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.

South African healthcare reforms towards universal healthcare - where to next?

The National Assembly approval of the National Health Insurance (NHI) Bill represents an important milestone, but there are many uncertainties concerning its implementation and timeline. The challenges faced by the South African healthcare system are huge, and we cannot afford to wait for NHI to address them all. It is critical that the process of strengthening the health system to advance universal healthcare (UHC) begins now, and there are several viable initiatives that can be implemented without delay. This article examines potential scenarios after the Bill is passed and ways in which UHC could be advanced. It begins with an overview of the trajectory of health system reform since 1994, then examines the scenarios that may emerge once the Bill is passed by Parliament and makes a case for finding ways in which UHC could be advanced within the country, regardless of any legal or financial barriers that may delay or limit NHI implementation.

A 13-year patient journey of infant giant clival chordoma: case report and literature review.

Chordomas are rare malignant bone tumours that develop from the ectopic remnants of the embryonic notochord. In contrast to adults, the majority in children under 16 present intra-cranially (63%). In 2006, we reported the youngest case of a large clival chordoma, a 15-week old baby, the second case to present without skull base involvement and the fourth case of chordoma in a patient with tuberous sclerosis (TS) Kombogiorgas (Childs Nerv Syst 22(10):1369-1374, 2006). In this report, we provide an update on this patient's journey through a range of therapeutic options and summarize an update of the literature, since 2006, for this patient group.

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.

Highly sensitive and flexible pressure sensor based on two-dimensional MoSe2 nanosheets for online wrist pulse monitoring.

The advancement of portable and flexible electronics that is integrated with multiple sensing functions has increasingly drawn considerable interest. The fabricated sensors would have the ability to sense multiple deformations like pressing, twisting and trivial vibrations such as pulses of wrist vibrations to mimic human skin. Presently, we implemented an easy, cost-effective and optimized fabrication technique for production of pressure sensors based on MoSe2 nanosheets coated on cellulose paper. The present sensor exhibits an incorporation of large pressure sensitivity of 18.42 kPa-1 in pressure range 0.001-0.5 kPa, 7.28 kPa-1 in pressure range 1-35 kPa and 2.63 kPa-1 in pressure range 40-100 kPa, working in broad pressure range (from 0.001 to 100 kPa) and long-term stability up to 200 deformation cycles at 2 kPa. The sensor showed excellent response towards the detection of vibrations of machines including cellular phone, compressor, etc. Besides, the sensor shows excellent environmental stability and exhibits immune piezo-resistive response to temperature variation.

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.

Flexible paper based piezo-resistive sensor functionalised by 2D-WSe2 nanosheets.

High-performance electronics demand extremely sensitive piezo-resistive sensors with important features such as low-fabrication cost, easy implementation, low power consumption and high-pressure sensitivity over broad pressure range. Herein, we report a flexible piezo-resistive paper-based device functionalised by WSe2 nanosheets. An efficient and low-cost fabrication strategy using Whatman filter paper and tissue paper is adopted for versatile sensing applications. The WSe2 nanosheets were synthesized by high-yield and size-controlled liquid phase exfoliation technique. The flexible WSe2 nanosheets-paper sensor shows excellent response in broad pressure range of 1 Pa-100 kPa with exceptionally high sensitivity of 29.24 kPa-1, current responsivity of 70 and response time of 100 ms. The pressure sensor is also employed to recognize the pressure generated due to finger tapping. Encouragingly, the piezo-resistive sensors can also sense extremely small pressure differences of about 1.4 Pa generated by water drops.

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.

Endodontic treatment-related antibiotic prescribing patterns of South African oral health professionals.

AIM: To assess the antibiotic prescribing patterns of South African dentists for patients undergoing endodontic treatment. METHODOLOGY: This study used data from 2013 health insurance claims submitted by South African oral health professionals to determine the antibiotic prescribing patterns related to endodontic treatment. A logistic regression model was used to test the fully adjusted statistical significance of the association between the exploratory variables (gender, age group, event type, abscess treatment, chronic health) and the dependent variable (antibiotic prescription). Odds ratios with 95% confidence intervals (CI) are reported, and a 95% CI excluding 1 was considered statistically significant. RESULTS: Almost 10% of endodontic treatments were prescribed an antibiotic. There were no significant differences in prescribing patterns by gender, age and chronic health status. Prescriptions were more common at the preparatory stage (9.4%) of root canal treatment compared to the therapy (4.7%) and canal filling (2%) stages. Patients who received apical surgery (OR = 2.28; 95% CI 1.38-3.76) and treatment of an abscess (OR = 2.57; 95% 1.82-3.63) had a significantly increased odds of being prescribed an antibiotic. Almost three-quarters of prescriptions were for narrow spectrum antibiotics. CONCLUSION: The frequency of antibiotic prescribing by South African dental practitioners for patients undergoing endodontic treatment is relatively low and predominantly involved narrow spectrum antibiotics. It, however, remains important that antibiotics are only prescribed when clinically essential, such as when there are obvious systemic effects. These include fever above 37 degrees, malaise, lymphadenopathy, trismus, increase swelling, cellulitis, osteomyelitis and persistent infection. The wider dissemination and adherence to clear evidence-based prescribing guidelines for antibiotics in this clinical area are important.

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

Os odontoideum in wolcott-rallison syndrome: a case series of 4 patients.

Wolcott-Rallison Syndrome is the commonest cause of neonatal diabetes in consanguineous families. It is associated with liver dysfunction, epiphyseal dysplasia, and developmental delay. It is caused by mutations in eukaryotic translation initiation factor 2-α kinase 3 (EIF2AK3).We report 4 children with WRS and Os Odontoideum resulting in significant neurological compromise. This cervical spine abnormality has not previously been described in this syndrome. This additional evidence broadens the clinical spectrum of this syndrome and confirms the role of EIF2AK3 in skeletal development. Furthermore, Os Odontoideum needs to be actively screened for in WRS patients to prevent neurological and respiratory compromise.

Pressure induced metallization with absence of structural transition in layered molybdenum diselenide.

Layered transition-metal dichalcogenides have emerged as exciting material systems with atomically thin geometries and unique electronic properties. Pressure is a powerful tool for continuously tuning their crystal and electronic structures away from the pristine states. Here, we systematically investigated the pressurized behavior of MoSe2 up to ∼ 60 GPa using multiple experimental techniques and ab-initio calculations. MoSe2 evolves from an anisotropic two-dimensional layered network to a three-dimensional structure without a structural transition, which is a complete contrast to MoS2. The role of the chalcogenide anions in stabilizing different layered patterns is underscored by our layer sliding calculations. MoSe2 possesses highly tunable transport properties under pressure, determined by the gradual narrowing of its band-gap followed by metallization. The continuous tuning of its electronic structure and band-gap in the range of visible light to infrared suggest possible energy-variable optoelectronics applications in pressurized transition-metal dichalcogenides.

Births in captive stump-tailed macaques (Macaca arctoides).

In this report, nighttime births of 3 stump-tailed macaques observed at the Aizawl Zoological Park, India, are described. Continuous focal observations were collected a long with video and still photographs, on the 3 parturitions, from the first observed onset of labour. The average time taken for infant birth, beginning with visibility of the head at the vaginal opening, was 45 s. The births observed were similar in many respects, regardless of parity and social context. The average time taken for consuming the placenta was 4 min 4 s and the average number of contractions was 6.3. In all cases births occurred with the infant emerging in the occiput posterior position, assisted by the mother. Individual variations existed in the number of contractions, intercontraction intervals, self-examination of the anogenital region, duration of labour and the interval between infant birth and the delivery of the placenta. Each mother ingested the placenta completely, while holding her neonate, but without paying much attention to the neonate during placentophagia. Placentophagia appears to provide nutrition to the mothers. Detailed data on parturition in non-human primates, and particularly for Macacaarctoides , are still scarce. Data, such as those presented here, contribute to our understanding of primate birth and the adaptive pressures that shape parturition behaviour and reproductive success.

An unusual manifestation of a rare pleuropulmonary blastoma presenting with spinal cord compression and its neurosurgical implications.

Pleuropulmonary blastomas (PPB) are rare and biologically aggressive paediatric tumours. Although central nervous system metastatic dissemination is a recognised complication of PPB, to our knowledge, spinal cord compression has been described only in six patients. We report a 5-year-old boy with a diagnosis of recurrent type III PPB that was initially thought to be an empyema, who developed features of thoracic spinal cord compression secondary to local tumour infiltration. Although PPB demonstrate significant biologically aggressive behaviour, aggressive surgical resections together with adjuvant chemotherapy can help limit disease progression without impacting on the quality of life. Spinal metastatic disease should also be treated vigorously. In this paper we discuss the treatment strategies available in the management of PPB.

Does direct admission from an emergency department with on-site neurosurgical services facilitate time critical surgical intervention following a traumatic brain injury in children?

OBJECTIVES: To compare the proportion of trauma craniotomies performed within 4 hours of presentation to emergency departments (ED) with and without on-site neurosurgery. DESIGN: A retrospective cohort analysis of data collected prospectively between January 2005 and April 2010 from patients with traumatic brain injury who were admitted to the paediatric intensive care unit (PICU) following traumatic brain injury. METHODS: Times for admission to ED, PICU and theatre were obtained through analysis of prospectively collected data management systems. Emergency department admission to neurosurgical theatre lag time was calculated using Microsoft Excel. Statistical analysis was performed using R (version 2.11.0). Subjects. Fifty-seven cases were identified. Twenty patients were admitted directly from ED to an on-site neurosurgical unit. The remaining 37 were transferred from regional EDs. RESULTS: Thirty-one craniotomies were performed. Thirteen in-patients admitted directly to hospital with neurosurgery on site. Eighteen in patients admitted at the local hospital and then transferred to the neurosurgical unit. Thirteen of Thirty-one (42%) craniotomies were performed within 4 hours. In the on-site group 10 of 13 (77%) craniotomies were performed within 4 hours compared to 3 of 18 (17%) in those transferred from regional ED (p = 0.001232) (Fisher exact test). Eleven patients were transferred directly from ED to neurosurgical theatre for emergency craniotomies. Within this subgroup, seven patients came from the cohort of admissions to a hospital with on-site neurosurgery. The remaining four patients were transferred from regional ED. There were eight extradural haematomas, one subdural haematoma and two intraparenchymal haemorrhages. The mean time from ED presentation to theatre was 1.68 hours and 5.46 hours for the on-site and regional transfer groups, respectively. There were no mortalities. CONCLUSIONS: Forty-two per cent of trauma craniotomies are performed within 4 hours. However, presentation to an ED with on-site neurosurgical services significantly facilitates time critical surgery in children following a traumatic brain injury.