schemes, should put more effort into the accessibility of general practitioner under their designated service providers. Furthermore, the prescribed minimum benefits should be reviewed to provide a comprehensive benefits basket without co-payment for members as recommended by the Medical Schemes Act Amendment Bill of 2018.

Estimating the healthcare cost of overweight and obesity in South Africa.

BACKGROUND: Overweight and obesity are major risk factors for noncommunicable diseases. This presents a major burden to health systems and to society in South Africa. Collectively, these conditions are overwhelming public healthcare. This is happening when the country has embarked on a journey to universal health coverage, hence the need to estimate the cost of overweight and obesity. OBJECTIVE: Our objective was to estimate the healthcare cost associated with treatment of weight-related conditions from the perspective of the South African public sector payer. METHODS: Using a bottom-up gross costing approach, this study draws data from multiple sources to estimate the direct healthcare cost of overweight and obesity in South Africa. Population Attributable Fractions (PAF) were calculated and multiplied by each disease's total treatment cost to apportion costs to overweight and obesity. Annual costs were estimated for 2020. RESULTS: The total cost of overweight and obesity is estimated to be ZAR33,194 million in 2020. This represents 15.38% of government health expenditure and is equivalent to 0.67% of GDP. Annual per person cost of overweight and obesity is ZAR2,769. The overweight and obesity cost is disaggregated as follows: cancers (ZAR352 million), cardiovascular diseases (ZAR8,874 million), diabetes (ZAR19,861 million), musculoskeletal disorders (ZAR3,353 million), respiratory diseases (ZAR360 million) and digestive diseases (ZAR395 million). Sensitivity analyses show that the total overweight and obesity cost is between ZAR30,369 million and ZAR36,207 million. CONCLUSION: This analysis has demonstrated that overweight and obesity impose a huge financial burden on the public health care system in South Africa. It suggests an urgent need for preventive, population-level interventions to reduce overweight and obesity rates. The reduction will lower the incidence, prevalence, and healthcare spending on noncommunicable diseases.