On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.102 n.11 Cape Town Jan. 2012
Public sector quality failure crisis for NHI?
Mounting evidence of deep, widespread dysfunction in the public health sector in most provinces must be cause for deep concern for our national health minister, Dr Aaron Motsoaledi, and his dedicated team as they gear up for the phased introduction of a more equitable delivery system.
In Izindaba,1 Chris Bateman reports on the R2 billion in underspending nationally on vital infrastructure (plus millions more in several other healthcare areas), all meant to underpin the incoming National Health Insurance (NHI). This and what seems to be a losing battle to redress long-neglected healthcare facilities in the Eastern Cape (its Director-General, Dr Siva Pillay, ironically attributing dysfunction in part to gross under-funding) and elsewhere seem to render the impending NHI's quality-based accreditation of healthcare facilities a very distant if not even somewhat fantastic goal. Aggravating matters are endemic corruption and the treacle-like speed and clumsy modus operandi of the Public Works Department (in the Eastern Cape backed by the much-touted state-funded Coega Development Corporation). Izindaba juxtaposes this with warnings from international health policy and financing experts that for universal health coverage to succeed, the public sector should at least begin approaching the quality of the private sector. Serious, urgent collaboration is indicated.
Modern management of hepatobiliary disease in children
The modern management of hepatobiliary disease in children is addressed in Part 2 of this edition. Treatment of infants and children so afflicted began with the Kasai operation, which became established surgical treatment in 1962. Today many of these children can be offered liver transplantation, including living donor transplantation, and reviews and research relating to this treatment are presented.
Dogs are not always man's best friend ...
but rather a major source of morbidity, and even mortality, accounting for 1 in 10 visits to emergency units. A KwaZulu-Natal survey2 examines the demography of dog bites. Children (aged 4 - 7 years) are at greatest risk, and young men are more likely to be bitten than young women. Given that rabies is endemic, the fear is of rabies transmission, and there is negligible hope of preventing onset and progression of the disease. This applies particularly to bites that break the skin and cause bleeding. The analysis by Kent et al. shows that bites should be graded according to severity, and vaccine and/or rabies immunoglobulin (which is expensive) administered accordingly.
Nevirapine for PMTCT in immunocompetent pregnant women - a warning
Bera and Mia3 address the uncertainty over use of nevirapine (NVP)-based antiretroviral therapy in pregnancy, following an advisory issued in 2005 by the US Food and Drug Administration that HIV-infected women with CD4 counts >250 cells/ul were at particular risk of developing hepatotoxicity. Their analysis of 14 prospective and retrospective studies from around the world, involving some 2 600 women, confirms an approximately 5% risk of NVP-induced hepatitis and a similar risk of severe skin reactions. Why relatively immunocompetent women are more vulnerable is perhaps explained by the fact that these toxicities are immune-mediated.
Cape Town TB cure rates
Cape Town Metro Health District can report tuberculosis cure rates of 80%.4 This happy outcome reflects the allocation of additional funding to boost dedicated TB programme staff. More nursing staff were employed and TB clerks appointed to administer the TB programme at high-burden primary care clinics in the city. Additionally, a cadre of TB assistants has been established to undertake home visits and recall sputum-positive TB suspects and trace defaulters. The TB staff are also charged with identifying and investigating child contacts and commencing either prophylaxis or treatment.
SA's deepening skills shortage ahead of NHI
A shortage of all cadres of health personnel is recognised. Two papers, one from UKZN and one from Wits, suggest solutions.5,6
An increased intake for medical training is an obvious measure, given that there is a many-fold excess of worthy applicants over those accepted into our universities' medical programmes. However, as is outlined, considerable expansion of the teaching facilities and training platforms is required, which might include use of private sector facilities.
The training and graduation of clinical associates is now well established at three universities, and the first graduates have integrated successfully into healthcare teams at district-level hospitals under doctor supervision. There is now a call for a substantial scaling up of the training of these 'generalists' to provide five per district hospital. In its turn, this would require funding from government and the opening of additional district training sites, while managing the sensitivities around scopes of practice of the nursing, pharmacy and medical professions.
We do a fine job, but ...
Given our unenviable primacy among English-speaking nations for the greatest caseload of blunt and penetrating trauma, South Africa has developed impressive specialist expertise and state-of-the-art education in the field of emergency medicine. This is the conclusion of a group of British and Australian emergency physicians who recently conducted a tour of 6 hospitals in 3 cities and one major town.7 We are especially strong in pre-hospital and retrieval care and have trauma surgeons who are among the best in the world. But we fail in-hospital in aspects such as timeous analgesic administration, structured triage, permitting relatives access to patients undergoing resuscitation, ultrasound for rapid diagnosis of life-threatening injury, and adequate supervision of junior staff.
Mirroring the documented extremely high prevalence of type 2 diabetes in the South African Indian population, Erasmus et al.8 offer the startling insights that a third of adults of mixed ancestry in the Western Cape have the disorder, and that more than half of affected persons are unaware of their condition. So, the predicted epidemic in developing countries is upon us. Since diabetes is, in truth, ultimately a micro- and macrovascular disease, we must now prepare for the 'time-bombs' of ischaemic heart disease, stroke and renal insufficiency.
2. Kent SJW, Naicker B, Wood DR. Demographics and management of dog-bite victims at a level two hospital in KwaZulu-Natal S Afr Med J 2012;102(10):845-847. [http://dx.doi.org/10.7196/SAMJ.5934] [ Links ]
3. Bera E, Mia R. Safety of nevirapine in HIV-infected pregnant women initiating antiretroviral therapy at higher CD4 counts: A systemic analysis and meta-analysis. S Afr Med J 2012;102(10):855-859. [http://dx.doi.org/10.7196/SAMJ.5700] [ Links ]
8. Erasmus RT, Soita DJ, Hassan MS, Blanco-Blanco E, Vergotine Z, Matsha TE. High prevalence of diabetes mellitus and metabolic syndrome in a South African coloured population: Baseline data of a study in Bellville, Cape Town. S Afr Med J 2012;102(10):841-844. [http://dx.doi.org/10.7196/SAMJ.5670] [ Links ]