EDITOR'S CHOICE

Two reasons why NHI just might work

As we so often highlight in our Izindaba news columns, endemic dysfunction and corruption in several of our nine provincial health departments constantly threaten to sink the vital patient equity and access which our impending National Health Insurance (NHI) scheme hopes to improve. This month we focus on two ambitious systemic 'clean-up' projects being piloted in specific areas, with a pair of the worst-affected provinces given priority.^[1,2] Dr Aaron Motsoaledi, National Health Minister, has pragmatically intervened in the long-standing and seemingly intractable dispute between vital role players at Gauteng's ailing academic hospitals. He has also set up a national Academy for Leadership and Management in Health Care, one of whose first 'fire-fighting' tasks was to engage with and up-skill hospital chief executive officers (CEOs) in the virtually stalled Limpopo Province - and do the same for just under a quarter of the nation's other public sector hospital CEOs - survivors of a protracted earlier weeding out of the underqualified and inefficient. The Gauteng academic hospital national pilot scheme will overhaul lines of authority and procurement and set minimum limits for equipment and stock (giving clinicians and hospital CEOs more say). There are new, motivated and experienced leaders and facilitators everywhere, handpicked to drive vital changes. Things might just be looking up.

South Africa's food (in)security

October 16 marks World Food Day. Note, 'marks' and not 'celebrates, as there is little to celebrate in a world of burgeoning populations, decreasing food production and climate change. The editorial from Battersby and McLachlan^[3] all too vividly illustrates the South African reality.

A third of SA's children are malnourished - our 'nutritional transition'

In low-to middle-income countries (China, Brazil and Mexico) a mixed pattern of over- and under-nutrition, both representing malnutrition, can exist in communities. The same is emerging in South Africa, as Moodley et al. show.^[4] Anthropometric data collected during the 2011 Human papillomavirus HPV Vaccination Demonstration Project^[5] measured the height and weight of girls attending 31 KwaZulu-Natal primary schools. While 9% were overweight and a further 4% obese, the same numbers were underweight and their growth stunted (4% and 9%, respectively).

Advances in surgical procedures in SA

Colleagues at the Chris Hani Baragwanath Academic Hospital, describe their experience with the management of the rare but third most common paediatric hepatic malignancy, namely undifferentiated embryonal sarcoma of the liver (UESL).^[6] Prognosis in UESL has improved with the aggressive use of multimodal therapy. Should the lesion initially be resectable, based on imaging, primary surgical excision to ensure decreased tumour burden before chemotherapy achieves optimal results. When imaging predicts an incomplete excision, the recommendation is that an open biopsy should be performed, followed by neo-adjuvant chemotherapy, repeat imaging, surgical excision, and further chemotherapy.

Continuing the paediatric surgical theme, Gopal et al.^[7] highlight the versatility of median sternotomy (MS) in dealing with children requiring treatment of penetrating mediastinal trauma, anterior and posterior mediastinal masses, acquired tracheo-oesophageal fis1tulas secondary to button battery impaction, bronchial foreign bodies and bilateral pulmonary metastases secondary to malignancy. MS should be within the armamentarium of access techniques of the general paediatric surgeon since it provides unrivalled access to the mediastinum and is well-tolerated.

Readers will be well aware of the hazards of cultural circumcision in our own context. Voluntary medical male circumcision (VMMC) is a priority HIV-preventive intervention. The World Health Organization is actively seeking circumcision techniques that are quicker, easier, and safer than open surgical methods to facilitate male circumcision scale-up in sub-Saharan Africa.

The first, and likely not the last, randomised controlled trial^[8] details use of the Gomco circumcision clamp with cyanoacrylate skin adhesive, compared with the open surgical dorsal slit technique under local anaesthesia. In this Mozambican study, under the auspices of the Catholic University of Mozambique, removal of the foreskin with the Gomco instrument, and sealing the wound with tissue adhesive, had several advantages: it required much less operative time, was easier to perform, had much better cosmetic results and was potentially safer. The timesaving and ease of this technique have important implications for VMMC scale-up. The authors suggest that a disposable plastic, Gomco-like device be produced for use and evaluation for in resource-limited settings.

The South African Vascular Surgical Cardiac Risk Index (SAVS-CRI)^[9] seeks to predict the clinical risk of perioperative major adverse cardiovascular events (MACEs) in vascular surgery patients. Risk stratification permits identification of patients at risk for cardiac complications, optimises treatment of comorbid conditions prior to surgery and offers high-risk patients the option of conservative management rather than surgery. The clinical risk factors for peri-operative MACE in SA vascular surgery patients differ in their importance from those described in the international literature. Six independent predictors of peri-operative MACE were identified: age >65 years, history of ischaemic heart disease, a history of diabetes, chronic β-blockade, prior coronary revascularisation and the vascular surgical procedure. While this SAVS-CRI appears to have superior clinical performance to the Revised Cardiac Risk Index (RCRI) that is widely utilised in European and American surgical populations, the results of this study require prospective validation in an independent SA cohort.

Intraoperative cell salvage in SA

Colleagues working at the Pietermaritzburg group of hospitals^[10] offer a solution to the problem of emergency surgical interventions involving trauma and obstetrics and gynaecology (typically ruptured ectopic pregnancy) and requiring immediate blood transfusion without the benefit of advance warning. The solution is cell salvage (CS) at the hands of anaesthetists attending such emergency surgical procedures, and reinfusion of salvaged autologous blood. There was obvious benefit to the patients, as there was no banked blood available due to shortages at the blood bank. CS proved beneficial to the community also - approximately 200 units of blood were not required to be drawn from the SA National Blood Service and were available for other patients.

Janet Seggie

1. Bateman C. Hope at last for crisis-ridden Gauteng academic hospitals? S Afr Med J 2013;103(10):705-706. [http://dx.doi.org/10.7196/SAMJ.7469]        [ Links ]

2. Bateman C. Health leadership training academy tackles worst first. S Afr Med J 2013;103(10):707-708. [http://dx.doi.org/10.7196/SAMJ.7480]        [ Links ]

3. Battersby J, McLachlan M. Urban food insecurity: A neglected public health challenge. S Afr Med J 2013;103(10):716-717. [http://dx.doi.org/10.7196/SAMJ.7463]        [ Links ]

4. Tathiah N, Moodley I, Mubaiwa V, Denny L, Taylor M. South Africa's nutritional transition: Overweight, obesity, underweight and stunting in female primary school learners in rural KwaZulu-Natal, South Africa. S Afr Med J 2013;103(10):718-723. [http://dx.doi.org/10.7196/SAMJ.6922]        [ Links ]

5. Moodley I, Tathiah N, Mubaiwa V, Denny L. High uptake of Gardasil vaccine among 9 - 12-year-old schoolgirls participating in a HPV vaccination demonstration project in KwaZulu-Natal Province. S Afr Med J 2013;103(5):318-321. [http://dx.doi.org/10.7196/SAMJ.6414]        [ Links ]

6. Geel JA, Loveland, JA, Pitcher GJ, Beale P, Kotzen J, Poole JE. Management of undifferentiated embryonal sarcoma of the liver in children: A case series and management review. S Afr Med J 2013;103(10):728-731. [http://dx.doi.org/10.7196/SAMJ.6058]        [ Links ]

7. Gopal M, Chung S-H, Westgarth-Taylor C, Fartacek R, Loveland J. The versatility of median sternotomy in general paediatric surgery. S Afr Med J 2013;103(10):732-735. [http://dx.doi.org/10.7196/SAMJ.6769]        [ Links ]

8. Millard PS, Wilson HR, Veldkamp PJ, Sitoe N. Rapid, minimally invasive adult voluntary male circumcision: A randomised trial. S Afr Med J 2013;103(10):736-742. [http://dx.doi.org/10.7196/SAMJ.6856]        [ Links ]

9. Moodley Y, Naidoo P, Biccard BM. The South African Vascular Surgical Cardiac Risk Index (SAVS-CRI): A prospective observational study. S Afr Med J 2013;103(10):746-750. [http://dx.doi.org/10.7196/SAMJ.6967;         [ Links ]

10. Solomon L, von Rahden RP, Allorto NL. Intraoperative cell salvage in South Africa: Feasible, beneficial and economical. S Afr Med J 2013;103(10):754-757. [http://dx.doi.org/10.7196/SAMJ.7355]        [ Links ]