Healthcare Gazette - 2017 Jul/Aug

HEALTHCARE GAZETTE

JULY/AUGUST 2017• ISSN 2078-9750

THE UPS AND DOWNS OF HEALTHCARE COSTS PG 16 5

15

NEWS

A small step – or a giant leap – for healthcare in SA?

22

RESEARCH

Label vegetables differently to increase consumption

28

FEATURE

The weightiness of SA’s obesity burden

H EALT H CAR E G A ZE TTE | J A NU A RY 2 0 1 6 WWW.HMPG.CO.ZA

FOCUS

Birds, bees, pollen ... sneeze!

Celebrating the Milestones

giftof

The

quality

Dual impact on functional and social limitations results in greater improvement in quality of life for Heart Failure patients.* 1 • Unique† loop diuretic with predictable bioavailability and long half-life 2 • Once daily dosing • Fewer restrictions on daily life and social limitations* 1 • Significant improvement in NYHA class (p=0.00017) 3 • S ignificantly reduced hospital days (p=0.02) and re-admissions to hospital for heart failure (p<0.01) and other cardiovascular causes (p=0.03) 4 • UNAT® - Attenuates myocardial remodeling and improves LV function 5

* vs furosemide † Compared to furosemide, characteristics demonstrated that were not found in furosemide NYHA – New York Heart Association References: 1. Wargo K, Banta W. A Comprehensive Review of the Loop Diuretics: Should Furosemide Be First Line? Ann Pharmacother 2009;43:1836-47. 2. Muller K, Gamba G, Jaquet F, Hess B. Torasemide vs. furosemide in primary care patients with chronic heart failure NYHA II to IV—efficacy and quality of life. The European Journal of Heart Failure 2003;5:793-801. 3. Cosin J, Diez J, on behalf of the TORIC investigators.

Torasemide in chronic heart failure: results of the TORIC study. The European Journal of Heart Failure 2002;4:507–513. 4. Murray M, Deer M, Ferguson J, Dexter P, Bennett S, Perkins S, et al. Open-label Randomized Trial of Torsemide Compared with Furosemide Therapy for Patients with Heart Failure. Am J Med 2001;111:513–520. 5. Yamato M, Sasaki T, Honda K, Fukuda M, Akutagawa O, Okamoto M, et al. Effects of Torasemide on Left Ventricular Function and Neurohumoral Factors in Patients With Chronic Heart Failure. Circ J 2003;67:384-390 Unat® 2,5, Torasemide 2,5 mg, Reg. No: 28/18.1/0292. Unat® 5, Torasemide 5 mg, Reg. No.: 28/18.1/0293. Unat® 10, Torasemide 10 mg, Reg. No: 28/18.1/0294. For full prescribing information, refer to the package insert approved by the medicines regulatory authority. Applicant: MEDA Pharma South Africa (Pty) Ltd. Reg. No.: 2010/000051/07, Suite #166, Private Bag X9976, Sandton, 2146, South Africa. Tel: 27 11 451 1300 Fax: 27 11 451 1400. Email: info@medapharma.co.za. Web: www.meda.co.za ZA.UNA.17.8.375

Contents | 01

Co nt ent s

4 NEWS 4 Local healthcare innovations impress 5 A small step – or a giant leap – for healthcare in SA? 6 Funding of NHI services – questions remain unanswered 7 Where to for medical aid schemes?

8

RESEARCH 14 Increasing emergence of drugresistant gonorrhoea

14 Eating fish frequently helps rheumatoid arthritis

8 Milk-bank regulations being revised

15 Label vegetables differently to increase consumption

8 International honour for Bara doctor

15 Cut out sugary drinks when eating protein-rich meals

9 Using artificial sweeteners to lose weight? Think again!

28 FOCUS 28 Birds, bees, pollen … sneeze!

15 Weight gain in early life linked to problems later on

10 Declining funding to fight malaria increases risk

FEATURES

10 Restless legs contribute to pregnancy woes

16 The ups and downs of healthcare costs

14 Can computer scientists “solve” cancer?

22 The weightiness of SA’s obesity burden

PRESS RELEASE 31 Five healthy trends in hospital cleaning machinery

END NOTE

32 Making the NHI work in SA

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02 | Ed’s Letter

Ed’s Letter EDITOR Marilyn de Villiers CONTRIBUTORS Marilyn de Villiers Bridget Farham

M A R I LY N D E V I L L I E R S

Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham

FROM THE EDITOR’S DESK Of 1 427 facilities inspected The publication of the in the 4 years to March 2016, Cabinet-approved National Health Insurance (NHI) Policy just 89 scored a pass mark of 70% or more.

White Paper on 28 June The latest White Paper provided some answers to the many questions that have does not refer to this, other than to note that “healthdominated NHI discussion systems-strengthening since the government first initiatives will continue to committed itself, in 2011, be implemented.” It merely to providing all citizens notes that the pilot phase with “a defined package has now ended, and that of comprehensive [health] “useful lessons” learned will services” through NHI. be “scaled up” in the next But many questions phases of implementation. remain unanswered, and In this edition of even more have emerged Healthcare Gazette, we following the White Paper’s look at some aspects of release.

In April 2012, the Ministry the NHI, including issues surrounding NHI funding, of Health announced that the role of medical aids the “piloting” of the NHI in the future, and how was to begin in 11 districts. medical practitioners will be However, reports published remunerated within an NHI towards the end of last year environment. indicated that the pilot was With the NHI White not going particularly well, Paper making it clear despite repeat inspections that one of the greatest and ZAR145 million spent.

stumbling blocks to universal access to quality health care in SA is the cost of healthcare delivery, we turn the spotlight on one of the largest burdens on SA’s over-stretched healthcare sector: obesity. This is not a new problem, but despite the attention it has received over the years, it appears to be getting worse. Why is this? What can, or should, healthcare professionals do differently? Is it just a healthcare problem? What do you think?

Letters to the editor can be emailed to me at healthcaregazetteeditor@ gmail.com. We’d also welcome your feedback, constructive comments and suggestions for future articles.

I look forward to hearing from you.

Till next time.

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

MANAGING EDITOR Naadia van der Bergh COPYEDITOR Kirsten Morreira PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens CHIEF OPERATING OFFICER Diane Smith | +27 (0)12 481 2069 dianes@hmpg.co.za SALES MANAGER (CAPE TOWN) Azad Yusuf SALES REPRESENTATIVES Renée Hinze Ladine van Heerden Charmalin Simpson CUSTOMER SERVICE AND ONLINE SUPPORT Gertrude Fani | +27 (0)21 532 1281 publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 tshepisom@hmpg.co.za LAYOUT AND DESIGN Clinton Griffin Travis Arendse Printed by Tandym Print HG online issues: https://issuu.com/ hmpg/stacks The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org).

For information on subscribing to Healthcare Gazette, please contact sales@hmpg.co.za.

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LOCAL HEALTHCARE INNOVATIONS IMPRESS

IMPRESSIVE INNOVATIONS within the SA healthcare industry were highlighted at the 7th annual Africa Health Exhibition & Congress 2017 held in Midrand recently.

These included a world-first, smartphone-based diagnostic hearing tool – the hearScope from the hearX Group – that helps to diagnose middle-ear infection, a leading cause of preventable hearing loss.

The hearScope consists of a smart, user-friendly, mobile app and a pen-like otoscope that is said to be more accurate than traditional otoscopes when combined with the capabilities of the mobile application.

The hearX Group has also developed a free, smartphonebased “test your hearing” app which anyone can download and use to give an indication of hearing loss, potentially encouraging them to visit a medical professional for treatment.

Thembekile Asset Management Solutions introduced the Sanitag, a real-time Radio Frequency Identification (RFID) and RealTime Location Services (RTLS) system which can be used to improve the safety and security of vulnerable individuals in care.

Sanitag enables the location of anyone wearing an RFID tag

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– an elderly person or a baby, for example – to be visually pinpointed on an easy-tofollow map. It also allows for motion sensing and inactivity monitoring.

Setting predefined patient boundaries, it can be used to prevent wandering for at-risk patients, as well as for fall detection. An Infant Tracking Safety solution uses a mother/ infant tag to help prevent mixups and kidnappings, while a Lone-Worker Tracker provides for emergency-worker tracking, improving their safety and security while also allowing for their faster dispatch to emergency scenes.

News | 05

A SMALL STEP – OR A GIANT LEAP – FOR HEALTHCARE IN SA? THE NATIONAL HEALTH Insurance (NHI) Policy White Paper, which has been approved by Cabinet and was published on 28 June 2017, sets out the framework for the second (2017 - 2022) and third (2023 - 2026) phases of the implementation of NHI. The ultimate goal of NHI is to give all South Africans access to comprehensive, quality healthcare services. This, the White Paper notes, “will necessitate massive reorganisation of the current healthcare system”.

To facilitate implementation of the NHI, seven “institutions, bodies and commissions” are to be established. These include:

National Tertiary Health Services Committee

This committee will deal with the proposed governance arrangements regarding tertiary

health services in SA, ensuring an integrated approach with the secondary/regional services.

National Governing Body on Training and Development

The National Governing Body on Training and Development will recommend policy related to health-sciences student education and training, as well as oversee and monitor its implementation.

National Health Pricing Advisory Committee

This committee is charged with developing the pay mechanisms for contracted healthcare providers at the primary healthcare level on a risk-adjusted capitation system that also includes an element of performance-based pay.

It will also implement interim measures to “stabilise pricedetermination mechanisms in the private health system” until the full implementation of NHI in 2026, and will develop recommendations on the establishment of a Health Care Pricing Authority.

Ministerial Advisory Committee on Health Care Benefits for NHI

This committee will implement a service benefits framework which comprises a database of current health services provided at the community level; fixed primary healthcare facilities and hospitals in the public health sector; and a costing model which estimates the cost to provide these services in the public sector.

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

National Advisory Committee on Consolidation of Financing Arrangements This committee will consolidate current healthcare funding streams into a single financing pool without having to wait for additional NHI funding through taxes.

Ministerial Advisory Committee on Health Technology Assessment

This committee will determine the benefits to be covered under NHI in terms of prioritisation, selection, distribution, management and interventions for health promotion, disease prevention,

diagnosis, treatment and rehabilitation.

National Health Commission

This commission is being set up to develop and implement an all-inclusive approach to the prevention and control of noncommunicable diseases.

FUNDING OF NHI SERVICES – QUESTIONS REMAIN UNANSWERED THE RECENT PUBLICATION OF the National Health Insurance (NHI) White Paper has done little to clarify how much NHI will actually cost, or where the funding is going to come from.

That’s according to Charles Simkins, head of research at the Helen Suzman Foundation, who believes that one of the major issues is the fact that there is still no clarity on the package of services that are to be funded by NHI. “Until these decisions are taken, it is not possible to estimate the cost of National Health Insurance. It is the fundamental reason why the National Treasury has not delivered the analysis which, it was promised, would accompany the policy,” he said.

The White Paper itself states that “NHI will cover comprehensive healthcare services”.

These include (but are not limited to): public health service benefits such as prevention and health promotion, including primary healthcare outreach and appropriate home care;

maternal, women and child health, including family planning and reproductive-health services; HIV and tuberculosis; chronic non-communicable diseases; and violence and injuries.

Emergency medical services will include basic life support; intermediate life support; advanced life support; medical rescue; screening and triage; initial assessment, stabilisation and management; and cardiopulmonary resuscitation.

Hospital-based services will cover such areas as emergency medicine, internal medicine,

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nephrology and renal disease, including dialysis; oncology; psychiatry; obstetrics and gynaecology; paediatrics and neonatology; surgery; orthopaedics; and organ transplant.

Also to be covered are additional services such as nutrition; mental health; oralhealth rehabilitation services; optometry services; basic curative services; environmental health; and clinical support services.

Mental and disability healthcare services will be integrated into the primary

News | 07

healthcare services, while sexual and reproductive health, rare disease and dread diseases will also be covered.

However, a detailed list of services that will be covered must still be drawn up by the

not-yet-established NHI Benefits Advisory Committee.

“The policy document excuses itself fro m trying to determine what the NHI will cost, preferring to frame the questions around the implications of

different scenarios for the design and implementation of reforms to move towards universal health coverage. It is thus far from clear how this addresses the costestimation problem,” Simkins concluded.

WHERE TO FOR MEDICAL AID SCHEMES? “EVENTUALLY, MEDICAL AIDS will have to give way because we want one medical scheme for everyone,” health minister Dr Aaron Motsoaledi said recently, in answer to a question about the future of medical aid schemes.

But how or when this was going to happen has always been a little vague.

Some maintained that because people won’t want to pay for medical insurance/ aid twice (as NHI contributions will be compulsory), medical aid schemes as we know them will die a natural death. But there’s also been a view that although medical aid schemes may or should be prohibited from funding services provided by NHI, they would continue to fund complementary medical services.

It is now clear, following the publication of the latest NHI Policy White Paper, that the latter view is what the government has in mind, although whether it will actually work out like that remains to be seen.

The White Paper states: “Once NHI is fully implemented, medical

schemes will transform to providing complementary cover” that can only be used to “fill gaps in the service coverage offered by the NHI.” It is important, the policy emphasises, that “mechanisms are put into place to streamline healthcare services to ensure value for money and to eliminate duplicative cover and double dipping.”

In addition, the White Paper notes that “individuals will not be allowed to opt out of making the mandatory pre-payment towards NHI, though they may choose

not to utilise NHI healthcare services”.

And until the NHI is up and running? The White Paper points out that there are 83 medical aid schemes, offering 323 benefit options.

Benefit options are to be restricted to one per scheme, with standardisation of healthcare services across the schemes aligned to services provided, or not provided, by the NHI. In addition, it appears that the government is going to scrap the current tax rebate individuals receive on their medical aid contributions. It also plans to halt the medical scheme contribution subsidies it pays to the various government, police, parliamentary, municipal workers’ union and state-owned entity medical schemes. All this money is to be channelled into the NHI funding arrangement.

Will medical aid schemes survive? Will it be necessary that they survive, not only in the long term, but in the interim phase until the NHI is fully operational?

These are questions that only time will answer.

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MILK-BANK REGULATIONS BEING REVISED

ACCORDING TO THE WHO, exclusive breastfeeding for the first 6 months of an infant’s life is the cornerstone of good health and survival.

Breastmilk helps to reduce infections by strengthening these babies’ immune systems.

“This is even more important for babies born prematurely and of very low birth weight,” said Stasha Jordan, executive director of the SA Breastmilk Reserve.

She pointed out that not all infants have access to breastmilk, with local health authorities attributing low rates of exclusive breastfeeding to the prevalence of poverty and misinformation.

According to a study by local medical researchers, formally employed HIV-negative mothers were twice as likely to stop breastfeeding by 12 weeks as those who were not employed.

In this study, most of the women had little or no maternity-leave

provision. Soon after giving birth, many poor mothers had to return to work – and then what little income they earned went towards purchasing formula milk instead.

“In the face of increasing need for human breastmilk, it is important that we work to overcome the ‘negative’ attitude and misperception SA women have towards breastfeeding.

Improving access to breastmilk banking is one step in the right direction,” Ms Jordan said.

“However, we need to carefully consider the ethical considerations of breastmilk banking, to prevent hurting the same infants we are looking to protect. It is therefore important to carefully consider the regulations around milk banking in SA.” The SA Department of Health is currently developing regulations on milk banking.

“This provides an opportunity to reflect on the importance of treating donated breastmilk in accordance with the ethical standard that guides the human tissue- and organ-donation sector,” she concluded.

INTERNATIONAL HONOUR FOR BARA DOCTOR

r Raymond Setzen delivers a paper at the 3rd Yangtze D International Summit of Minimally-invasive and Noninvasive Medicine in Chongqing, China

DR RAYMOND SETZEN, HEAD of the high-intensity focused ultrasound (HIFU) unit at Chris Hani Baragwanath Hospital (Bara), has been appointed vice president of the International Society for Minimally Invasive and Noninvasive Medicine (ISMINIM).

The announcement of his 4-year appointment was made at the 3rd Yangtze International Summit of Minimally Invasive and

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Noninvasive Medicine held in Chongqing, China, in July.

Dr Setzen was at the summit, which attracted over 1 400 delegates from around the world, to deliver a lecture on the SA experience of the clinical deployment of HIFU ablation therapy for the treatment of fibroids.

According to Dr Setzen, minimally invasive and noninvasive treatment of tumours

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USING ARTIFICIAL SWEETENERS TO LOSE WEIGHT? THINK AGAIN! ARTIFICIAL SWEETENERS, including aspartame, sucralose and stevia, may be associated with long-term weight gain and increased risk of obesity, diabetes, high blood pressure and heart disease.

That’s according to a report, “Non-nutritive sweeteners and cardiometabolic health: A systematic review and metaanalysis of randomised controlled trials and prospective cohort studies”, published in the Canadian Medical Association Journal in July 2017.

The researchers from the University of Manitoba’s George and Fay Yee Centre for Healthcare Innovation and the Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, noted that while there is wide consumption of non-nutritive sweeteners, their impact on longterm health is uncertain.

They conducted a systematic review of 37 studies that followed over 400 000 people for an average of 10 years. Seven of these studies were randomised controlled trials (RCTs) involving

1 003 people followed for an average of 6 months.

The trials did not show a consistent effect of artificial sweeteners on weight loss. The longer, 10-year observational studies showed a link between consumption of artificial sweeteners and increases in weight and waist circumference, as well as a higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. In the 6-month-long RCTs,

the non-nutritive sweeteners had no significant positive or negative effect on BMI or other health conditions.

The authors concluded that evidence from RCTs did not clearly support the intended weight-loss benefits of nonnutritive sweeteners, while the observational data suggested that routine consumption of artificial sweeteners may be associated with increased BMI and cardiometabolic risk.

has become a major trend in modern medicine, as it promises less harm to patients and fewer complications. “With fibroids affecting 20% - 40% of women of childbearing age, and the condition being three to five times more common among black women than their white and Asian counterparts – it is the most common complaint among female patients presenting at

Bara’s gynaecology clinic – HIFU offered what we believed was an excellent alternative to traditional treatments,” he said.

The ISMINIM was established in 2013 to promote: the development of the highest standards of clinical practice in the field of minimally invasive and non-invasive therapeutic medicine, through education and research; research

in all aspects of minimally invasive and non-invasive medicine and related sciences, including clinical research in the promotion of quality and personalised healthcare; and closer fellowship among all members in the different branches of minimally invasive and non-invasive medicine, and greater cooperation among all members and allied healthcare professionals.

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DECLINING FUNDING TO FIGHT MALARIA INCREASES RISK GLOBAL MALARIA-ELIMINATION funding is declining at a time when it remains crucial to eliminating the disease worldwide, according to a study published in the open-access Malaria Journal.

Researchers at the University of California, San Francisco Global Health Group noted that while government funding for malaria elimination has been increasing in many affected countries since 2000, this increase in government financing does not fully bridge the gap resulting from a decline in external funding since 2010.

Lack of funding or inefficient use of funds may increase the risk of malaria resurgences.

This is the first study that systematically tracks Development Assistance for Health (DAH) – donor funding – and Government Health Expenditure (GHE) – government funding – for 35

declines as the country moves closer to becoming malaria free."

So, for example, Botswana’s donor funding for malaria eradication has completely dried up, while SA’s, after declining significantly between 2002 and 2009, went against the world trend and increased substantially after 2010. However, SA government funding to combat malaria has declined, as has Swaziland’s. On the other hand, government spending in Botswana and Namibia has increased significantly.

malaria-eliminating countries, including SA, Swaziland, Botswana and Namibia. The study covers the period from 1990 to 2013, with projections to 2017.

Rima Shretta, the corr­esponding author, said: “Our findings demonstrate growing uncertainty about the future availability of donor funding for malaria. The study highlights the need for sustainable financing solutions that bridge the gap between the amount of funding a government can provide based on its economy, and the amount donated by external partners, which

Percentage increase/decrease in government and donor expenditure on malaria 2002 - 2004

SA

Swaziland Botswana

Namibia

DAH

–12.9

2005 - 2009

GHE

DAH

GHE

2010 - 2013/4 DAH

GHE

5.1

–34.7

– 1.8

31.6

– 5.9

0

–1.5

74.4

8.6

–2.7

– 8.9

0

– 6.1

0

29.3

– 100

9.1

92

11.9

24.5

– 0.6

43.2

5.2

RESTLESS LEGS CONTRIBUTE TO PREGNANCY WOES THE NEXT TIME A WOMAN IN her third trimester of pregnancy complains of poor sleep patterns, daytime sleepiness and poor daytime function, don’t

dismiss this as just a normal part of pregnancy.

A recent study of 1 563 pregnant women revealed that restless-leg syndrome (RLS)

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affects 36% of women in their third trimester. Half of the women with RLS had moderate to severe symptoms. The study results are published in the July issue

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of the Journal of Clinical Sleep Medicine.

RLS is an irresistible urge to move your legs, typically in the evenings. The researchers from the University of Michigan Sleep Disorders Center in Ann Arbor, USA, found that pregnant women with RLS were twice as likely to report poor sleep quality and poor daytime function compared with pregnant women without RLS. They were also more likely to have

excessive daytime sleepiness.

In addition, the study found a positive relationship between RLS severity and the sleep-wake disturbances.

“While we expected that RLS would be relatively common in pregnant women, we were surprised to observe just how many had a severe form,” said lead author Galit Levi Dunietz, a postdoctoral research fellow at Sleep Disorders Center.

“These women experienced RLS

symptoms at least four times per week.”

According to the authors, many healthcare providers attribute patient complaints of poor sleep and daytime sleepiness during pregnancy to normal physiological changes. However, this study suggests that there could be more to it. By screening women for RLS and using non-pharmacological approaches to treat them, the burden of these symptoms could be alleviated for many women.

CAN COMPUTER SCIENTISTS “SOLVE” CANCER? MICROSOFT CORPORATION – developer of the world’s most widely used computer programs – is turning its research guns on the cancer conundrum.

Rather than using test tubes and beakers, Microsoft believes cancer can be “solved” using algorithms and computers, as well as through the collaboration of computer scientists and biologists.

Microsoft research teams are using a wide range of different approaches in this quest. These range from developing powerful algorithms that help scientists understand how cancers develop, and what treatments will work best to fight them, through “moonshot” efforts that could one day allow scientists to program cells to fight cancer.

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Jeanette M Wing, Microsoft’s corporate vice president in charge of the company’s basic research labs, said the company’s overarching philosophy toward solving cancer focuses on two approaches: ¾¾ The idea that cancer and other biological processes are information-processing systems.

That means that the tools that are

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“

We’re in a revolution with respect to cancer treatment.”

David Hackerman, senior director of the genomics group at Microsoft used to model and reason about computational processes – such as programming languages, compilers and model checkers – can also be used to model and reason about biological processes. ¾¾ The idea that researchers can apply techniques such as machine learning (artificial intelligence) to the plethora of biological data that has suddenly become available, and use those sophisticated analysis tools to better understand and treat cancer.

The research teams’ efforts come amid major breakthroughs in understanding the role genetics plays in both getting and treating cancer.

“We’re in a revolution with respect to cancer treatment,” said David Hackerman, senior director of the genomics group at Microsoft. “Even 10 years ago, people thought that you treat the tissue: you have brain cancer, you get brain-cancer treatment. You have lung cancer, you get lungcancer treatment. Now, we know it’s just as, if not more, important to treat the genomics of the cancer, e.g. which genes have gone bad in the genome.”

While mapping the human genome and other genetic material is giving scientists a wealth of information for understanding cancer and

developing more personalised and effective treatments, the sheer amount of data also presents huge challenges.

That’s an area where computer scientists really help the biological sciences. Some of the most promising approaches involve using machine learning to automatically do the legwork that can make precision medicine unwieldy.

“If you look at the combination of things that Microsoft does really well, then it makes perfect sense for Microsoft to be in this industry,” said Andrew Phillips, who heads the biologicalcomputation research group at Microsoft’s Cambridge, UK, lab.

In his field specifically, Phillips said researchers benefit from Microsoft’s history as a software innovator.

“We can use methods that we’ve developed for

programming computers to program biology, and then unlock even more applications and even better treatments,” he said.

Of course, none of these tools will help fight cancer and save lives unless they are accessible and understandable to biologists, oncologists and other cancer researchers.

Microsoft researchers say they have taken great pains to make their systems easy to use, even for people without any background – or particular interest – in technology and computer science.

That includes everything from learning to speak the language of doctors and biologists, to designing computer-based tools that mimic the systems people use in their labs.

Phillips, however, cautions that they are still in the very early stages of this research, and those kinds of long-term goals remain far off.

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BITE-SIZED SUMMARIES OF THE LATEST SCIENTIFIC ADVANCES Eating fish frequently helps rheumatoid arthritis

even after taking fish-oil consumption into account.

Tedeschi SK, Bathon JM, Giles JT, Lin TC, Yoshida K, Solomon DH. The relationship between fish consumption and disease activity in rheumatoid arthritis. Arthritis Care

Increasing emergence of drugresistant gonorrhoea New data from 77 countries show that gonorrhoea is becoming increasingly resistant to treatment, and high-income countries in particular are reporting infections that are impossible to treat.

Data are from the WHO global gonococcal antimicrobial surveillance programme, which monitors trends in drug-resistant gonorrhoea. The new data were published in PloS Medicine. Nearly all countries (97%) that report data found strains resistant to ciprofloxacin, and 81% of countries reported increasing resistance to azithromycin. Even more

worryingly, 66% of countries reported the emergence of strains resistant to the current last-resort treatment, extendedspectrum cephalosporins (ESCs), oral cefixime or injectable ceftriaxone. In addition, three countries – Japan, France and Spain – reported gonorrhoea superbugs.

Although most verified treatment failures are from high-income countries, this is probably a reflection of surveillance levels in resource-poor countries, and may not reflect the true burden of ESC treatment failure.

Wi T, Lahra MM, Ndowa F, et al. Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action.

PLoS Med 2017;358:e1002344. https://doi.org/10.1371/journal. pmed.1002344

Eating fish at least twice a week is associated with reduced disease activity in patients with rheumatoid arthritis (RA), according to research reported in Arthritis Care and Research. The study, a cross-sectional analysis of data from 176 patients who were taking part in a large study investigating sub-clinical cardiovascular disease in RA, found higher levels of joint swelling and tenderness in patients who ate fish less than once a month.

Most participants in the study had longstanding RA and were taking disease-modifying antirheumatic drugs (DMARDs). Patients filled in a food frequency questionnaire that detailed their diet over the previous year, and their frequency of fish consumption was analysed in relation to RA activity.

There was a clinically significant reduction in RA symptoms in people who ate fish frequently when compared with those who never ate fish, or who ate it less than once a month.

The difference remained

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Res (Hoboken) 2017. https://doi. org/10.1002/acr.23295

Research | 15

Label vegetables differently to increase consumption Labelling vegetables using language usually used with more indulgent foods increases their consumption more than using plain labels or those describing health effects, according to a study published in JAMA Internal Medicine. The study was carried out on staff and students at a cafeteria at Stanford University, California. Each day of the autumn term of 2016, one vegetable dish was labelled randomly in one of four ways – basic (e.g. green beans), describing what was absent (e.g. low-sodium bok choy), health-positive (e.g. vitaminrich corn) or indulgent (e.g. rich buttery roasted sweetcorn). The labelling changed, but there was no change in the way that the vegetables were prepared.

Labelling a vegetable dish indulgently was associated with a 25% increase in the number of people selecting the dish

than when it was given a basic label, a 41% increase over a healthy restrictive label and a 35% increase over a health-positive label.

Indulgent labelling was associated with a 23% higher mass of vegetables eaten than basic labelling.

Turnwald BP, Boles DZ, Crum AJ. Association between indulgent descriptions and vegetable consumption: twisted carrots and dynamite beets. JAMA Intern Med 2017. https://doi.org/10.1001/ jamainternmed.2017.1637

Cut out sugary drinks when eating protein-rich meals

Weight gain in early life linked to problems later on

A sugary drink with a high-protein meal may negatively affect energy balance, change food preferences and lead to increased fat storage, according to a study published recently in BMC Nutrition.

Researchers found that a sugar-sweetened drink decreased fat oxidation by 8%. This fat oxidation is what starts the breakdown of fat molecules. A sugar-sweetened drink consumed with a 15% protein meal decreased fat oxidation by 7.2 g; with a 30% protein meal, it decreased by 12.6 g.

Researchers also found that the combination also increased the study subject’s desire to eat savoury and salty foods for hours after eating.

The study was very short and carried out on individuals who were a healthy weight, so cannot be generalised.

A study published in JAMA suggests that moderate weight gain from early to middle adulthood is associated with a significantly increased risk of major chronic diseases and mortality in later life.

The study analysed 18 years of data from 92 837 US women from the Nurses’ Health Study (1976 - 2012), and 15 years of data from 25 303 US men from the Health Professionals Followup Study (1986 - 2012).

Participants recalled their weight during early adulthood (18 years in women and 21 years in men) and then reported their weight at the age of 55 years. The incidence of later cardiovascular disease, cancer and death was recorded. A composite health aging outcome was defined as being free of 11 chronic diseases and major cognitive or physical problems.

Moderate weight gain (between 2.5 and 9.9 kg) over 37 years in women and 34 years in men was associated with higher rates of type 2 diabetes, hypertension, cardiovascular disease and obesity-related cancers than among those who maintained a healthy weight.

Shanon L. Casperson, Clint Hall and James N. Roemmich.

Postprandial energy metabolism and substrate oxidation in response to the inclusion of a sugar- or non-nutritive sweetened

Zheng Y, Manson JE, Yuan C.

beverage with meals differing in

Associations of weight gain from

protein content.

early to middle ddulthood with

BMC Nutrition 2017;3:49.

major health outcomes later in life.

https://doi.org/10.1186/s40795-

JAMA 2017;18(3):255-269. https://

017-0170-2

doi.org/10.1001/jama.2017.7092

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

THE UPS AND DOWNS OF HEALTHCARE COSTS Healthcare in SA currently follows the expensive fee-for-service model. Experts recommend shifting to value-based care, which focuses on efficient spending, where practitioners aim to prevent illness or to treat it as quickly and efficiently as possible.

It remains to be seen whether the proposed NHI results in this shift

By Marilyn de Villiers

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

Feature | 17

S

A’S PUBLIC HEALTHCARE system, which is supposed to provide healthcare for about 80% of the country’s population, is widely regarded as weak, generally overstretched and poorly resourced, despite the fact that SA spends almost 9% of GDP on healthcare. Just over 40% of this is government expenditure.

On the other hand, while the private healthcare system is regarded as efficient, it is often criticised for being too expensive, and therefore beyond the reach of many.

There is considerable debate about whether National Health Insurance (NHI) will have the capacity to address these issues.

The July 2017 NHI Policy White Paper makes it clear that one of the greatest stumbling blocks to universal access to quality healthcare in SA is the cost of healthcare delivery in both the public and private sectors.

Within the private sector, much of the blame for its “exorbitant costs” is laid squarely at the door of the current fee-forservice model, in which healthcare providers are paid for each service they provide (see sidebar). This incentivises over-servicing and has no accountability to patients.

Dr Ernst Marais, COO of the Independent Clinical Oncology Network (ICON), a doctor-driven network of SA oncology professionals that is championing a shift to value-based care in the country, said that the government appeared to regard NHI as the panacea to the country’s underperforming public healthcare system, by improving the quality in the public sector and reducing costs in the private sector.

“However, there are question marks around the affordability of the plan. Inability to cover practice expenses under NHI could force providers to shut up shop,” he said.

Nevertheless, Dr Marais believed that the

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

“

“Fee-forService will not be used as a mechanism for provider payment … private providers will be reimbursed through a capitation model … [and] outcomes will be measured and monitored through a performance management framework … in accordance with agreed upon performance standards.”

- National Health Insurance Policy White Paper, July 2017

FEE-FOR-SERVICE PUSHES UP HEATHCARE COSTS There is a range of reasons for the large increases in medical scheme expenditure over the recent past, including the dominant fee-forservice reimbursement mechanism that encourages providers to supply more services than may strictly be necessary from a clinical perspective.

Fee-for-service (FFS) is a method of provider payment where there is a separate payment to a healthcare provider for each medical service rendered to a patient.

Medical schemes reimburse for all services regardless of their impact on patient health. In a FFS environment, there is little countervailing pressure to discourage providers from delivering unnecessary services.

National Health Insurance Policy White Paper, July 2017

“

There are question marks around the affordability of the NHI. Inability to cover practice expenses under NHI could force providers to shut up shop”

Dr Brian Ruff rising cost of healthcare would make it imperative to find ways to make medical funds go further, especially when SA transitions to NHI. According to the NHI White Paper, all healthcare providers will be assessed against indicators of clinical care, health outcomes and clinical governance, rather than simply on delivery or perceived quality of services.

WHAT EFFECT COULD THIS HAVE?

Diana Verrilli, vice president of Payer and Revenue Cycle Services at US-based McKesson Specialty Health, said there was mounting evidence that a shift from feefor-service to value-based healthcare could improve the patient experience of care (including quality and satisfaction), result in a healthier population and – importantly – reduce the per capita cost of healthcare.

“In a value-based care model, healthcare providers are incentivised to achieve better health outcomes for patients – either by preventing illness, or by treating it as quickly and cost-effectively as possible.

The focus is on efficient spending to get outcomes that matter to patients – notably their quality of life and health,” she said at ICON’s conference on value-based care in oncology, held in Cape Town recently.

Her work in the US with McKesson, a shareholder of the US Oncology Network, has been at the forefront of assisting healthcare providers to deliver better care at lower costs by encouraging a focus on providing the right care at the most appropriate cost.

“The value-based model is turning traditional thinking – that says in order to improve health outcomes we have to spend more – on its head,” said Dr Marais.

“With a value-based approach, it is actually possible to reduce costs and improve outcomes simply by focusing on different things and – importantly – taking the entire care continuum into consideration.” Patient centricity is key to the success of the model, which means that patient support needs to be individualised.

“The principle of value-based care is that you are paid for where you add the most value, and insurance companies and third-party payers are willing to pay more for measured outcomes,” Dr Marais explained.

“A shift to this kind of reimbursement has been shown to deliver benefits to all stakeholders in the sector, including and most importantly – patients.”

Dr Brian Ruff, a health-systems expert and co-founder of PPO Serve, an integrated healthcare management company, agreed that there has to be a move away from the fee-for-service model which, in addition to encouraging and rewarding over-servicing, also fragments the delivery of care, as it is billable only by single clinicians and not organised teams.

He believed that the concept of global fees would shift the emphasis towards preventive, outcomes-based care, rather than just for the type and number of services rendered. It would also promote teamwork, which would enable clinicians to better follow complex clinical protocols that deliver good outcomes.

However, he said the current formulations of global fees put forward by schemes are not popular with professional medical bodies, because they violate some basic principles. “The HPCSA has urged practitioners not to enter into any alternative fee arrangements while this is being resolved,” he added, and pointed out that the current models can compromise

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FRAUD DRIVES UP HEALTHCARE COSTS Fraud, waste and abuse are among the biggest contributors to escalating healthcare costs, as the fee-for-service model of payment encourages people to overcharge or overservice for profit.

That’s according to Gerhard van Emmenis, acting principal officer of Bonitas Medical Fund, which last year identified over ZAR79 million in irregular claims involving medical practitioners. To date, the fund has recovered millions of rands, which could be used to pay for 57 000 more family-practitioner consultations, or potentially be used to fund an additional 18 lung or liver transplants. Bonitas estimates that fraud adds between ZAR192 and ZAR410 per month to every principal member’s medical aid contributions.

Bonitas also estimates that between 10 and 15% of private healthcare claims contain elements of fraudulent information – adding an estimated ZAR22-billion to the annual cost of private healthcare in SA. The culprits are not just medical practitioners. Guilty parties are found all along the healthcare delivery chain – from medical practitioners through to employees, service providers and members. There has also been an increase in collusion between members and healthcare providers.

Fraudulent activity includes: fraud: “bogus doctors” who submit claims using another doctor’s practice number ¾¾ T ime-based health practitioners: some have been found to bill as much as 50 - 60 working hours a day ¾¾ Over-billing: billing for services not rendered ¾¾ Using incorrect codes for services (at a higher tariff) ¾¾ Waiving of deductibles and/or co-payments ¾¾ Billing for a non-covered service as a covered one ¾¾ Unnecessary or false prescribing of drugs ¾¾ Doctors admitting patients who have used up all their out-of-hospital benefits to hospital, just to access more benefits. If hospital occupancy is low, the hospital may well extend the stay. ¾¾ Identity

Gerhard van Emmenis

“

Value-based healthcare can improve patients’ experience of care, result in a healthier population and reduce healthcare costs

patient care by encouraging “cutting corners” to save money, because they contain no balancing rewards for good outcomes.

“As fee-for-services is billable only by single clinicians and not organised teams, it fragments the delivery of care.

These problems are contributing to the affordability crisis and escalating scheme premiums,” he said.

Dr Ruff’s solution is the creation of what he calls the “value-fee contract”, which serves the interests of patients, clinicians and funders, and is based on clear principles.

The value-fee contract would have two components: a professional team fee and a value-add fee. “Clinicians bill collectively for their services from their independently

owned multidisciplinary teams. These professional-team fees cannot contain financial risk, because clinicians don’t have financial reserves. The value component is based on measures that include both patient satisfaction and clinical outcomes.

“The base professional fee reflects the enrolled patient risk profile (the severity of their conditions), the multidisciplinary professional input required and management costs. The value-linked ‘add-on’ is like a hotel star rating system. Consistently high-performing teams in terms of patient satisfaction, outcomes and cost management can bill higher fees,” he explained.

Value-based fees can be monthly for populations, or for a defined episode of care, such as a hip-joint replacement or maternity care.

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Feature | 21

Writing in the Harvard Business Review last year, Laura Kaiser and Dr Thomas Lee stated that the shift from volume-based to value-based healthcare was inevitable.

Under this approach, innovative providers aim to compete for and attract more customers with lower prices and higherquality care and services. As value-based payments gradually replace the fee-forservice model, providers that have not adapted will be left behind.

“However, the biggest impediment to change invariably is the shift from fee-forservice to value-based reimbursement, because performing and billing a smaller number of services may be perceived to erode the short-term revenue of providers, because most providers’ business models still depend on fee-for-service revenues, with the healthcare professional getting paid according to the number of procedures, tests, investigations and so on they perform,” Dr Marais said.

However, Kaiser and Lee argued that there was a compelling business case for acting now, to achieve value-based care without worrying about when the market will make the shift. Provider organisations

that are leading the way, they said, would gain expertise in managing the risk of caring for a population under a prepaid budget. And those who start sooner will be better positioned for success.

Ms Verrilli agreed. “Payers now emphasise that physicians should come up with treatment recommendations that are in the best interest of the patient, and rightly so. I think what’s important is having standards of care and making sure that every patient has equal access. And such programmes (value-based care) give healthcare providers the ability to deliver that value and standard of care at the appropriate level,” she said.

Ms Verrilli maintained that while the NHI scheme is necessary, it is essential that government also give serious consideration to the principle of value-based healthcare.

“Value-based care means that healthcare providers now must care about what happens to patients prior to arriving in their office, and also about what happens to the patients when they leave that office.

The goal always should be to advance better care, smarter spending and a healthier population,” she concluded.

DAY HOSPITALS HAVE A ROLE TO PLAY IN NHI While there are many factors contributing to the increase in private healthcare costs, the biggest culprit is private hospital costs, says Bibi Goss-Ross, group operations manager, Advanced Health Limited.

According to the Council for Medical Schemes’ 2014 - 2015 report, total hospital expenditure amounted to 37.6% of the ZAR124.1 billion that medical schemes paid to all healthcare providers in 2014, up 11.6% from the previous year.

“This is not sustainable,” Goss-Ross says. “When one considers that some 70% of surgical procedures currently done in acute hospitals can be performed safely in day surgery facilities, the saving could be enormous.

However, only about 13% of all surgical procedures in SA are attended to in day hospitals – an extremely low figure compared with the international norm. ”Day hospitals have a clear role to play in the NHI environment, taking the overflows from the state facilities for short-stay surgery procedures,” she concluded.

Bibi Goss-Ross

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Feature | 23

THE WEIGHTINESS OF SA’S OBESITY BURDEN Obesity and its related diseases are on the rise, having overtaken HIV as the leading cause of death in SA. Although the obesity epidemic cuts across demographics, food insecurity has been identified as one cause among low-income groups. Health education, as well as regulation and fiscal measures, are required to tackle the problem

By Marilyn de Villiers

S

OUTH AFRICANS GENERALLY are fat – and are getting fatter. As an excess of body fat is a wellknown risk factor for cardiovascular disease (CVD), type 2 diabetes and a host of other conditions, this has serious implications not only for the country’s already overburdened healthcare sector, but for the economy as a whole.

That, in a nutshell, was the resounding message that came through loud and clear during the Public Health conference that formed part of the 7th annual Africa Health Exhibition & Congress 2017, which took place in June 2017 at the Gallagher Convention Centre in Johannesburg.

For the record, the WHO defines obesity as “a condition of abnormal or excess fat accumulation in adipose tissue, to the extent that health may be impaired”.

Overweight and obesity is not confined to any particular demographic in the country: rich and poor, urban and rural, black and white – we are all becoming increasingly overweight.

Prof. Karen Hofman, Associate Professor, School of Public Health at the University of the Witwatersrand (Wits) put this into perspective. She stated that surveys within the private healthcare sector revealed a 26.91% prevalence of type 2 diabetes in 2013 – an increase of 67.9% between 2008 and 2013.

Figures released by the Department of Health (DoH) last year showed that almost 70% of women and 40% of men in SA are overweight or obese, with 43% of deaths in the country now associated with obesityrelated diseases. These obesity-related diseases have now overtaken HIV in SA as a cause of death.

“Between them, diabetes and hypertension are starting to overwhelm the public healthcare sector,” she said.

“Obesity-related disability costs the healthcare sector more over a greater number of years than smoking-related costs. In fact, type 2 diabetes consumed between 7% and 12% of total healthcare costs in 2010 – between ZAR11.5 billion

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“

Rich and poor, urban and rural, black and white – South Africans are all becoming increasingly overweight

THE SOUR TASTE OF SWEETNESS ¾¾ Drinking 1 - 2 sugarsweetened beverages (SSBs) per day increases the risk of developing type22 diabetes by 25% – California Center for Health Policy ¾¾ Sports and energy drinks are the fastestgrowing soft-drink markets in SA ¾¾ South Africans consume about 31 kg of sugar per person per year, of which a third is consumed through SSBs ¾¾ A 350 ml can of a carbonated SSB contains about 10 teaspoons of sugar ¾¾ A 250 ml glass of fruit juice contains about 10 teaspoons of sugar. ¾¾ WHO recommends consumption of no more than six teaspoons of sugar per day.

and ZAR20.5 billion. It’s predicted that total health expenditure on diabetes will rise to ZAR14.4 billion - ZAR26.2 billion by 2030.”

Prof. Pamela Naidoo, CEO, Heart and Stroke Foundation SA (HSFSA) said obesity is a “global epidemic”. And SA is not immune.

A survey conducted by the HSFSA in 2016 and 2017 revealed that most South Africans were overweight, with a body mass index (BMI) of 29.6 and 29.9, respectively (see Table 1).

BMI is considered to be the most useful population-level measure of obesity, but several speakers at the conference warned against regarding BMI as the only measure.

Prof. Naidoo pointed out that BMI reflects weight in kg/height in m2, but does not distinguish between weight associated with muscle and weight associated with fat.

“The measure of intra-abdominal or central fat to reflect changes in risk factors for CVD and other chronic diseases is better than BMI,” she said, adding that scientific studies have also used other anthropometric indices such as waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) for assessing obesity and obesity-related health risks. The measurement of obesity among children and adolescents is not clear-cut either, with growth patterns, including changes in height and weight, having to be taken into account.

Among the elderly, there are changes in body composition and height that also need to be considered.

“There are also further complexities underpinning obesity that affect the way in which obesity should be evaluated. We need to consider the influence of lifestyle changes on adiposity, while genetic variants may be related to adiposity – studies have shown that genetic factors explain 40% - 80% of the variance in BMI and risk of obesity,” she said. “Knowledge of genotype variation will help in tailored interventions for reduction in overweight and obesity.”

However, Prof. Naidoo acknowledged that, because there was no agreement on which index should be applied universally to define obesity, there was little option but to follow the WHO recommendation that BMI cut-points should be retained as the international classification.

In his presentation, “When Shape Matters”, Annibale Cois, Chief Director,

Environmental Health and Public Health Services, National DoH, emphasised that not all fat is created equal.

“Considering measures of body-fat distribution in addition to indicators of total body fat allows for a better characterisation of CVD risk and its trends, both at individual and population level,” he said.

Like Prof. Naidoo, he said that carrying excess weight around the waist – producing an “apple” shape as opposed to a “pear” shape – was a greater risk factor than the pear shape for developing one or more of the non-communicable diseases related to overweight and obesity.

According to Mr Cois, the prevalence of abdominal obesity is increasing faster than the prevalence of general obesity across the SA population. “Among women of all population groups, BMI and waist circumference (WC) have both increased between 1998 and 2014/15. This is extremely worrying,” he said. “Among men, BMI is increasing among older subjects and whites, while WC is increasing in most groups.

“These results suggest that the adverse health consequences associated with obesity may be increasingly underestimated by trends in BMI alone, especially among women and subjects with high socioeconomic status,” he added.

However, even people with lower socioeconomic status are at risk.

Wits’ Prof. Hofman said surveys had shown that at 13 years of age, 20% of urban (Soweto) girls and 14% of rural girls are overweight/obese; by age 15, this has risen to 24% and 16%, respectively, increasing again at age 17 to 27% and 18%, respectively, among Soweto and rural girls.

According to Prof. Thandi Puoane of the Community and Health Faculty at the School of Public Health, University of the Western Cape, food insecurity – only having access to food which is largely of poor quality – is linked to obesity among low-income groups.

“There has been an increase in the number of people who are food insecure and so eat a diet that is not diverse and consists mainly of energy-dense foods that are high in carbohydrates with high fat, high sugar and salt and less micronutrients. Most micronutrients are obtained from fresh fruit and vegetables,” she added.

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

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WHAT WEIGHT-LOSS METHODS WORK BEST? Douketis et al. (2005) conducted a systematic review of long-term studies investigating dietary/lifestyle, pharmacological and surgical methods of weight loss, and found that: ¾¾ Dietary/lifestyle therapy provides <5 kg loss after 2 - 4 years ¾¾ P harmacological therapy provides 5 - 10 kg weight loss after 1 - 2 years ¾¾ Surgical therapy provides 25 - 75 kg weight loss after 2 - 4 years.

An energy-dense diet high in carbohydrates and fat leads to obesity

“

Obesityrelated diseases in SA have overtaken HIV as a cause of death.

Prof. Puoane said that there was growing evidence that low-income mothers struggling with depression or food insecurity utilised obesogenic childfeeding practices and unfavourable parenting practices that could influence the weight status of their children, leading to overweight children and adolescents and, ultimately, obese adults.

“If food insecurity is not dealt with, we are likely to see an increase in the burdens associated with non-communicable diseases.

Policy actions are needed to protect the poor from accessing unhealthy food by making healthy choices the easy choices.

“Policymakers and programme administrators can also help to reduce food insecurity by increasing the resources available to low-income households through food assistance programmes. Subsidies of healthy food will assist the poor in eating healthily,” Prof. Puoane added.

WHAT CAN BE DONE?

Prof. Naidoo proposed what she called biobehavioural interventions at the primarycare level with physicians/healthcare practitioners counselling individuals at risk.

There should also be health education and health promotion via mass-media

campaigns, school-based interventions and worksite interventions.

There should also be regulation and fiscal measures, including subsidies on fruit and vegetables, as well as taxes on foods high in fat, regulation (or self-regulation) of food advertising to children and compulsory food labelling.

“SA is moving in the right direction with salt regulations and SSB [sugar-sweetened beverage] taxation (see sidebar, p28). But interventions need to be multi-pronged and done simultaneously across the board.

“Ultimately, the success of overweightand obesity-regulation programmes is reliant on individual take-up of the healthpractitioner-recommended behavioural strategies for weight loss, such as increased physical activity, consumption of nutritionvaluable food combined with individual and family-based counselling,” she concluded.

With SSBs, it’s a case of “buy now, pay later” in terms of deteriorating health and rising healthcare costs, says Prof. Karen Hofman.

She maintains that taxing SSBs – therefore driving up the cost of these drinks – will deter demand, encourage demand for healthier alternatives and convince the industry to reconsider the formulation

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Feature | 27

Table 1. Source: Heart and Stroke Foundation of SA

Classification

HSFSA 2016 % of participants (4 332, with average age 45.6 years)

BMI (kg/m2)

Risk of co-morbidities

Underweight

<18.5

Nutritional deficiencies, including iron-deficiency anaemia, fertility problems, osteoporosis, immunesystem dysfunction, hair loss, poor wound healing 2.19

Normal weight

18.5 - 24.9

Overweight

25 - 29.9

Obese class 1

30 - 34.9

Obese class 2

35 - 39.9

Obese class 3

≥40

Non-communicable diseases such as type 2 diabetes, cardiovascular disease, hypertension, osteoarthritis, sleep apnoea, metabolic syndrome, and some cancers Associated with non-alcoholic fatty liver disease, infertility, poor wound healing and increased mortality

of their products, and their marketing strategies.

She told delegates at the recent Public Health Conference that a 20% tax on SSBs in SA could reduce obesity in men by 3.8%, and by 2.4% in women. This translates into preventing obesity in up to 220 000 people, reducing diabetes prevalence by 4% and slashing the cost of treating obesity-related diseases by millions of rands.

However, while a 20% tax on SSBs was initially proposed in the 2016 Budget, it was subsequently reduced to 11% in the 2017 Budget, following submissions to Parliament and consultations with stakeholders.

According to Prof. Hofman, research has shown that consuming SSBs on a regular basis (1 - 2 cans per day) potentially increases the risk for developing type 2 diabetes by 25%, whether a person is obese or not. If a person is already obese, the consumption of sugary drinks can up the risk to 50%.

But why target only SSBs and not sugar in general?

“Because the sugar in SSBs is liquid sugar, it is absorbed differently in the bloodstream than sugar taken in a solid form. As it absorbs very rapidly, it causes a rapid spike in blood-glucose levels, increasing the demand for insulin from

HSFSA 2017 % of participants (1 185, with average age 50.2 years)

2.28

25.35

26.58

36.21

26.41

22.49

22.11

8.39

13.00

5.38

9.62

the pancreas. Over time, this leads to pancreatic exhaustion, resulting in glucose intolerance and the subsequent development of type-2 diabetes,” Prof.

Hofman explains.

However, she concedes that the tax should be regarded as only the first step in a multipronged strategy that is needed to reduce obesity and convince people, and the industry, of the harms it is causing to people’s health. There was also a need to improve the country’s food-labelling laws and to regulate the marketing of sugarsweetened products to children.

Prof. Hofman says that SA’s tobacco laws are proof that imposing a tax to make potentially harmful products less affordable does have a significant impact. Since the DoH started its clamp-down on smoking in SA two decades ago, the number of smokers has dropped from 40% of the population to 20%.

“Imposing a tax is just the beginning of educating consumers to make the healthy choice and easy choice. Talking about SSB taxes and the reasons behind [them] is a public health message that could not only change behaviour, but also convince the industry to reconsider what they are putting into their products,” she concludes.

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“

Almost 70% of women and 40% of men in SA are overweight or obese, with 43% of deaths in the country now associated with obesity-related diseases” – SA Department of Health.

BIRDS, BEES, POLLEN … SNEEZE! Allergic rhinitis, more commonly known as “hay fever”, reduces quality of life, and results in high medical costs, as well as loss of productivity in the school-going and working populations. Treatment should be based on three approaches: environmental control, pharmacotherapy and allergen immunotherapy

By Marilyn de Villiers

T

HE IMMINENT ARRIVAL OF spring will bring with it a plethora of blocked and runny noses, postnasal drips and coughs, red and tearing eyes, sneezing and itching – all characteristics of allergic rhinitis (AR), or what is commonly referred to as “hay fever”.

While the classification into two types of AR – perennial and seasonal – is now considered outdated (the International Allergic Rhinitis and its Impact on Asthma – ARIA – workshop, supported by the WHO, classifies AR into four groups based on symptom duration and symptom severity – see sidebar on p29, AR, by any name and classification, is no joke.

The 2016 revision of the ARIA guidelines, which offers updated advice for clinicians and doctors about the most commonly used treatments for AR, notes that AR affects 10% - 40% of the global population. While it is not life-threatening, it reduces quality of life, hinders work and school performance, and is a frequent reason for visits to the doctor.

“Medical costs are large, but avoidable costs associated with lost work productivity are even larger than those incurred by asthma,” ARIA states.

It is also worth bearing in mind that, as ARIA points out, AR is also frequently associated with asthma, which is found in 15% - 38% of patients with AR, and nasal symptoms are present in 6% - 85% of patients

with asthma. In addition, AR is a risk factor for asthma, and uncontrolled moderate-to-severe AR affects asthma control.

However, R J Green et al., on behalf of the SA Allergic Rhinitis Working Group, note in their article “Chronic rhinitis in South Africa” (South African Medical Journal, 2013), that not all cases of chronic rhinitis have an allergic basis. Therefore, not all cases of blocked and runny noses, sneezing and itching – whether persistent or intermittent – will respond to AR therapy.

Prof. Green says that most patients with AR have an IgE or type I allergic basis. In SA, because grass pollen is a major allergen (such as across the Highveld), the disease is usually persistent over several months, and usually moderate to severe in nature. It may thus resemble non-allergic rhinitis, a condition where ongoing symptoms are present for long periods, but where there is no IgE basis.

However, a positive allergy test does not always confirm AR in isolation. Specific IgE may be a pointer to AR, but specific symptoms need to be present before the diagnosis is made.

According to Prof. Green, laboratory tests to confirm the diagnosis of AR should be selected based on careful history-taking, rather than by applying a large panel of allergy tests.

In an article, “Allergic rhinitis in South Africa – Update 2014”, a consensus

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Focus | 29

document prepared on behalf of the SA Allergic Rhinitis Working Group (SAARWG) and published in Current Allergy & Clinical Immunology, the most common SA allergens were identified as follows ¾¾ Global: trees, such as plane, eucalyptus and oak, house dust mite, cockroaches, animal danders (cats, dogs, horses) and fungal spores (moulds). ¾¾ Truly indigenous: Buffalo and Kikuyu grass, acacia trees, food products such as abalone, molluscs, fish, mopane worms, marula fruit and the African wild orange, and animal products (cobra venom (rinkhals), impala, wildebeest, African penguin and porcupine ¾¾ Global but with significant interest by researchers in southern Africa: spider mites and imbuia wood.

AR is just one of the clinical manifestations of exposure to these allergens. However, it is almost always the result of inhaled allergens. Climate and humidity are also important factors affecting common allergen occurrence in different regions of southern Africa (see table).

DIAGNOSIS OF AR

Writing in the August 2009 SA Pharmaceutical Journal, Prof. Nadine Butler, of the School of Pharmacy, University of the Western Cape says a detailed clinical history, followed – if recurrent or chronic rhinitis systems persist – by further investigation, is necessary.

The clinical history should consider whether the patient complains of intense itching of the soft palate and external auditory canal, explosive sneezing at certain times of the day (commonly early mornings and evenings) and rhinorrhoea (profuse, watery or postnasal drip). These are usually early symptoms, followed by nasal congestion, leading to sinus congestion, mouth breathing and disturbed sleep. Conjunctivitis can accompany nasal symptoms.

Patients with recurrent or chronic rhinitis require allergy testing. According to Prof.

Butler, skin-prick testing is the optimal means of testing as it is the least expensive.

However, she maintains that the inclusion of a large number of allergens (beyond the common ones listed in this article) is

unnecessary, expensive and time-consuming.

An alternative is a specific blood radioallergoabsorbent (RAST) test, such as CAPRAST or Phadiatop.

TREATMENT OF AR

Prof. Butler says treatment of AR should be based on three approaches: environmental control, pharmacotherapy and allergen immunotherapy.

Environmental control or allergen avoidance measures

According to Prof. Butler, these should be considered the primary treatment, as they can improve the patient’s symptoms and reduce the need for pharmacotherapy. Such measures would include reducing housedust mites through regular vacuuming and damp dusting; using anti-allergy mattresses and pillow covers; exposing mattresses to sunlight regularly; washing bed linen in hot water; removing carpets from bedrooms; and not allowing pets into bedrooms (or at least, bathing them regularly).

Irritants such as cigarette smoke, aerosol perfumes and deodorants should be avoided; and swimmers should use nose clips to reduce exposure to chlorine.

During pregnancy, only nonpharmacological, environmental measures are recommended.

Pharmacotherapy

According to SAARWG, topical use of corticosteroids – particularly corticosteroid sprays – is the mainstay of treatment for AR. They need to be used every day, and the technique of administration is crucial to obtain the desired benefit.

However, while corticosteroids remain the drug of choice, antihistamines appear to be more acceptable for the treatment of young children, and are effective.

Prof. Butler recommends that mild symptoms be treated with long-acting second-generation antihistamines, such as loratadine, cetirizine, fexofenadine or the new-generation antihistamines desloratadine and levocetirizine.

“The older first-generation antihistamines (chlorpheniramine, diphenhydramine, hydroxyzine) are not recommended because of their sedating effects. However, since

H EALT H CARE G A ZE TTE | J U LY /A U G U S T 2 0 1 7

ARIA CLASSIFICATION OF ALLERGIC RHINITIS: ¾¾ Intermittent symptoms: less than 4 days per week or less than 4 weeks ¾¾ Mild: normal sleep; normal daily activities, sport and leisure; normal work and school; no troublesome symptoms ¾¾ Persistent symptoms: more than 4 days per week and longer than 4 weeks ¾¾ Moderate/severe: one or more of the following – abnormal sleep; impairment of daily activities, sport and leisure; problems caused at work or school; troublesome symptoms.

“

Allergic rhinitis (hay fever) affects 10% - 40% of the global population

Allergen occurrence in southern Africa Bloemfontein Cape Town Gaborone

Harare

Johannesburg

46%

27%

N/A

N/A

35%

Dust mites

34%

73%

N/A

53%

41%

51%

38%

41%

35%

45%

Moulds

N/A

N/A

28%

15%

N/A

Mould mix

N/A

N/A

N/A

N/A

53%

37%

22%

21%

17%

N/A

Weeds

N/A

N/A

25%

N/A

N/A

Cats

Grasses

Trees

Source: “Allergic Rhinitis in South Africa – Update 2014” (SA Allergic Rhinitis Working Group)

“

Not all cases of chronic rhinitis – blocked and runny noses, sneezing and itching – have an allergic basis, and therefore will not respond to AR therapy

these are the only antihistamines currently available in some public sector facilities, patients should be advised to preferably use them at night or only on an ‘as required’ basis,” she says.

Her other recommendations include, for intermittent AR: ¾¾ Sodium cromoglycolate could also be used, or topical antihistamines (levocabastine or azelastine), which are effective for acute symptomatic relief. ¾¾ Oral/topical antihistamines should be used in combination with intranasal steroids. ¾¾ Intranasal steroids should be used with caution in the elderly. ¾¾ If intranasal steroids are used (beclomethasone, budesonide, flunisolide, fluticasone propionate or triamcinolone acetonide), patients must be carefully instructed that the nozzle of the spray should be directed upwards and not towards the nasal septum.

Further symptomatic treatment can be added.

For intermittent AR in adults and children: ¾¾ Short-course oral steroids ¾¾ Consider allergen immunotherapy.

For persistent AR with rhinorrhoea in adults: ¾¾ Nasal ipratropium bromide ¾¾ Consider allergen immunotherapy For persistent AR with nasal congestion in adults: ¾¾ Antihistamines or oral/nasal decongestants ¾¾ Short course oral steroids ¾¾ Consider specific immunotherapy ¾¾ Surgical nasal turbinate reduction.

Allergen immunotherapy

According to Prof. Butler, specific-allergen immunotherapy is indicated for patients who are confirmed to be sensitive to single, unavoidable allergens, usually grass pollen or house-dust mites, in an attempt to reduce their pharmacotherapy requirements.

SAARWG also maintains that allergen immunotherapy is an important therapeutic option.

In its Patient Information Brochure on Immunotherapy, the Allergy Society of SA (ALLSA) points out that immunotherapy is the only form of medical treatment which may be able to cure allergies. However, it does not always work for every patient, particularly those with more than one allergy. It is particularly effective for patients who have severe symptoms due to housedust mites, although immunotherapy is also available for cat, dog, horse, grass pollens, tree pollens, weed pollens and some mould allergies.

Immunotherapy may be given orally as drops under the tongue administered at home, or subcutaneously by a doctor.

Oral immunotherapy, which is preferred for desensitisation to airborne allergens, should be continued for 3 years. Once a patient has undergone a full course of immunotherapy, exposure to that allergen should no longer result in clinical reactions.

ALLSA emphasises that it is important, before immunotherapy is initiated, that the patient be carefully evaluated by a doctor experienced in treating allergies, and in the use of immunotherapy.

Allergy tests need to be performed, and allergen-avoidance measures should be implemented.

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PRESS RELEASE

FIVE HEALTHY TRENDS IN HOSPITAL CLEANING MACHINERY

Cleaning is a priority issue for healthcare facilities. Dust and germs represent a serious threat to patients with reduced resistance to disease. That’s why it is vital that hospitals are kept clean and germ-free.

Poor cleaning regimens can spread disease, demotivate staff, reduce patient confidence and damage institutional reputations. And expensive, inefficient cleaning machinery also drains the budget.

According to Gavin Herold, General Manager for Nilfisk South Africa, one of the world’s leading cleaning-equipment suppliers, there are five key areas where the new innovative generation of automatic scrubbers, burnishers, vacuums and carpet extractors can make a big difference in healthcare: Versatility. Healthcare spaces are cluttered and variable. There are hard-toclean and high-traffic areas, along with ultrahard or vinyl-type floor finishes. Historically, hard-floor care equipment has revolved around traditional disc floor machines and scrubbers, but equipment manufacturers are now offering a significantly more diverse range of options. The new generation of equipment is also more compact with standon, walk-behind and rider models, allowing greater access to divergent spaces. Small, battery-operated micro-scrubbers can now be used in nurse stations and other tight areas that could only be mopped by hand in the past. They can also be easily transferred between facilities.

Noise reduction. Healthcare facilities usually don’t have downtime for cleaning.

The machinery has to be used while patients and staff are in attendance. This makes recent developments in noise suppression a significant improvement – new-generation scrubbers (sometimes referred to as stealth scrubbers) like the Nilfisk SC1500 have a

Quiet Mode for cleaning in sound-sensitive areas, and have noise levels comparable to a dishwashing machine. They are also more efficient, working quickly on one floor pass with the minimum of disruption.

Eco-friendliness. The latest technology either radically reduces the use of detergents or replaces them completely with water.

New generation scrubbers use a detergentdispensing system that allows the operator to use the minimal amount of detergent needed for cleaning an area, while providing a burst of power in heavily soiled areas. In hospitals, respiratory problems and other health issues associated with air contaminants create a need for floor-cleaning practices with highefficiency, particulate air filters on vacuums that reduce exposure to volatile organic compounds and fragrances.

Productivity. By doing the job more quickly, better and more reliably, investment in the new technologies produces a quick return in terms of reduced labour costs, resources and maintenance. Single machines for different spaces, one-pass efficiency and faster carpet drying (30 minutes or less) are just some of the ways productivity can be improved substantially.

There’s also the upside of increased safety through the reduced risk of chemical fumes, slippery floors and accidents. Floors are made cleaner and safer, using fewer chemicals and detergents.

Lower bills. It is possible to achieve significant reductions in consumption of water, electricity and disposables. Recent water shortages around the country, especially in the Western Cape, have highlighted the value of new-generation scrubbers which, paired with a squeegee design, leave floors dry in a single pass and reduce water consumption markedly.

The machinery also eliminates the need to use multiple chemicals, which ultimately reduces supply-chain costs.

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Nilfisk cleaning machinery

PRESS CONTACTS: Emma Corder Nilfisk (Pty) Ltd T +27 21 691 0080 emma.corder@nilfisk.com Samantha Claase Ogilvy Public Relations T +27 21 467 1346 samantha.claase@ogilvy.co.za

32 | End note

MAKING THE NHI WORK IN SA

A BIOGRAPHY

With a B. Journalism and BA Honours (English) from Rhodes University, Marilyn de Villiers has spent some 40 years wordsmithing in some form or another. She spent nearly a decade as a news and financial reporter for a Johannesburg daily newspaper. After the birth of her children, she began freelancing – writing features and supplements as well as a weekly technology column for the newspaper.

She also freelanced as a writer for PR agencies and eventually moved fulltime into public relations. More recently, she returned to freelance writing and editing, and has also published two novels.

S SA MOVES TOWARDS rolling out universal health coverage (UHC) through the implementation of a National Health Insurance (NHI) scheme, the focus remains on the viability and sustainability of such a system in a country burdened by a myriad of health and socioeconomic challenges.

“It is a social mandate that requires governments to acknowledge that healthcare is a basic human right. They also need to implement financial and delivery mechanisms that will help to achieve access to needed services in a progressive and sustainable way,” said Dr Anuschka Coovadia, KPMG’s head of healthcare for Africa, and a member of the Global KPMG Centre for Universal Health Coverage.

“UHC doesn’t guarantee universal healthcare – the crux is the way delivery is incentivised through appropriate financial mechanisms. As SA is already spending more than 8% of its GDP on healthcare – more than the 5% suggested by the WHO – the focus should not be about spending more money, but on how the available money could be spent better to improve access and outcomes.”

In SA, the 2008 decision to go the NHI route has elicited furious debate on the costs and suitability of this ambitious plan, given the country’s challenges – huge socioeconomic issues, an overburdened and dysfunctional public health system, a dire shortage of healthcare professionals and other resources, a relatively unaffordable private sector, rising medical inflation and growing disease burden.

According to Dr Coovadia, UHC has a direct impact not only on improving a

country’s health, but also on issues such as economic growth and stability. It is therefore imperative that the focus should move away from the cost and potential payment systems, to the mechanisms needed to deliver the services that will be covered by the NHI package in an affordable and accessible way.

“We need to create incentives, payment systems, governance and technology platforms that can really incentivise multidisciplinary healthcare teams to provide healthcare that will ensure continuity of care and population health management through promotive and preventive healthcare,” she said.

“The current practice of curative and individualised medicine is unaffordable and unsustainable. UHC is about creating the right systems, checks, balances and interfaces so that we optimise the resources we are the custodians of, and derive the best outcomes for our population.”

According to Dr Coovadia, decisions relating to issues such as the package of services and how they will be provided should be dealt with in a much more transparent way, involving patients as well as all stakeholders in both the public and private sectors, including NGOs, NPOs, donor funders and civil society.

“Government can’t deliver UHC alone – we need both the private and public sectors and a proper framework to the management thereof if we want to achieve success,” she concluded.

Dr Coovadia spoke at the 7th annual Africa Health Exhibition & Congress 2017, held from 7 to 9 June 2017 at the Gallagher Convention Centre in Johannesburg.

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